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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., (Copyright © 2013 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Published by Elsevier Ltd. All rights reserved.)

Objective: To evaluate the risk of recurrence of adverse perinatal outcomes in second pregnancies in developing countries., Methods: Data from the 2004-2008 Global Survey on Maternal and Perinatal Health were used to determine the outcomes of singleton second pregnancies for 61 780 women in 23 developing countries. The mother-infant pairs had been followed up until discharge or for 7 days postpartum., Findings: At the end of their second pregnancies, women whose first pregnancy had ended in stillbirth (n = 1261) or been followed by neonatal death (n = 1052) were more likely than women who had not experienced either outcome to have given birth to a child with a birth weight of < 1500 g (odds ratio, OR: 2.52 and 2.78, respectively) or 1500-2499 g (OR: 1.22 and 1.60, respectively), or to an infant requiring admission to an intensive care unit (OR: 1.64 and 1.68, respectively). At the end of their second pregnancies, those whose first pregnancy had ended in a stillbirth were at increased risk of another stillbirth (OR: 2.35) and those whose first infant had died as a neonate were at increased risk of having the second infant die within the first 7 days of life (OR: 2.82). These trends were found to be largely unaffected by the continent in which the women lived., Conclusion: In the developing world, a woman whose first pregnancy ends in stillbirth or is followed by the death of the neonate is at increased risk of experiencing the same outcomes in her second pregnancy.

Introduction: Improving equity in access to services for the treatment of complications that arise during pregnancy and childbirth, namely Emergency Obstetric Care (EmOC), is fundamental if maternal and neonatal mortality are to be reduced. Consequently, there is a growing need to monitor equity in access to EmOC. The objective of this study was to develop a simple questionnaire to measure equity in utilization of EmOC at Wolisso Hospital, Ethiopia and compare the wealth status of EmOC users with women in the general population., Methods: Women in the Ethiopia 2005 Demographic and Health Survey (DHS) constituted our reference population. We cross-tabulated DHS wealth variables against wealth quintiles. Five variables that differentiated well across quintiles were selected to create a questionnaire that was administered to women at discharge from the maternity from January to August 2010. This was used to identify inequities in utilization of EmOC by comparison with the reference population., Results: 760 women were surveyed. An a posteriori comparison of these 2010 data to the 2011 DHS dataset, indicated that women using EmOC were wealthier and more likely to be urban dwellers. On a scale from 0 (poorest) to 15 (wealthiest), 31% of women in the 2011 DHS sample scored less than 1 compared with 0.7% in the study population. 70% of women accessing EmOC belonged to the richest quintile with only 4% belonging to the poorest two quintiles. Transportation costs seem to play an important role., Conclusions: We found inequity in utilization of EmOC in favour of the wealthiest. Assessing and monitoring equitable utilization of maternity services is feasible using this simple tool.

Objectives: To determine the effectiveness of birth plans in increasing use of skilled care at delivery and in the postnatal period among antenatal care (ANC) attendees in a rural district with low occupancy of health units for delivery but high antenatal care uptake in northern Tanzania., Methods: Cluster randomised trial in Ngorongoro district, Arusha region, involving 16 health units (8 per arm). Nine hundred and five pregnant women at 24 weeks of gestation and above (404 in the intervention arm) were recruited and followed up to at least 1 month postpartum., Results: Skilled delivery care uptake was 16.8% higher in the intervention units than in the control [95% CI 2.6-31.0; P = 0.02]. Postnatal care utilisation in the first month of delivery was higher (difference in proportions: 30.0% [95% CI 1.3-47.7; P < 0.01]) and also initiated earlier (mean duration 6.6 ± 1.7 days vs. 20.9 ± 4.4 days, P < 0.01) in the intervention than in the control arm. Women's and providers' reports of care satisfaction (received or provided) did not differ greatly between the two arms of the study (difference in proportion: 12.1% [95% CI -6.3-30.5] P = 0.17 and 6.9% [95% CI -3.2-17.1] P = 0.15, respectively)., Conclusion: Implementation of birth plans during ANC can increase the uptake of skilled delivery and post delivery care in the study district without negatively affecting women's and providers' satisfaction with available ANC services. Birth plans should be considered along with the range of other recommended interventions as a strategy to improve the uptake of maternal health services., (© 2013 Blackwell Publishing Ltd.)

