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Summary Background We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. Methods In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. Results From May 1, 2010, to Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23 015 (7·3%) women had potentially life-threatening disorders and 3024 (1·0%) developed an SMO. 808 (26·7%) women with an SMO had post-partum haemorrhage and 784 (25·9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0·826 [95% CI 0·802–0·851]). Interpretation High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. Funding UNDP–UNFPA–UNICEF–WHO–World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Background: Zinc is necessary for central nervous system development, and maternal zinc status has been associated with developmental differences in offspring. Objective: The objective was to evaluate differences in cognitive, social, and behavioral function in Peruvian children at 54 mo of age whose mothers participated during pregnancy in a zinc supplementation trial. Design: We attempted to follow up 205 children from a prenatal zinc supplementation trial and present data on 184 (90%) children—86 whose mothers took 25 mg zinc/d in addition to 60 mg iron and 250 lg folic acid and 98 whose mothers took iron and folic acid only. Following a standardized protocol, we assessed children’s intelligence, language and number skills, representational ability, interpersonal understanding, as well as adaptive behavior and behavioral adjustment. We also assessed aspects of the mother (eg, age, education, verbal intelligence, stresses, and social support in parenting) and the home environment [HOME (Home Observation for the Measurement of the Environment) inventory]. Results: No differences were observed between any of the tests used to characterize cognitive, social, or behavioral development (P . 0.05). Child sex, parity, or treatment compliance did not modify the effects of supplementation on any outcomes. Conclusion: The addition of zinc to prenatal supplements did not influence developmental outcomes in Peruvian children when assessed at 4.5 y of age. Am J Clin Nutr doi: 10.3945/ajcn.2010. 29407.

Summary As in many other regions of the world, caesarean section (CS) rates in Latin America are increasing. Studies elsewhere have shown that providing feedback to caregivers regarding their own performance relative to their peers can significantly reduce the rates. Our objectives are to calculate risk-adjusted CS rates for hospitals in Latin America and to identify factors associated with differences among risk-adjusted rates. We included 120 randomly selected institutions in eight countries of Latin America, representing 97 095 pregnancies. We used random-effects models to calculate a risk-adjusted rate for each hospital and to identify hospitals significantly higher or lower than a benchmark rate. We conducted a regression analysis to identify characteristics of hospitals associated with differences among risk-adjusted rates. The overall CS rate was 35%, ranging from 0% to 85%. Risk-adjusted CS rates ranged from 11% to 78%. Three-quarters of hospitals had risk-adjusted rates significantly above the previously identified benchmark of 20%. Characteristics of institutions explained 48% of the variability among risk-adjusted rates, including being a private as opposed to a public institution, having some economic incentive for CS as opposed to no incentive, and having ≥50 maternity beds. Strategies to halt further increases in CS rates and reduce rates to levels that reflect the best quality of care, are urgently needed worldwide. The involvement of local quality control departments is an essential component in achieving success. Our results can be used to identify institutions that can be targets for further interventions to reduce CS rates.

Objective To test whether zinc supplementation during pregnancy would reduce infant morbidity rates. Study design A double-blind, randomized controlled trial of prenatal zinc supplementation was conducted from 1995 to 1997 in a periurban slum of Lima, Peru. Participants were randomly assigned to receive daily supplementation with zinc (15 mg zinc + 60 mg iron + 250 μg folic acid) or placebo (60 iron + 250 μg folic acid) from 10 to 24 weeks gestation until 1 month postpartum. Anthropometry was measured monthly from birth through age 12 months, and morbidity and dietary intake were measured weekly from 6 to 12 months (n = 421). Results The average percentage of observation days with diarrhea among infants prenatally treated with zinc (5.8%) was reduced compared with infants in the control group (7.7%) ( P = .01). Prenatal zinc supplementation reduced the likelihood of an infant experiencing diarrheal episodes of acute diarrhea lasting longer than 7 days (OR 0.66, 95% CI 0.43, 0.99, P = .04) and mucus in the stool (OR 0.65 95% CI 0.46, 0.92, P = .01) adjusting for infant age, breastfeeding, season, and hygiene and sanitation covariates. No treatment effects on respiratory illnesses, fever, or skin conditions were detected. Conclusions Improving prenatal zinc nutrition protected against diarrheal morbidity in infant offspring through 12 months of age.

