Search

IntroductionPreterm birth is the leading cause of child mortality. This study aimed to develop and validate programmatically feasible and accurate approaches to estimate newborn gestational age (GA) in low resource settings.MethodsThe WHO Alliance for Maternal and Newborn Health Improvement (AMANHI) study recruited pregnant women from population-based cohorts in five countries (Bangladesh, Ghana, Pakistan, Tanzania and Zambia). Women Results7428 liveborn infants were included (n=536 preterm, ConclusionThe best machine-learning model (10 neonatal characteristics and LMP) estimated GA within ±15.7 days of early ultrasound dating. Simpler models performed reasonably well with marginal increases in prediction error. These models hold promise for newborn GA estimation when ultrasound dating is unavailable.

Background Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa. Methods and findings This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We used standard operating procedures, data collection tools, and training to harmonise study implementation across sites. Three home visits during pregnancy and 2 home visits after birth were conducted to collect maternal morbidity information and maternal, foetal, and newborn outcomes. We measured blood pressure and proteinuria to define hypertensive disorders of pregnancy and woman’s self-report to identify obstetric haemorrhage, pregnancy-related infection, and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28 weeks or those who died during pregnancy were included in the analysis. We used meta-analysis to combine site-specific estimates of burden, and regression analysis combining all data from all sites to examine associations between the maternal morbidities and adverse outcomes. Among approximately 735,000 women of reproductive age in the study population, and 133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927 pregnancies had morbidity data collected at least once in both antenatal and in postnatal period, and 114,050 of them were included in the analysis. Overall, 32.7% of included pregnancies had at least one major direct maternal morbidity; South Asia had almost double the burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia; 23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95% CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI 0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95% CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about 11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepartum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of postpartum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per 1,000 live births with variation by country and region. Direct maternal morbidities were associated with each of these outcomes. Conclusions Our findings imply that health programmes in sub-Saharan Africa and South Asia must intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and stillbirths. Trial registration The study is not a clinical trial., Author summary Why was this study done? Estimates of severe direct maternal morbidity are largely based on hospital-based studies with inconsistent definitions and varying selection criteria. Limited data are available from South Asia and sub-Saharan Africa, the 2 regions with the highest maternal and newborn morbidity and mortality, where a larger proportion of births occur at home. What did the researchers do and find? We collected data on maternal morbidities from a cohort of women in the community in multiple sites in sub-Saharan Africa and in South Asia. Out of a cohort of >114,000 women, we found that about 1 in 3 women suffer a maternal morbidity, which was notably higher than the previously reported data. We found that the prevalence of preeclampsia and eclampsia was about 1%, which was lower than previously reported. About 11% of women reported having prolonged or obstructed labour, which was somewhat higher than published estimates. The burden of pregnancy-related infection in postpartum period was higher in South Asia than in sub-Saharan Africa. This is the first study, to our knowledge, to describe the burden of antepartum haemorrhage and late antepartum infection and to clearly demonstrate the association of direct maternal morbidity with adverse pregnancy outcomes. What do these findings mean? Higher burden of direct maternal morbidity and its association with adverse outcomes highlights the need for improving health of women and mothers, including promotion of preconception health and nutrition, and high-quality antepartum, intrapartum and postpartum care.

Objective Omphalitis, or umbilical cord infection, is an important cause of newborn morbidity and mortality in low-resource settings. We tested an algorithm that task-shifts omphalitis diagnosis to community-level workers in sub-Saharan Africa. Methods Community-based field monitors and Zambian paediatricians independently evaluated newborns presenting to health facilities in Southern Zambia using a signs and symptoms checklist. Responses were compared against the paediatrician's gold standard clinical diagnosis. Results Of 1009 newborns enrolled, 6.2% presented with omphalitis per the gold standard clinical diagnosis. Paediatricians' signs and symptoms with the highest sensitivity were presence of pus (79.4%), redness at the base (50.8%) and newborn flinching when cord was palpated (33.3%). The field monitor's signs and symptoms answers had low correlation with paediatrician's answers; all signs and symptoms assessed had sensitivity Conclusion Despite extensive training, field monitors could not consistently identify signs and symptoms associated with omphalitis in the sub-Saharan African setting.