Background: About 20 million cesareans occur each year in the world and rates have steadily increased in almost all middle- and high-income countries over the last decades. Maternal request is often argued as one of the key forces driving this increase. Italy has the highest cesarean rate of Europe, yet there are no national surveys on the views of Italian women about their preferences on route of delivery. This study aimed to assess Italian women's preference for mode of delivery, as well as reasons and factors associated with this preference, in a nationally representative sample of women., Methods: This cross sectional survey was conducted between December 2010-March 2011. An anonymous structured questionnaire asked participants what was their preferred mode of delivery and explored the reasons for this preference by assessing their agreement to a series of statements. Participants were also asked to what extent their preference was influenced by a series of possible sources. The 1st phase of the study was carried out among readers of a popular Italian women's magazine (Io Donna). In a 2nd phase, the study was complemented by a structured telephone interview., Results: A total of 1000 Italian women participated in the survey and 80% declared they would prefer to deliver vaginally if they could opt. The preference for vaginal delivery was significantly higher among older (84.7%), more educated (87.6%), multiparous women (82.3%) and especially among those without any previous cesareans (94.2%). The main reasons for preferring a vaginal delivery were not wanting to be separated from the baby during the first hours of life, a shorter hospital stay and a faster postpartum recovery. The main reasons for preferring a cesarean were fear of pain, convenience to schedule the delivery and because it was perceived as being less traumatic for the baby. The source which most influenced the preference of these Italian women was their obstetrician, followed by friends or relatives., Conclusion: Four in five Italian women would prefer to deliver vaginally if they could opt. Factors associated with a higher preference for cesarean delivery were youth, nulliparity, lower education and a previous cesarean.

We determined a series of quality control (QC) analyses to assess the usability of DNA collected and processed from different countries utilizing different DNA extraction techniques prior to genome-wide association studies (GWAS). The quality of DNA collected utilizing four different DNA extraction techniques and the impact of shipping DNA at different temperatures on array performance were evaluated. Fifteen maternal-fetal pairs were used from four countries. DNA was extracted using four approaches: whole blood, blood spots with whole genome amplification (WGA), saliva and buccal swab. Samples were sent to a genotyping facility, either on dry ice or at room temperature and genotyped using Affymetrix SNP array 6.0. QC measured included extraction techniques, effect of shipping temperatures, accuracy and Mendelian concordance. Significantly fewer (50 % ) single nucleotide polymorphisms (SNPs) passed QC metrics for buccal swab DNA (P < 0.0001) due to missing genotype data (P < 0.0001). Whole blood or saliva DNA had the highest call rates (99.2 0.4 % and 99.3 0.2 % , respectively) and Mendelian concordance. Shipment temperature had no effect. DNA from blood or saliva had the highest call rate accuracy, and buccal swabs had the lowest. DNA extracted from blood, saliva and blood spots were found suitable for GWAS in our study.

Pregnancy and childbirth represent a critical time period when a woman can be reached through a variety of mechanisms with interventions aimed at reducing her risk of a preterm birth and improving her health and the health of her unborn baby. These mechanisms include the range of services delivered during antenatal care for all pregnant women and women at high risk of preterm birth, services provided to manage preterm labour, and workplace, professional and other supportive policies that promote safe motherhood and universal access to care before, during and after pregnancy. The aim of this paper is to present the latest information about available interventions that can be delivered during pregnancy to reduce preterm birth rates and improve the health outcomes of the premature baby, and to identify data gaps. The paper also focuses on promising avenues of research on the pregnancy period that will contribute to a better understanding of the causes of preterm birth and ability to design interventions at the policy, health care system and community levels. At minimum, countries need to ensure equitable access to comprehensive antenatal care, quality childbirth services and emergency obstetric care. Antenatal care services should include screening for and management of women at high risk of preterm birth, screening for and treatment of infections, and nutritional support and counselling. Health workers need to be trained and equipped to provide effective and timely clinical management of women in preterm labour to improve the survival chances of the preterm baby. Implementation strategies must be developed to increase the uptake by providers of proven interventions such as antenatal corticosteroids and to reduce harmful practices such as non-medically indicated inductions of labour and caesarean births before 39 weeks of gestation. Behavioural and community-based interventions that can lead to reductions in smoking and violence against women need to be implemented in conjunction with antenatal care models that promote women's empowerment as a strategy for reducing preterm delivery. The global community needs to support more discovery research on normal and abnormal pregnancies to facilitate the development of preventive interventions for universal application. As new evidence is generated, resources need to be allocated to its translation into new and better screening and diagnostic tools, and other interventions aimed at saving maternal and newborn lives that can be brought to scale in all countries.