To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes.In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latter's association with maternal characteristics and perinatal outcomes.Of the 97,095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section.Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

Little is known about how maternal zinc intake influences growth in utero and in postnatal life in humans.We aimed to assess the effect of maternal zinc supplementation during pregnancy on infant growth through age 1 y.A double-blind, randomized controlled trial of prenatal zinc supplementation was conducted from 1995 to 1997 in Lima, Peru. Women (n = 1295) were enrolled at 15.6 +/- 4.6 wk gestation and assigned to receive daily supplements with zinc (15 mg Zn + 60 mg Fe + 250 microg folic acid) or without zinc (60 Fe + 250 microg folic acid) through pregnancy to 1 mo after delivery. At birth, 546 infants were followed for 12 mo to assess growth. Anthropometric measures of body size and composition were collected monthly, and morbidity and dietary intake surveillance was carried out weekly.No differences in maternal socioeconomic characteristics by treatment group or follow-up period were found. Infants born to mothers prenatally supplemented with zinc had significantly (P0.05) larger average growth measures beginning in month 4 and continuing through month 12. In longitudinal regression modeling, prenatal zinc was associated with greater weight (by 0.58 +/- 0.12 kg; P0.001), calf circumference (by 1.01 +/- 0.21 cm; P0.001), chest circumference (by 0.60 +/- 0.20 cm; P = 0.002), and calf muscle area (by 35.78 +/- 14.75 mm(2); P = 0.01) after adjustment for a range of covariates. No effect was observed for linear growth.Maternal zinc supplementation in this population was associated with offspring growth, which is suggestive of lean tissue mass accretion.

Objective To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery. Design Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health. Setting 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data Participants 106 546 deliveries reported during the three month study period, with data available for 97 095 (91% coverage). Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics. Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective. Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.

OBJECTIVE To compare glucose and rice-based oral rehydration solution with rice-based oral rehydration solution containing recombinant human lactoferrin and recombinant human lysozyme in diarrhea outcomes. PATIENTS AND METHODS We conducted a randomized, double-blind controlled trial in children with acute diarrhea and dehydration. One hundred and forty children 5 to 33 months old were block randomized to receive low osmolarity WHO-ORS (G-ORS), rice-based ORS (R-ORS), or rice-based ORS plus lactoferrin and lysozyme (Lf/Lz-R-ORS). Intake and output were monitored for 48 h in the ORU, with continued monitoring through home and clinic follow-up for 14 d. RESULTS The G-ORS and R-ORS groups did not show any differences in diarrhea outcomes and were therefore combined as the control group. Intent-to-treat analysis showed a significant decrease in duration of diarrhea (3.67 d vs 5.21 d, P = 0.05) in the Lf/Lz-R-ORS group as compared with the control group and a significant increase in the number of children who achieved 48 h with solid stool, 85% vs 69% (P < 0.05). There were no significant differences [corrected] in volume of diarrhea or [corrected] the percentage of children who had a new diarrhea episode after achieving the endpoint. CONCLUSIONS Addition of recombinant human lactoferrin and lysozyme to a rice-based oral rehydration solution had beneficial effects on children with acute diarrhea.

Fetal and maternal data were monitored serially at 6 gestational ages from 20 to 38 weeks in 195 Peruvian fetuses. Digitized data included fetal heart rate and motor activity, as well as maternal heart rate and electrodermal conductance. Time series analysis evaluated the development of synchrony in 2 streams of fetal functioning and between mothers and fetuses. Intrafetal synchrony between heart rate and motor activity developed in an orderly fashion, with peak cross-correlation approaching an asymptote at 5 s at 28 weeks. Synchrony was not observed between fetal heart rate and maternal measures. Fetal motor activity exhibited synchrony with both maternal electrodermal and heart rate activity. Implications for revealing fundamental properties of neural development prior to birth are discussed.