Background: Chlorhexidine umbilical cord washes reduce neonatal mortality in south Asian populations with high neonatal mortality rates and predominantly home-based deliveries. No data exist for sub-Saharan African populations with lower neonatal mortality rates or mostly facility-based deliveries. We compared the effect of chlorhexidine with dry cord care on neonatal mortality rates in Zambia. Methods: We undertook a cluster-randomised controlled trial in Southern Province, Zambia, with 90 health facility-based clusters. We enrolled women who were in their second or third trimester of pregnancy, aged at least 15 years, and who would remain in the catchment area for follow-up of 28 days post-partum. Newborn babies received clean dry cord care (control) or topical application of 10 mL of a 4% chlorhexidine solution once per day until 3 days after cord drop (intervention), according to cluster assignment. We used stratified, restricted randomisation to divide clusters into urban or two rural groups (located

Conducting research in areas with diverse cultures requires attention to community sensitization and involvement. The process of community engagement is described for a large community-based, cluster-randomized, controlled trial comparing daily 4% chlorhexidine umbilical cord wash to dry cord care for neonatal mortality prevention in Southern Province, Zambia. Study preparations required baseline formative ethnographic research, substantial community sensitization, and engagement with three levels of stakeholders, each necessitating different strategies. Cluster-specific birth notification systems developed with traditional leadership and community members using community-selected data collectors resulted in a post-natal home visit within 48 hours of birth in 96% of births. Of 39,679 pregnant women enrolled (93% of the target of 42,570), only 3.7% were lost to follow-up or withdrew antenatally; 0.2% live-born neonates were lost by day 28 of follow-up. Conducting this trial in close collaboration with traditional, administrative, political, and community stakeholders facilitated excellent study participation, despite structural and sociocultural challenges.

OBJECTIVE: The objective of the Alliance for Maternal and Newborn Health Improvement (AMANHI) gestational age study is to develop and validate a programmatically feasible and simple approach to accurately assess gestational age of babies after they are born. The study will provide accurate, population-based rates of preterm birth in different settings and quantify the risks of neonatal mortality and morbidity by gestational age and birth weight in five South Asian and sub-Saharan African sites. METHODS: This study used on-going population-based cohort studies to recruit pregnant women early in pregnancy (