Objective: We sought to describe obstetric care capacity of nongovernment organization (NGO)-/faith-based organization (FBO)-run institutions compared to government-run institutions in 3 African countries using the World Health Organization Global Survey. We also compared delivery characteristics and outcomes., Study Design: This is a descriptive analysis of the 22 NGO-/FBO-run institutions in Uganda, Kenya and Democratic Republic of Congo delivering 11,594 women, compared to 20 government-run institutions delivering 25,825 women in the same countries and period., Results: Infrastructure, obstetric services, diagnostic facilities, and anesthesiology at NGO/FBO institutions were comparable to government institutions. Women delivering at NGO/FBO institutions had more antenatal care, antenatal complications, and cesarean delivery. NGO/FBO institutions had higher obstetrician attendance and lower rates of eclampsia, preterm birth, stillbirth, Apgar <7, and neonatal near miss., Conclusion: NGO/FBO institutions are comparable to government institutions in capacity to deliver obstetric care. NGO/FBOs have been found effective in providing delivery care in developing countries and should be appropriately recognized by stakeholders in their efforts to assist nations achieve international goals., (Copyright © 2012 Mosby, Inc. All rights reserved.)

The present paper provides an overview of the Safe Motherhood Initiative, Healthy Newborn Partnership, and Child Survival Partnership and their eventual merge into the Partnership for Maternal, Newborn and Child Health (PMNCH) in 2005. The promise and past successes of the PMNCH are highlighted, with a particular focus on the PMNCH's partner-centric approach showing the importance of collaboration for progress. The aims of the strategic framework for 2012-2015 are presented within the context of the Global Strategy for Women's and Children's Health, launched in 2010, and growing political momentum to achieve Millennium Development Goals 4 and 5 (reduce child mortality and improve maternal health, respectively). The next 4 years leading to 2015 are critical, and the global community must continue to work together to ensure all women and children are reached with key interventions proven to reduce mortality., (Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

The Special Programme of Research in Human Reproduction (HRP), co-sponsored by the UNDP, UNFPA, WHO, and the World Bank, is celebrating 40 years of activities with an expansion of its mandate and new co-sponsors. When it began, in 1972, the main focus was on evaluating the acceptability, effectiveness, and safety of existing fertility-regulating methods, as well as developing new, improved modalities for family planning. In 1994, HRP not only made major contributions to the Plan of Action of the International Conference on Population and Development (ICPD); it also broadened its scope of work to include other aspects of health dealing with sexuality and reproduction, adding a specific perspective on gender issues and human rights. In 2002, HRP's mandate was once again broadened to include sexually transmitted infections and HIV/AIDS and in 2003 it was further expanded to research activities on preventing violence against women and its many dire health consequences. Today, the work of the Programme includes research on: the sexual and reproductive health of adolescents, women, and men; maternal and perinatal health; reproductive tract and sexually transmitted infections (including HIV/AIDS); family planning; infertility; unsafe abortion; sexual health; screening for cancer of the cervix in developing countries, and gender and reproductive rights. Additional activities by the Programme have included: fostering international cooperation in the field of human reproduction; the elaboration of WHO's first Global Reproductive Health Strategy; work leading to the inclusion of ICPD's goal 'reproductive health for all by 2015' into the Millennium Development Goal framework; the promotion of critical interagency statements on the public health, legal, and human rights implications of female genital mutilation and gender-biased sex selection. Finally, HRP has been involved in the creation of guidelines and tools, such as the 'Medical eligibility criteria for contraceptive use', the 'Global handbook for family planning providers', the 'Definition of core competencies in primary health care', and designing tools for operationalizing a human rights approach to sexual and reproductive health programmes., (Copyright © 2012 S. Karger AG, Basel.)