Rates of cesarean section continue to increase throughout the world. The authors analyzed data from the 2005 World Health Organization global survey on maternal and perinatal health in an attempt to clarify the association between operative delivery and pregnancy outcome at the institutional level. The database consisted of a multistage stratified sample of 24 geographic regions in 8 Latin American countries. Data were collected for all women admitted to 120 institutions (randomly chosen from 410 hospitals) who were admitted for delivery over a 3-month period. Data were obtained for 97,095 of 106,546 deliveries-a coverage rate of 91%. The median rate of cesarean delivery was 33%. Factors that helped to determine operative delivery rates included primiparity, previous operative delivery, and institutional complexity. Private hospitals consistently had higher rates than did public institutions. After adjusting for risk factors, cesarean rates correlated positively with postpartum antibiotic treatment as well as with severe maternal morbidity and mortality. The most common indication for cesarean delivery was the spectrum of cephalopelvic disproportion/dystocia/failure to progress. Next most common in public hospitals was fetal distress and at private centers, previous cesarean delivery without complications. On multiple linear regression analysis, the only factors independently associated with cesarean delivery were primiparity, previous cesarean delivery, and institutional complexity. Only primiparity and previous cesarean delivery remained significant for elective operative deliveries. After adjusting for preterm delivery, an increased rate of cesarean delivery correlated with increased fetal mortality and more frequent admission of infants to intensive care for 1 week or longer. The frequency of preterm delivery and neonatal mortality increased when rates of cesarean delivery reached 10% to 20%. These findings indicate that a high cesarean delivery rate does not necessarily indicate good-quality care. Perinatal outcomes should be closely scrutinized at institutions where high operative delivery rates prevail.

The purpose of this trial was to determine whether calcium supplementation of pregnant women with low calcium intake reduces preeclampsia and preterm delivery.Randomized placebo-controlled, double-blinded trial in nulliparous normotensive women from populations with dietary calcium600 mg/d. Women who were recruited before gestational week 20 received supplements (1.5 g calcium/d or placebo) throughout pregnancy. Primary outcomes were preeclampsia and preterm delivery; secondary outcomes focused on severe morbidity and maternal and neonatal mortality rates.The groups comprised 8325 women who were assigned randomly. Both groups had similar gestational ages, demographic characteristics, and blood pressure levels at entry. Compliance were both 85% and follow-up losses (calcium, 3.4%; placebo, 3.7%). Calcium supplementation was associated with a non-statistically significant small reduction in preeclampsia (4.1% vs 4.5%) that was evident by 35 weeks of gestation (1.2% vs 2.8%; P = .04). Eclampsia (risk ratio, 0.68: 95% CI, 0.48-0.97) and severe gestational hypertension (risk ratio, 0.71; 95% CI, 0.61-0.82) were significantly lower in the calcium group. Overall, there was a reduction in the severe preeclamptic complications index (risk ratio, 0.76; 95% CI, 0.66-0.89; life-table analysis, log rank test; P = .04). The severe maternal morbidity and mortality index was also reduced in the supplementation group (risk ratio, 0.80; 95% CI, 0.70-0.91). Preterm delivery (the neonatal primary outcome) and early preterm delivery tended to be reduced among women who wereor = 20 years of age (risk ratio, 0.82; 95% CI, 0.67-1.01; risk ratio, 0.64; 95% CI, 0.42-0.98, respectively). The neonatal mortality rate was lower (risk ratio, 0.70; 95% CI, 0.56-0.88) in the calcium group.A 1.5-g calcium/day supplement did not prevent preeclampsia but did reduce its severity, maternal morbidity, and neonatal mortality, albeit these were secondary outcomes.

Objective To test the hypothesis that micronutrient beverages can provide the daily iron and zinc needs of small children. Study design Forty children aged 6 to 9 years were recruited (Lima, Peru). For 4 weeks, they received a daily serving of a beverage containing multiple micronutrients. Over 2 consecutive days, subjects received stable isotope-labeled servings of the beverage with and without a meal as well as an intravenous dose of zinc. Iron and zinc bioavailability were assessed using mass spectrometry. Results Iron absorption was significantly lower with a meal than without (9.8 ± 6.7% versus 11.6 ± 6.9%, P =.04), but zinc absorption was not (24.5 ± 10.7% versus 22.8 ± 7.6%, P =.2). In either case, however, a single daily serving provided most of the iron and zinc requirements for the children. Conclusions Single daily servings of multinutrient-fortified beverages can meet much of the mineral needs for small children. Food has a small inhibitory effect on iron, but not zinc, absorption; therefore, these beverages can be efficacious even when given with a meal.

