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AIM: To determine the rates of multiple gestation stillbirth and perinatal and neonatal mortality and to determine health care system characteristics related to perinatal mortality of these pregnancies in low- and middle-income countries. METHODS: Pregnant women residing within defined geographic boundaries located in six countries were enrolled and followed to 42 days postpartum. RESULTS: Multiple gestations were 0.9% of births. Multiple gestations were more likely to deliver in a health care facility compared with singletons (70 and 66% respectively p < 0.001) to be attended by skilled health personnel (71 and 67% p < 0.001) and to be delivered by cesarean (18 versus 9% p < 0.001). Multiple-gestation fetuses had a relative risk (RR) for stillbirth of 2.65 (95% confidence interval [CI] 2.06 3.41) and for perinatal mortality rate (PMR) a RR of 3.98 (95% CI 3.40 4.65) relative to singletons (both p < 0.0001). Neither delivery in a health facility nor the cesarean delivery rate was associated with decreased PMR. Among multiple-gestation deliveries physician-attended delivery relative to delivery by other health providers was associated with a decreased risk of perinatal mortality. CONCLUSIONS: Multiple gestations contribute disproportionately to PMR in low-resource countries. Neither delivery in a health facility nor the cesarean delivery rate is associated with improved PMR. Thieme Medical Publishers 333 Seventh Avenue New York NY 10001 USA.

Objective To determine population-based neonatal mortality rates in low- and middle-income countries and to examine gestational age, birth weight, and timing of death to assess the potentially preventable neonatal deaths. Methods A prospective observational study was conducted in communities in five low-income countries (Kenya, Zambia, Guatemala, India, and Pakistan) and one middle-income country (Argentina). Over a 2-year period, all pregnant women in the study communities were enrolled by trained study staff and their infants followed to 28 days of age. Results Between October 2009 and March 2011, 153,728 babies were delivered and followed through day 28. Neonatal death rates ranged from 41 per 1000 births in Pakistan to 8 per 1000 in Argentina; 54% of the neonatal deaths were >37 weeks and 46% weighed 2500 g or more. Half the deaths occurred within 24 hours of delivery. Conclusion In our population-based low- and middle-income country registries, the majority of neonatal deaths occurred in babies >37 weeks' gestation and almost half weighed at least 2500 g. Most deaths occurred shortly after birth. With access to better medical care and hospitalization, especially in the intrapartum and early neonatal period, many of these neonatal deaths might be prevented.

OBJECTIVE: To describe the staffing and availability of medical equipment and medications and the performance of procedures at health facilities providing maternal and neonatal care at African, Asian, and Latin American sites participating in a multicenter trial to improve emergency obstetric/neonatal care in communities with high maternal and perinatal mortality. STUDY DESIGN: In 2009, prior to intervention, we surveyed 136 hospitals and 228 clinics in 7 sites in Africa, Asia, and Latin America regarding staffing, availability of equipment/medications, and procedures including cesarean section. RESULTS: The coverage of physicians and nurses/midwives was poor in Africa and Latin America. In Africa, only 20% of hospitals had full-time physicians. Only 70% of hospitals in Africa and Asia had performed cesarean sections in the last 6 months. Oxygen was unavailable in 40% of African hospitals and 17% of Asian hospitals. Blood was unavailable in 80% of African and Asian hospitals. CONCLUSIONS: Assuming that adequate facility services are necessary to improve pregnancy outcomes, it is not surprising that maternal and perinatal mortality rates in the areas surveyed are high. The data presented emphasize that to reduce mortality in these areas, resources that result in improved staffing and sufficient equipment, supplies, and medication, along with training, are required. Fil: Manasyan, Albert. Centre for Infectious Disease Zambia; Zambia. University of Alabama at Birmingahm; Estados Unidos Fil: Saleem, Sarah. Aga Khan University; Pakistán Fil: Koso Thomas, Marion. Eunice Kennedy Shriver National Institute of Child Health and Human Development; Estados Unidos Fil: Althabe, Fernando. Instituto de Efectividad Clínica y Política de Salud. Departamento de Investigación en Salud Madre e Infantil. Buenos Aires; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Pasha, Omrana. Aga Khan University; Pakistán Fil: Chomba, Elwyn. Centre for Infectious Disease Zambia; Zambia. University of Alabama at Birmingahm; Estados Unidos. University of Zambia; Zambia Fil: Goudar, Shivaprasad S.. KLE; India Fil: Patel, Archana. Indira Gandhi Government Medical College; India Fil: Esamai, Fabian. Moi University; Kenia Fil: Garces, Ana. Francisco Marroquin University; Guatemala Fil: Kodkany, Bhala. KLE; India Fil: Belizan, Jose. Instituto de Efectividad Clínica y Política de Salud. Departamento de Investigación en Salud Madre e Infantil. Buenos Aires; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: McClure, Elizabeth M.. Research Triangle Institute; Estados Unidos Fil: Derman, Richard J.. Christiana Health Care; Estados Unidos Fil: Hibberd, Patricia. Indiana University; Estados Unidos Fil: Liechty, Edward A.. Massachusetts General Hospital for Children; Estados Unidos Fil: Hambidge, K. Michael. State University of Colorado Boulder; Estados Unidos Fil: Carlo, Waldemar A.. Centre for Infectious Disease Zambia; Zambia Fil: Buekens, Pierre. Tulane School of Public Health and Tropical Medicine; Estados Unidos Fil: Moore, janet. Research Triangle Institute; Estados Unidos Fil: Wright, Linda L.. Eunice Kennedy Shriver National Institute of Child Health and Human Development; Estados Unidos Fil: Goldenberg, Robert L.. Columbia University; Estados Unidos