Background: Most maternal deaths, intrapartum-related stillbirths, and newborn deaths in low income countries are preventable but simple, effective methods for improving safety in institutional births have not been devised. Checklist-based interventions aid management of complex or neglected tasks and have been shown to reduce harm in healthcare. We hypothesized that implementation of the WHO Safe Childbirth Checklist program, a novel childbirth safety program for institutional births incorporating a 29-item checklist, would increase delivery of essential childbirth practices linked with improved maternal and perinatal health outcomes., Methods and Findings: A pilot, pre-post-intervention study was conducted in a sub-district level birth center in Karnataka, India between July and December 2010. We prospectively observed health workers that attended to women and newborns during 499 consecutively enrolled birth events and compared these with observed practices during 795 consecutively enrolled birth events after the introduction of the WHO Safe Childbirth Checklist program. Twenty-nine essential practices that target the major causes of childbirth-related mortality, such as hand hygiene and uterotonic administration, were evaluated. The primary end point was the average rate of successful delivery of essential childbirth practices by health workers. Delivery of essential childbirth-related care practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p<0.001). There was significant improvement in the delivery of 28 out of 29 individual practices. No adverse outcomes relating to the intervention occurred. Study limitations are the pre-post design, potential Hawthorne effect, and focus on processes of care versus health outcomes., Conclusions: Introduction of the WHO Safe Childbirth Checklist program markedly improved delivery of essential safety practices by health workers. Future study will determine if this program can be implemented at scale and improve health outcomes.

Purpose of Review: This review discusses the unprecedented global commitment to improve maternal health and scientific advancements in the field achieved during the last year., Recent Findings: Achievements at political, scientific, and programmatic levels targeted at improving maternal health, especially in low-resource settings, are described. Remaining challenges are discussed and the most promising areas of research and practice aimed at addressing these challenges are identified., Summary: For the first time in decades, it is evident that progress in reducing mortality on a global scale is possible. Results showing increases in coverage of key maternal health interventions and the establishment of a system for promoting accountability are key determinants of that progress.

Background: Understanding spontaneous preterm birth ([PTB] < 37 weeks) is difficult due to heterogeneities associated with multitudes of risk factors and pathophysiological pathways. Several biomarkers are routinely used clinically for predicting preterm labor; however, these factors are either nonspecific or detected too late., Objective: Systematic review of literature on PTB biomarkers in the last 40 years to map out the existing knowledge and gaps in understanding PTB biomarkers., Search Strategies: Five electronic databases were searched for human studies on PTB biomarkers published in any language between 1965 and 2008., Selection Criteria: The phenotype of interest for final data extraction was exclusively spontaneous PTB with no rupture of membranes. Data extraction included (a) general characteristics of the study (clinical setting, period, and study design), (b) study/participant characteristics (inclusion and exclusion criteria, race/ethnicity, number of participants, gestational age at sampling, (c) characteristics of the biomarker (type, rationale for its selection, type of biological sample, and assay used, and (d) concentration of biomarkers in cases and controls., Data Collection and Analysis: The search yielded 7255 citations and data were extracted from 217 articles which met our inclusion and exclusion criteria., Main Results: A total of 116 different biomarkers were reported and these were assayed 578 times in the 217 included studies. Over two thirds of the 217 studies were performed on North American or European populations. No reliable biomarkers emerged as a risk predictor of PTB., Conclusions: Identifying similar studies on biomarkers for the prediction of PTB was a very challenging task due heterogeneities in study design, sampling issues (types, timing and processing), assay methods, and analyses. Major areas of concern identified in this review include poor phenotype definition, nonideal study designs and poor rationale for biomarker selection and assays and population stratification issues.

Background: Many women in Sub-Saharan African countries do not receive key recommended interventions during routine antenatal care (ANC) including information on pregnancy, related complications, and importance of skilled delivery attendance. We undertook a process evaluation of a successful cluster randomized trial testing the effectiveness of birth plans in increasing utilization of skilled delivery and postnatal care in Ngorongoro district, rural Tanzania, to document the time spent by health care providers on providing the recommended components of ANC., Methods: The study was conducted in 16 health units (eight units in each arm of the trial). We observed, timed, and audio-recorded ANC consultations to assess the total time providers spent with each woman and the time spent for the delivery of each component of care. T-test statistics were used to compare the total time and time spent for the various components of ANC in the two arms of the trial. We also identified the topics discussed during the counselling and health education sessions, and examined the quality of the provider-woman interaction., Results: The mean total duration for initial ANC consultations was 40.1 minutes (range 33-47) in the intervention arm versus 19.9 (range 12-32) in the control arm p < 0.0001. Except for drug administration, which was the same in both arms of the trial, the time spent on each component of care was also greater in the intervention health units. Similar trends were observed for subsequent ANC consultations. Birth plans were always discussed in the intervention health units. Counselling on HIV/AIDS was also prioritized, especially in the control health units. Most other recommended topics (e.g. danger signs during pregnancy) were rarely discussed., Conclusion: Although the implementation of birth plans in the intervention health units improved provider-women dialogue on skilled delivery attendance, most recommended topics critical to improving maternal and newborn survival were rarely covered.