To estimate neonatal mortality, particularly within 24 hours of birth, in six low- and lower-middle-income countries.We analysed epidemiological data on a total of 149 570 live births collected between 2007 and 2013 in six prospective randomized trials and a cohort study from predominantly rural areas of Bangladesh, Ghana, India, Pakistan, the United Republic of Tanzania and Zambia. The neonatal mortality rate and mortality within 24 hours of birth were estimated for all countries and mortality within 6 hours was estimated for four countries with available data. The findings were compared with published model-based estimates of neonatal mortality.Overall, the neonatal mortality rate observed at study sites in the six countries was 30.5 per 1000 live births (range: 13.6 in Zambia to 47.4 in Pakistan). Mortality within 24 hours was 14.1 per 1000 live births overall (range: 5.1 in Zambia to 20.1 in India) and 46.3% of all neonatal deaths occurred within 24 hours (range: 36.2% in Pakistan to 65.5% in the United Republic of Tanzania). Mortality in the first 6 hours was 8.3 per 1000 live births, i.e. 31.9% of neonatal mortality.Neonatal mortality within 24 hours of birth in predominantly rural areas of six low- and lower-middle-income countries was higher than model-based estimates for these countries. A little under half of all neonatal deaths occurred within 24 hours of birth and around one third occurred within 6 hours. Implementation of high-quality, effective obstetric and early newborn care should be a priority in these settings.Estimer la mortalité néonatale, en particulier dans les 24 heures suivant la naissance, dans six pays à revenu faible et intermédiaire - tranche inférieure.Nous avons analysé des données épidémiologiques portant sur un total de 149 570 naissances vivantes qui avaient été recueillies entre 2007 et 2013 lors de six essais prospectifs randomisés et d'une étude de cohorte réalisés dans des zones majoritairement rurales du Bangladesh, du Ghana, d'Inde, du Pakistan, de Tanzanie et de Zambie. Le taux de mortalité néonatale ainsi que la mortalité dans les 24 heures suivant la naissance ont été estimés pour tous ces pays; la mortalité dans les 6 heures suivant la naissance a été estimée pour quatre pays sur lesquels nous avions des données. Les résultats ont été comparés aux estimations de la mortalité néonatale publiées, qui ont été établies d'après des modèles.Globalement, le taux de mortalité néonatale observé sur les sites étudiés dans les six pays était de 30,5 pour 1000 naissances vivantes (de 13,6 en Zambie à 47,4 au Pakistan). La mortalité globale dans les 24 heures suivant la naissance était de 14,1 pour 1000 naissances vivantes (de 5,1 en Zambie à 20,1 en Inde) et 46,3% de l'ensemble des décès néonataux étaient survenus dans les 24 heures (de 36,2% au Pakistan à 65,5% en Tanzanie). Le taux de mortalité dans les 6 heures suivant la naissance était de 8,3 pour 1000 naissances vivantes, soit 31,9% de la mortalité néonatale totale.La mortalité néonatale dans les 24 heures suivant la naissance dans des zones majoritairement rurales de six pays à revenu faible et intermédiaire-tranche inférieure était supérieure aux estimations établies d'après des modèles pour ces pays. Un peu moins de la moitié des décès néonataux étaient survenus dans les 24 heures suivant la naissance et environ un tiers dans les 6 heures. La mise en place de soins obstétriques et néonataux efficaces et de haute qualité devrait être une priorité dans ces pays.Calcular la mortalidad neonatal, especialmente durante las 24 horas posteriores al nacimiento, en países con ingresos bajos y países con ingresos medios más bajos.Se analizaron datos epidemiológicos de un total de 149 570 nacidos vivos recopilados entre 2007 y 2013 en seis ensayos aleatorizados prospectivos y un estudio de cohortes de zonas principalmente rurales de Bangladesh, Ghana, India, Pakistán, la República Unida de Tanzanía y Zambia. Se calculó la tasa de mortalidad neonatal y la mortalidad durante las 24 horas posteriores al nacimiento en todos los países y se estimó la tasa de mortalidad en 6 horas en cuatro países con información disponible. Los resultados se compararon con estimaciones publicadas basadas en modelos de mortalidad neonatal.En general, la tasa de mortalidad neonatal observada en los lugares de estudio de los seis países fue de 30,5 por cada 1 000 nacidos vivos (alcance: 13,6 en Zambia a 47,4 en Pakistán). En conjunto, la mortalidad durante las primeras 24 horas fue de 14,1 por cada 1 000 nacidos vivos (alcance: 5,1 en Zambia a 20,1 en India) y el 46,3% de todas las muertes neonatales se produjo durante las primeras 24 horas (alcance: 36,2% en Pakistán a 65,5% en la República Unida de Tanzanía). La mortalidad en las primeras 6 horas fue de 8,3 por cada 1 000 nacidos vivos, es decir, un 31,9% de mortalidad neonatal.La mortalidad neonatal durante las 24 horas posteriores al nacimiento en zonas principalmente rurales de seis países con ingresos bajos y países con ingresos medios más bajos fue superior a las estimaciones basadas en modelos realizadas para estos países. Algo menos de la mitad de todas las muertes neonatales se produjeron durante las 24 horas posteriores al nacimiento y cerca de un tercio durante las primeras 6 horas de vida. En estos lugares, la implementación de obstetricia eficaz y de alta calidad y la atención a recién nacidos debería ser una prioridad.تقدير معدل وفيات الأطفال حديثي الولادة، وبالأخص في غضون 24قمنا بتحليل البيانات الوبائية لإجمالي 149,570عمومًا، كان معدل وفيات الأطفال حديثي الولادة الذي لوحظ في مواقع الدراسة في ستة بلدان يبلغ 30.5 لكل 1000 من المواليد على قيد الحياة (نطاق القياس: 13.6 في زامبيا إلى 47.4إن معدل الوفيات للأطفال حديثي الولادة في غضون 24旨在评估 6 个中低收入国家的新生儿死亡率、尤其是出生后 24 小时内的死亡率。.我们一共对 149 570 名新出生婴儿的流行病学数据进行了分析，该数据来自于 2007 年至 2013 年对巴基斯坦、印度、加纳、孟加拉国、坦桑尼亚联合共和国及赞比亚主要乡村地区进行的 6 项前瞻性随机试验和一项队列研究。 我们对所有国家的新生儿死亡率以及新生儿出生后 24 小时内的死亡率进行了评估，并对拥有可用数据的 4 个国家的新生儿出生后 6 小时内的死亡率进行了评估。 我们将调查结果与已发布的、基于模型的新生儿死亡率估算结果进行了比较。.总体而言， 6 个国家的研究地的实际新生儿死亡率为每 1000 名新出生婴儿中有 30.5 名死亡（范围： 从赞比亚的 13.6 到巴基斯坦的 47.4）。 新生儿出生后 24 小时内死亡率为每 1000 名新出生婴儿中共有 14.1 名死亡（范围： 从赞比亚的 5.1 到印度的 20.1），且 46.3% 的新生儿死亡案例发生在婴儿出生后 24 小时内（范围： 从巴基斯坦的 36.2% 到坦桑尼亚联合共和国的 65.5%）。 婴儿出生后 6 小时内的死亡率为每 1000 名新出生婴儿中有 8.3 名死亡，即新生儿死亡率为 31.9%。.6 个中低收入国家主要乡村地区的新生儿出生后 24 小时内的死亡率均高于这些国家的基于模型的估算结果。 略低于一半的新生儿死亡案例发生在婴儿出生后 24 小时内，而大约三分之一的案例发生在婴儿出生后 6 小时内。 上述国家应将实施优质、有效的产科护理和早期新生儿护理视为工作重点。.Дать оценку смертности новорожденных, особенно в первые 24 часа жизни, в шести странах с низким уровнем дохода и уровнем дохода ниже среднего.Проведен анализ эпидемиологических данных, полученных в результате рождения 149 570 живых детей в промежутке с 2007 по 2013 год, на основании шести проспективных рандомизированных исследований и одного когортного исследования в преимущественно сельских регионах Бангладеша, Ганы, Замбии, Индии, Объединенной Республики Танзании и Пакистана. Были рассчитаны показатели смертности новорожденных в первые 24 часа для всех стран, а оценка смертности в первые шесть часов была получена для четырех стран с доступными данными. Результаты сравнили с опубликованными показателями смертности новорожденных, рассчитанными на основе моделирования.В целом показатель смертности новорожденных, наблюдаемый в центрах проведения исследования шести стран, составил 30,5 на 1000 рождений живых детей (от 13,6 в Замбии до 47,4 в Пакистане). Смертность в течение первых суток в целом составляла 14,1 на 1000 рождений живых детей (диапазон: от 5,1 в Замбии до 20,1 в Индии) или 46,3% от всех смертей новорожденных (от 36,2% в Пакистане до 65,5% в Объединенной Республике Танзания). Смертность в первые шесть часов составляла 8,3 на 1000 рождений живых детей или 31,9% от всех смертей новорожденных.Смертность новорожденных в первые 24 часа в преимущественно сельских регионах шести стран с низким уровнем дохода и уровнем дохода ниже среднего была выше, чем показатели, рассчитанные на основе моделирования для этих же стран. Чуть менее половины всех смертей новорожденных произошли в течение 24 часов после рождения, и около трети произошли в течение первых шести часов. Поэтому внедрение высококачественной эффективной акушерской помощи и ухода за новорожденными должно стать первостепенной задачей.