Longitudinal neurobehavioral development was examined in 237 fetuses of low-risk pregnancies from 2 distinct populations--Baltimore, Maryland, and Lima. Peru--at 20, 24, 28, 32, 36, and 38 weeks gestation. Data were based on digitized Doppler-based fetal heart rate (FHR) and fetal movement (FM). In both groups. FHR declined while variability, episodic accelerations, and FM-FHR coupling increased, with discontinuities evident between 28 and 32 weeks gestation. Fetuses in Lima had higher FHR and lower variability, accelerations, and FM-FHR coupling. Declines in trajectories were typically observed 1 month sooner in Lima, which magnified these disparities. Motor activity differences were less consistent. No sex differences in fetal neurobehaviors were detected. It is concluded that population factors can influence the developmental niche of the fetus.

Objectives This study was undertaken to evaluate whether prenatal zinc supplementation affects maturation of fetal cardiac patterns. Study design A randomized double-blind controlled trial among 242 low-income Peruvian women was performed. Beginning at 10 to 16 weeks' gestation, women received supplements containing 60 mg iron, 250 μg folic acid with or without 25 mg zinc. Fetal heart rate (mean FHR, variability [HRV], number of accelerations) and movements (number and amplitude of movement bouts, time spent moving) were electronically monitored monthly from 20 weeks' gestation. Developmental trends were evaluated by supplement type among 195 women who completed the trial and had no serious complications of pregnancy. Results Zinc supplementation was associated with lower FHR, greater number of accelerations, and greater HRV. Supplementation effects on HRV and accelerations were more pronounced after 28 weeks' gestation. No differences in motor activity were observed. Conclusion Prenatal supplementation of zinc-deficient mothers may be beneficial to fetal neurobehavioral development.

Background: Iron-fortified school breakfasts have been introduced in Peru to combat childhood iron deficiency. Objective: We evaluated whether iron absorption from a school breakfast meal was improved by increasing the ascorbic acid content or by adding an alternative enhancer of iron absorption, Na 2 EDTA, Design: In a crossover design, iron absorption from test meals was evaluated by erythrocyte incorporation of 58 Fe and 57 Fe. The test meals (wheat bread and a drink containing cereal, milk, and soy) contained 14 mg added Fe (as ferrous sulfate) including 2.0-2.6 mg 58 Fe or 4.0-7.0 mg 57 Fe. Results: Geometric mean iron absorption increased significantly from 5.1% to 8.2% after the molar ratio of ascorbic acid to fortification iron was increased from 0.6:1 to 1.6:1 (P < 0.01; n = 9). Geometric mean iron absorption increased significantly from 2.9% to 3.8%, from 2.2% to 3.5%, and from 2.4% to 3.7% after addition of Na 2 EDTA at molar ratios relative to fortification iron of 0.3:1, 0.7:1, and 1:1, respectively, compared with test meals containing no added enhancers (P < 0.01; n = 10 for all). Iron absorption after addition of ascorbic acid ( molar ratio 0.6:1) was not significantly different from that after addition of Na 2 EDTA (molar ratio 0.7:1). Conclusions: Ascorbic acid and Na 2 EDTA did not differ significantly in their enhancing effects on iron absorption at molar ratios of 0.6:1 to 0.7:1 relative to fortification iron. Additional ascorbic acid (molar ratio 1.6:1) increased iron absorption significantly. Increasing the molar ratio of Na 2 EDTA to fortification iron from 0.3:1 to 1:1 had no effect on iron absorption.

Iron deficiency anemia is the most prevalent nutrient deficiency during pregnancy, yet there are few data on the effect of prenatal iron supplementation in women in developing countries.Our objective was to describe the effect of iron supplementation on hematologic changes during pregnancy, and the effect on those changes of adding zinc to the supplements.Pregnant women were enrolled in a randomized, double-masked study conducted at a hospital in a shantytown in Lima, Peru. Women were supplemented daily from 10-24 wk gestation to 4 wk postpartum with 60 mg Fe and 250 microg folic acid with or without 15 mg Zn. Hemoglobin and ferritin concentrations were measured in 645 and 613 women, respectively, at enrollment, at 28-30 and 37-38 wk gestation, and in the cord blood of 545 neonates.No differences in iron status were detected by supplement type, but hematologic changes were related to initial hemoglobin status. Women with anemia (hemoglobin110 g/L) showed steady increases in hemoglobin concentration throughout pregnancy whereas women with relatively higher initial hemoglobin concentrations had declining values during mid pregnancy, then rising values by 37-38 wk gestation. Women with an initial hemoglobin concentration95 g/L showed increases in serum ferritin by the end of the pregnancy. Despite supplementation, women with poorer hematologic status; who were younger, single, and multiparous; and who consumed fewer supplements were more likely to have anemia at the end of pregnancy.These hematologic changes are congruent with the effects of iron supplementation reported in placebo-controlled trials and the addition of zinc did not significantly affect them.