Background: Global disparities in maternal and newborn health represent one of the starkest health inequities of our times. Faith-based organizations (FBOs) have historically played an important role in providing maternal/newborn health services in African countries. However, the contribution of FBOs in service delivery is insufficiently recognized and mapped., Objectives: A systematic review of the literature to assess available evidence on the role of FBOs in the area of maternal/newborn health care in Africa., Search Strategy: MEDLINE and EMBASE were searched for articles published between 1989 and 2009 on maternal/newborn health and FBOs in Africa., Results: Six articles met the criteria for inclusion. These articles provided information on 6 different African countries. Maternal/newborn health services provided by FBOs were similar to those offered by governments, but the quality of care received and the satisfaction were reported to be better., Conclusion: Efforts to document and analyze the contribution of FBOs in maternal/newborn health are necessary to increase the recognition of FBOs and to establish stronger partnerships with them in Africa as an untapped route to achieving Millennium Development Goals 4 and 5., (Copyright © 2011 World Health Organisation and Ireland Ltd. Published by Elsevier Ireland Ltd.. All rights reserved.)

Pre-eclampsia and eclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. The exact prevalence, however, is unknown. The majority of pre-eclampsia related deaths in LMIC occur in the community and therefore, interventions must be focused at this level. There are a number of unique challenges facing LMIC but the principles of care for women with pre-eclampsia remain the same as in well resourced settings. Three primary delays lead to an increased incidence of maternal mortality from pre-eclampsia- delays in triage, transport and treatment. There are a number of other challenges facing LMIC and the health care worker shortage is particularly significant. Task shifting is a potential strategy to address this challenge. Community health care workers, specifically lady health care workers, are an integral part of the health care force in many LMIC and can be employed to provide timely care to women with pre-eclampsia. Prevention strategies should be applied to every pregnant woman since we cannot predict who will develop pre-eclampsia given the limitation in resources. Aspirin and calcium are the only two recommended therapies at this time. Measuring blood pressure and proteinuria is challenging in LMIC due to financial cost and lack of training. A detection tool that is affordable and can be easily applied is needed. Magnesium sulfate is the drug of choice for the prevention and treatment of eclampsia but it is underutilized due to barriers on multiple levels., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To examine the ability of three different proteinuria assessment methods (urinary dipstick, spot urine protein:creatinine ratio [Pr/Cr], and 24-hour urine collection) to predict adverse pregnancy outcomes., Methods: We performed a prospective multicentre cohort study, PIERS (Preeclampsia Integrated Estimate of RiSk), in seven academic tertiary maternity centres practising expectant management of preeclampsia remote from term in Canada, New Zealand, and Australia. Eligible women were those admitted with preeclampsia who had at least one antenatal proteinuria assessment by urinary dipstick, spot urine Pr/Cr ratio, and/or 24-hour urine collection. Proteinuria assessment was done either visually at the bedside (by dipstick) or by hospital clinical laboratories for spot urine Pr/Cr and 24-hour urine collection. We calculated receiver operating characteristic area under the curve (95% CI) for each proteinuria method and each of the combined adverse maternal outcomes (within 48 hours) or adverse perinatal outcomes (at any time). Models with AUC ≥ 0.70 were considered of interest. Analyses were run for all women who had each type of proteinuria assessment and for a cohort of women ("ALL measures") who had all three proteinuria assessments., Results: More women were proteinuric by urinary dipstick (≥ 2+, 61.4%) than by spot urine Pr/Cr (≥ 30 g/mol, 50.4%) or 24-hour urine collection (≥ 0.3g/d, 34.7%). Each proteinuria measure evaluated had some discriminative power, and dipstick proteinuria (categorical) performed as well as other methods. No single method was predictive of adverse perinatal outcome., Conclusion: The measured amount of proteinuria should not be used in isolation for decision-making in women with preeclampsia. Dipstick proteinuria performs as well as other methods of assessing proteinuria for prediction of adverse events.