Objective To evaluate the capacity of health facilities in Southern Province, Zambia, to perform routine obstetric care and emergency obstetric and neonatal care (EmONC). Methods Surveys were completed at 90 health centers and 10 hospitals between September 1, 2011, and February 28, 2012. An expanded set of signal functions for routine care and EmONC was used to assess the facilities’ capacity to provide obstetric and neonatal care. Results Interviews were completed with 172 health workers. Comprehensive EmONC was available in only six of 10 hospitals; the remaining four hospitals did not perform all basic EmONC signal functions. None of the 90 health centers performed the basic set of EmONC signal functions. Performance of routine obstetric care functions, health worker EmONC training, and facility infrastructure and staffing varied. Conclusion Assessment of the indicators for routine care revealed that several low-cost interventions are currently underused in Southern Province. There is substantial room for improvement in emergency and routine obstetric and neonatal care at the surveyed facilities. Efforts should focus on improving infrastructure and supplies, EmONC training, and adherence to the UN guidelines for routine and emergency obstetric care.

Background Global policy regarding optimal umbilical cord care to prevent neonatal illness is an active discussion among researchers and policy makers. In preparation for a large cluster-randomized control trial to measure the impact of 4% chlorhexidine as an umbilical wash versus dry cord care on neonatal mortality in Southern Province, Zambia, we performed a qualitative study to determine local perceptions of cord health and illness and the cultural belief system that shapes umbilical cord care knowledge, attitudes, and practices. Methods and Findings This study consisted of 36 focus group discussions with breastfeeding mothers, grandmothers, and traditional birth attendants, and 42 in-depth interviews with key community informants. Semi-structured field guides were used to lead discussions and interviews at urban and rural sites. A wide variation in knowledge, beliefs, and practices surrounding cord care was discovered. For home deliveries, cords were cut with non-sterile razor blades or local grass. Cord applications included drying agents (e.g., charcoal, baby powder, dust), lubricating agents (e.g., Vaseline, cooking oil, used motor oil) and agents intended for medicinal/protective purposes (e.g., breast milk, cow dung, chicken feces). Concerns regarding the length of time until cord detachment were universally expressed. Blood clots in the umbilical cord, bulongo-longo, were perceived to foreshadow neonatal illness. Management of bulongo-longo or infected umbilical cords included multiple traditional remedies and treatment at government health centers. Conclusion Umbilical cord care practices and beliefs were diverse. Dry cord care, as recommended by the World Health Organization at the time of the study, is not widely practiced in Southern Province, Zambia. A cultural health systems model that depicts all stakeholders is proposed as an approach for policy makers and program implementers to work synergistically with existing cultural beliefs and practices in order to maximize effectiveness of evidence-based interventions.