To assess the efficacy and acceptability of a daily and intermittent iron supplementation, a double-blind, placebo-controlled trial was conducted in a public school located in periurban Lima, Peru. Adolescent girls (n = 312), 12-18 y old, were randomly assigned to one of the following three groups: 1) 60 mg iron as ferrous sulfate daily from Monday to Friday; 2) 60 mg iron as ferrous sulfate 2 d/wk and 3 d placebo (intermittent); 3) placebo, from Monday to Friday. Field workers gave the girls supplements during school hours for 17 wk; 296 girls completed the trial. Girls took 94% of the expected dose of 85 pills. Few side effects were reported. Postintervention, hemoglobin (Hb), serum ferritin (SF) and free erythrocyte protoporphyrin (FEP) were improved significantly in the iron-supplemented groups compared with placebo (P

Background: Maternal zinc deficiency during pregnancy may be widespread among women in developing countries, but few data are available on whether prenatal zinc supplementation improves maternal and neonatal zinc status. Objective: We studied whether maternal zinc supplementation improved the zinc status of mothers and neonates participating in a supplementation trial in a shantytown in Lima, Peru. Design: Beginning at gestation week 10-24, 1295 mothers were randomly assigned to receive prenatal supplements containing 60 mg Fe and 250 μg folate, with or without 15 mg Zn. Venous blood and urine samples were collected at enrollment, at gestation week 28-30, and at gestation week 37-38. At birth, a sample of cord vein blood was collected. We measured serum zinc concentrations in 538 women, urinary zinc concentrations in 521 women, and cord zinc concentrations in 252 neonates. Results: At 28-30 and 37-38 wk, mothers receiving zinc supplements had higher serum zinc concentrations than mothers who did not receive zinc (8.8 ± 1.9 compared with 8.4 ± 1.5 μmol/L and 8.6 ± 1.5 compared with 8.3 ± 1.4 μmol/L, respectively). Urinary zinc concentrations were also higher in mothers who received supplemental zinc (P < 0.05). After adjustment for covariates and confounding factors, neonates of mothers receiving zinc supplements had higher cord zinc concentrations than neonates of mothers who did not receive zinc (12.7 ± 2.3 compared with 12.1 ± 2. 1 μmol/L). Despite supplementation, maternal and neonatal zinc concentrations remained lower than values reported for well-nourished populations. Conclusion: Adding zinc to prenatal iron and folate tablets improved maternal and neonatal zinc status, but higher doses of zinc are likely needed to further improve maternal and neonatal zinc status in this population.

Objective: Our objective was to examine whether improvement in maternal zinc status during pregnancy is positively associated with fetal neurobehavioral development in a Peruvian population. Study Design: We electronically monitored, at 32 and 36 weeks' gestation, 55 fetuses whose mothers were randomly assigned to receive, during pregnancy, a daily supplement containing 60 mg iron and 250 μg folate, with or without 15 mg zinc. Fetal heart rate and movement patterns were quantified in 55 and 34 fetuses, respectively, as indexes of neurobehavioral development. Results: Fetuses of mothers who received zinc supplementation showed fewer episodes of minimal fetal heart rate variability, increased fetal heart rate range, an increased number of accelerations, an increased number of movement bouts, an increased amount of time spent moving, and an increased number of large movements. Differences by supplementation type increased with gestational age and were statistically significant at 36 weeks' gestation ( P Conclusion: Improving maternal zinc status through prenatal supplementation may improve fetal neurobehavioral development. (Am J Obstet Gynecol 1998;180:483-90.)