Background: Definition of small for gestational age in various populations worldwide remains a challenge. References based on birthweight are deficient for preterm births, those derived from ultrasound estimates might not be applicable to all populations, and the individualised reference can be too complex to use in developing countries. Our aim was to create a generic reference for fetal weight and birthweight that overcame these deficiencies and could be readily adapted to local populations., Methods: We used the fetal-weight reference developed by Hadlock and colleagues and the notion of proportionality proposed by Gardosi and colleagues and made the weight reference easily adjustable according to the mean birthweight at 40 weeks of gestation for any local population. For application and validation, we used data from 24 countries in Africa, Latin America, and Asia that participated in the 2004-08 WHO Global Survey on Maternal and Perinatal Health (237,025 births). We compared our reference with that of Hadlock and colleagues (non-customised) and with that of Gardosi and colleagues (individualised). For every reference, the odds ratio (OR) of adverse perinatal outcomes (stillbirths, neonatal deaths, referral to higher-level or special care unit, or Apgar score lower than 7 at 5 min) for infants who were small for gestational age versus those who were not was estimated with multilevel logistic regression., Findings: OR of adverse outcomes for infants small for gestational age versus those not small for gestational age was 1·59 (95% CI 1·53-1·66) for the non-customised fetal-weight reference compared with 2·87 (2·73-3·01) for our country-specific reference, and 2·84 (2·71-2·99) for the fully individualised reference., Interpretation: Our generic reference for fetal-weight and birthweight percentiles can be easily adapted to local populations. It has a better ability to predict adverse perinatal outcomes than has the non-customised fetal-weight reference, and is simpler to use than the individualised reference without loss of predictive ability., Funding: None., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Rising cesarean section (CS) rates are a major public health concern and cause worldwide debates. To propose and implement effective measures to reduce or increase CS rates where necessary requires an appropriate classification. Despite several existing CS classifications, there has not yet been a systematic review of these. This study aimed to 1) identify the main CS classifications used worldwide, 2) analyze advantages and deficiencies of each system., Methods and Findings: Three electronic databases were searched for classifications published 1968-2008. Two reviewers independently assessed classifications using a form created based on items rated as important by international experts. Seven domains (ease, clarity, mutually exclusive categories, totally inclusive classification, prospective identification of categories, reproducibility, implementability) were assessed and graded. Classifications were tested in 12 hypothetical clinical case-scenarios. From a total of 2948 citations, 60 were selected for full-text evaluation and 27 classifications identified. Indications classifications present important limitations and their overall score ranged from 2-9 (maximum grade =14). Degree of urgency classifications also had several drawbacks (overall scores 6-9). Woman-based classifications performed best (scores 5-14). Other types of classifications require data not routinely collected and may not be relevant in all settings (scores 3-8)., Conclusions: This review and critical appraisal of CS classifications is a methodologically sound contribution to establish the basis for the appropriate monitoring and rational use of CS. Results suggest that women-based classifications in general, and Robson's classification, in particular, would be in the best position to fulfill current international and local needs and that efforts to develop an internationally applicable CS classification would be most appropriately placed in building upon this classification. The use of a single CS classification will facilitate auditing, analyzing and comparing CS rates across different settings and help to create and implement effective strategies specifically targeted to optimize CS rates where necessary.

Background: Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder., Methods: We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting., Findings: 261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility., Interpretation: The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia., Funding: Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background and Aim: Preterm birth is the major cause of infant mortality and morbidity in both developed and developing countries. In Europe, the prevalence rate of premature birth ranges from 5.5 to 11.4% - an average of 7.1% of all live births. In this report, we aim to compare the current health and social policies, as well as practices in 13 EU member states., Materials and Methods: Using desk research, relevant information was gathered from each of the 13 European countries with regard to the prevalence of preterm birth, the cost of preterm birth to healthcare budgets, and the relevant policies, guidelines and practices in place at the national and, in some cases, regional level. The information comes from a range of sources, including government and parent association websites, published scientific literature and media reports., Results: Despite the growing prevalence and increasing costs, neonatal and preterm infant health rank low on the policy agendas of EU member states., Conclusion: Based on the findings, there are a number of recommendations that should be considered. The European Union should (i) recognize the growing challenge of prematurity in Europe and its significant impact on infant morbidity and mortality, (ii) improve neonatal health through the development and implementation of coordinated EU health and social policies, (iii) address the lack of comparable European data on prematurity, including prevalence, mortality, acute morbidity and long-term impairment, (iv) also increase the standard of neonatal care across Europe by supporting the development and implementation of European medical guidelines and quality standards, (v) support the development of European postgraduate training programmes in Peri- and Neonatology in order to increase the quality and availability of trained healthcare professionals., (© 2010 The Author(s)/Journal Compilation © 2010 Foundation Acta Paediatrica.)

This article reviews formal and informal mechanisms through which the World Health Organization (WHO) is promoting policies for the advancement of women's health. Specific attention is given to select examples of innovative strategies the WHO has adopted in recent years to increase political commitment to women's and children's health and influence the development of policies supportive of country efforts to achieve Millennium Development Goals 4 (MDG4) and MDG 5 (to reduce child mortality and improve maternal health, respectively).

We analyzed Brazil's efforts in reducing child mortality, improving maternal and child health, and reducing socioeconomic and regional inequalities from 1990 through 2007. We compiled and reanalyzed data from several sources, including vital statistics and population-based surveys. We also explored the roles of broad socioeconomic and demographic changes and the introduction of health sector and other reform measures in explaining the improvements observed. Our findings provide compelling evidence that proactive measures to reduce health disparities accompanied by socioeconomic progress can result in measurable improvements in the health of children and mothers in a relatively short interval. Our analysis of Brazil's successes and remaining challenges to reach and surpass Millennium Development Goals 4 and 5 can provide important lessons for other low- and middle-income countries.

Normal fetal growth is a critical component of a healthy pregnancy and influences the long-term health of the offspring. However, defining normal and abnormal fetal growth has been a long-standing challenge in clinical practice and research. We review various references and standards that are used widely to evaluate fetal growth and discuss common pitfalls of current definitions of abnormal fetal growth. Pros and cons of different approaches to customize fetal growth standards are described. We further discuss recent advances toward an integrated definition for fetal growth restriction. Such a definition may incorporate fetal size with the status of placental health that is measured by maternal and fetal Doppler velocimetry and biomarkers, biophysical findings, and genetics. Although the concept of an integrated definition appears promising, further development and testing are required. An improved definition of abnormal fetal growth should benefit both research and clinical practice., (Published by Mosby, Inc.)

Objective: To describe the declining trend in maternal mortality observed in Mongolia from 1992 to 2007 and its acceleration after 2001 following implementation of the Maternal Mortality Reduction Strategy by the Ministry of Health and other partners., Methods: We performed a descriptive analysis of maternal mortality data collected through Mongolia's vital registration system and provided by the Mongolian Ministry of Health. The observed declining mortality trend was analysed for statistical significance using simple linear regression. We present the maternal mortality ratios from 1992 to 2007 by year and review the basic components of Mongolia's Maternal Mortality Reduction Strategy for 2001-2004 and 2005-2010., Findings: Mongolia achieved a statistically significant annual decrease in its maternal mortality ratio of almost 10 deaths per 100 000 live births over the period 1992-2007. From 2001 to 2007, the maternal mortality ratio in Mongolia decreased approximately 47%, from 169 to 89.6 deaths per 100 000 live births., Conclusion: Disparities in maternal mortality represent one of the major persisting health inequities between low- and high-resource countries. Nonetheless, important reductions in low-resource settings are possible through collaborative strategies based on a horizontal approach and the coordinated involvement of key partners, including health ministries, national and international agencies and donors, health-care professionals, the media, nongovernmental organizations and the general public.