Mild-to-moderate zinc deficiency may be relatively common worldwide, but the public health importance of this degree of zinc deficiency is not well defined. The purpose of this review was to provide a conceptual framework for evaluating the public health importance of maternal zinc deficiency as it relates to fetal growth and development, complications of pregnancy, labor and delivery, and maternal and infant health. The mechanisms through which zinc deficiency could influence health outcomes are well described. The results of experimental studies conducted in animal models have motivated concern about the potential health effects of mild-to-moderate maternal zinc deficiency. Observational studies in human populations have produced strong associations between poor maternal zinc status and various indicators of poor pregnancy outcome, but supplementation trials have not produced strong, or even consistent results. Supplementation trials are needed to define the public health importance of maternal zinc deficiency worldwide.

Objective The objective of the study was to examine whether blood pressure in early pregnancy and its rise in the second half of gestation are associated with spontaneous preterm birth in healthy, normotensive, nulliparous women. Study Design We included 5167 women with singleton gestation who participated in the World Health Organization Calcium Supplementation for the Prevention of Preeclampsia Trial. Systolic, diastolic, and mean arterial blood pressure and pulse pressure at baseline (12-19 weeks of gestation) and at the midthird trimester (30-34 weeks) were calculated. Rise in blood pressure was the difference between the midthird trimester and baseline. Preterm birth was defined as early preterm (less than 34 completed weeks) and late preterm birth (34-36 weeks). Results Women experiencing early or late preterm birth had over 10 mm Hg and 3 mm Hg higher rise, respectively, in systolic, diastolic, and mean arterial blood pressure than women delivering at term. A rise in systolic pressure over 30 mm Hg or diastolic pressure over 15 mm Hg was associated with a statistically significant 2- to 3-fold increase in risk of spontaneous preterm birth. Conclusion An excessive rise in either systolic or diastolic blood pressures from early pregnancy to the midthird trimester is associated with spontaneous preterm birth in a dose-response pattern.

La anemia en niños menores de tres años es un problema de salud pública en el Perú y el mundo. Se estima que la causa principal de la anemia, aunque no la única, es la deficiencia de hierro. Existen muchos estudios y revisiones sobre cómo esta carencia en los infantes impacta negativamente en el desarrollo psicomotor y, a pesar de corregirse la anemia, los niños con este antecedente presentan, a largo plazo, un menor desempeño en las áreas cognitiva, social y emocional. Estos hallazgos se describen en estudios observacionales, de seguimiento, así como en experimentales con grupo control. La anemia puede disminuir el desempeño escolar, y la productividad en la vida adulta, afectando la calidad de vida, y en general la economía de las personas afectadas. Se describen algunos posibles mecanismos de cómo la deficiencia de hierro, con o sin anemia, podría afectar el desarrollo en la infancia; por ello, causa preocupación la alta prevalencia de anemia que se observa en este grupo de edad. La prevención de la anemia en el primer año de vida debe ser la meta para evitar consecuencias en el desarrollo de la persona a largo plazo.

Background Caesarean section rates continue to increase worldwide with uncertain medical consequences. Auditing and analysing caesarean section rates and other perinatal outcomes in a reliable and continuous manner is critical for understanding reasons caesarean section changes over time. Methods We analyzed data on 97,095 women delivering in 120 facilities in 8 countries, collected as part of the 2004-2005 Global Survey on Maternal and Perinatal Health in Latin America. The objective of this analysis was to test if the "10-group" or "Robson" classification could help identify which groups of women are contributing most to the high caesarean section rates in Latin America, and if it could provide information useful for health care providers in monitoring and planning effective actions to reduce these rates. Results The overall rate of caesarean section was 35.4%. Women with single cephalic pregnancy at term without previous caesarean section who entered into labour spontaneously (groups 1 and 3) represented 60% of the total obstetric population. Although women with a term singleton cephalic pregnancy with a previous caesarean section (group 5) represented only 11.4% of the obstetric population, this group was the largest contributor to the overall caesarean section rate (26.7% of all the caesarean sections). The second and third largest contributors to the overall caesarean section rate were nulliparous women with single cephalic pregnancy at term either in spontaneous labour (group 1) or induced or delivered by caesarean section before labour (group 2), which were responsible for 18.3% and 15.3% of all caesarean deliveries, respectively. Conclusion The 10-group classification could be easily applied to a multicountry dataset without problems of inconsistencies or misclassification. Specific groups of women were clearly identified as the main contributors to the overall caesarean section rate. This classification could help health care providers to plan practical and effective actions targeting specific groups of women to improve maternal and perinatal care.

Peru has high rates of iron deficiency anemia. The prevalence is 35% in nonpregnant women of fertile age and 24.7% in adolescent girls in slums of periurban Lima. The major cause of anemia is low intake of dietary iron. A community-based, randomized behavioral and dietary intervention trial was conducted to improve dietary iron intake and iron bioavailability of adolescent girls living in periurban areas of Lima, Peru. Results show that there was a change in knowledge about anemia and improved dietary iron intake in the 71 girls who completed the study compared with the 66 girls in the control group. Although the 9-mo. intervention was not sufficient to improve hemoglobin levels significantly, there appeared to be a protective effect in maintaining the iron status of girls in comparison with the control group.

Iron absorption in adults is regulated by homeostatic mechanisms that decrease absorption when iron status is high. There are few data, however, regarding the existence of a similar homeostatic regulation in infants. We studied 2 groups of human milk-fed infants using (57)Fe (given as ferrous sulfate without any milk) and (58)Fe (given at the time of a breast-milk feeding) stable isotopes to determine whether healthy infants at risk for iron deficiency would regulate their iron absorption based on their iron status. We studied 20 Peruvian infants at 5-6 mo of age and 18 infants at 9-10 mo of age. We found no effect of infant hemoglobin concentration on iron absorption with 5-6 mo-old infants absorbing 19.2 +/- 2.1% and 9- to 10-mo-old infants absorbing 25.8 +/- 2.6% of the (57)Fe dose. For (58)Fe, 5- to 6-mo-old infants absorbed 42.6 +/- 5.0% and 9 to 10-mo-old infants absorbed 51.9 +/- 10.3%. Following log transformation, iron absorption from (57)Fe (r = -0.61, P =0.001) and (58)Fe (r = -0.61, P =0.001) were inversely correlated to serum ferritin (S-Ft). For both the (57)Fe and (58)Fe doses, infants with S-Ft12 mg/L (n = 11) had significantly higher iron absorption than those with S-Ft12 mg/L. We concluded that iron absorption in infants is related to iron status as assessed by serum ferritin but not hemoglobin concentration. Infants with low iron status upregulate iron absorption from breast milk at both 5-6 and 9-10 mo of age.

Prenatal iron supplements may adversely influence zinc absorption during pregnancy. To examine the impact of prenatal iron supplements on supplemental zinc absorption, fractional zinc absorption was measured in 47 pregnant Peruvian women during the third trimester of pregnancy (33 +/- 1 wk gestation). Of these 47 women, 30 received daily prenatal supplements from wk 10-24 of pregnancy until delivery. Supplements contained 60 mg of Fe and 250 microg of folate without [iron group (Fe), n = 16] or with [iron and zinc supplemented group (Fe + Zn), n = 14] 15 mg of Zn. The remaining 17 women [unsupplemented control group (C)] received no prenatal supplementation. Zinc concentrations were measured in plasma, urine and cord blood and percentage zinc absorption was determined following dosing with oral ((67)Zn) and intravenous ((70)Zn) stable zinc isotopes. Percentage zinc absorption was significantly lower than controls in fasting women receiving iron- containing prenatal supplements (20.5 +/- 6.4 vs. 20.2 +/- 4.6 vs. 47.0 +/- 12.6%, Fe, Fe + Zn and C groups, respectively, P: < 0.0001, n = 40). Plasma zinc concentrations were also significantly lower in the Fe group compared to the C group (8.2 +/- 2.2 vs. 9.2 +/- 2.2 vs. 10.9 +/- 1. 8 micromol/L, Fe, Fe + Zn and C groups, respectively, P: = 0.002), and cord zinc concentrations were significantly related to maternal plasma Zn levels (y = 6.383 + 0.555x, r = 0.486, P: = 0.002). The inclusion of zinc in prenatal supplements may reduce the potential for iron supplements to adversely influence zinc status in populations at risk for deficiency of both these nutrients.