Background: Virtual worlds are rapidly becoming part of the educational technology landscape. Second Life (SL) is one of the best known of these environments. Although the potential of SL has been noted for health professions education, a search of the world's literature and of the World Wide Web revealed a limited number of formal applications of SL for this purpose and minimal evaluation of educational outcomes. Similarly, the use of virtual worlds for continuing health professional development appears to be largely unreported., Methods: We designed and delivered a pilot postgraduate medical education program in the virtual world, Second Life. Our objectives were to: (1) explore the potential of a virtual world for delivering continuing medical education (CME) designed for physicians; (2) determine possible instructional designs using SL for CME; (3) understand the limitations of SL for CME; (4) understand the barriers, solutions, and costs associated with using SL, including required training; and (5) measure participant learning outcomes and feedback. We trained and enrolled 14 primary care physicians in an hour-long, highly interactive event in SL on the topic of type 2 diabetes. Participants completed surveys to measure change in confidence and performance on test cases to assess learning. The post survey also assessed participants' attitudes toward the virtual learning environment., Results: Of the 14 participant physicians, 12 rated the course experience, 10 completed the pre and post confidence surveys, and 10 completed both the pre and post case studies. On a seven-point Likert scale (1, strongly disagree to 7, strongly agree), participants' mean reported confidence increased from pre to post SL event with respect to: selecting insulin for patients with type 2 diabetes (pre = 4.9 to post = 6.5, P= .002); initiating insulin (pre = 5.0 to post = 6.2, P= .02); and adjusting insulin dosing (pre = 5.2 to post = 6.2, P= .02). On test cases, the percent of participants providing a correct insulin initiation plan increased from 60% (6 of 10) pre to 90% (9 of 10) post (P= .2), and the percent of participants providing correct initiation of mealtime insulin increased from 40% (4 of 10) pre to 80% (8 of 10) post (P= .09). All participants (12 of 12) agreed that this experience in SL was an effective method of medical education, that the virtual world approach to CME was superior to other methods of online CME, that they would enroll in another such event in SL, and that they would recommend that their colleagues participate in an SL CME course. Only 17% (2 of 12) disagreed with the statement that this potential Second Life method of CME is superior to face-to-face CME., Conclusions: The results of this pilot suggest that virtual worlds offer the potential of a new medical education pedagogy to enhance learning outcomes beyond that provided by more traditional online or face-to-face postgraduate professional development activities. Obvious potential exists for application of these methods at the medical school and residency levels as well.

Calcium supplementation in mothers with low calcium intake has been of interest recently because of its association with optimal fetal growth and improved pre-eclampsia-related outcomes. While the effects of calcium supplementation have demonstrated benefits in prolonging gestation and subsequently improving birthweight, no specific studies have identified the longitudinal effects of supplementation on fetal growth in utero. Data were analysed in the context of the World Health Organization trial of calcium supplementation in calcium-deficient women. Five hundred and ten healthy, primiparous pregnant Argentinean women were randomised (at <20 weeks gestation) to either placebo (n = 230) or calcium supplements (1500 mg calcium/day in 3 divided doses; n = 231). Growth parameters in utero were assessed with serial ultrasound scans. Birthweight, length, head, abdominal and thigh circumferences were recorded at delivery. No differences were found in fetal biometric measurements recorded at 20, 24, 28, 32 and 36 weeks gestation between fetuses of women who were supplemented with calcium and those who were not. Similarly, neonatal characteristics and anthropometric measurements recorded at delivery were comparable in both groups. We conclude that calcium supplementation of 1500 mg calcium/day in pregnant women with low calcium intake does not appear to impact on fetal somatic or skeletal growth.

Objective: To analyse preterm birth rates worldwide to assess the incidence of this public health problem, map the regional distribution of preterm births and gain insight into existing assessment strategies., Methods: Data on preterm birth rates worldwide were extracted during a previous systematic review of published and unpublished data on maternal mortality and morbidity reported between 1997 and 2002. Those data were supplemented through a complementary search covering the period 2003-2007. Region-specific multiple regression models were used to estimate the preterm birth rates for countries with no data., Findings: We estimated that in 2005, 12.9 million births, or 9.6% of all births worldwide, were preterm. Approximately 11 million (85%) of these preterm births were concentrated in Africa and Asia, while about 0.5 million occurred in each of Europe and North America (excluding Mexico) and 0.9 million in Latin America and the Caribbean. The highest rates of preterm birth were in Africa and North America (11.9% and 10.6% of all births, respectively), and the lowest were in Europe (6.2%)., Conclusion: Preterm birth is an important perinatal health problem across the globe. Developing countries, especially those in Africa and southern Asia, incur the highest burden in terms of absolute numbers, although a high rate is also observed in North America. A better understanding of the causes of preterm birth and improved estimates of the incidence of preterm birth at the country level are needed to improve access to effective obstetric and neonatal care.

Objective: We postulated that calcium supplementation of calcium-deficient pregnant women would lower vascular resistance in uteroplacental and fetoplacental circulations., Study Design: Pulsatility index (PI) and resistance index (RI) (uterine and umbilical arteries) and presence of bilateral uterine artery diastolic notching were assessed by Doppler ultrasound between 20-36 weeks' gestation in 510 healthy, nulliparous Argentinean women with deficient calcium intake in a randomized, placebo-controlled, double-blinded trial., Results: Average umbilical and uterine artery RI and PI tended to be lower in the supplemented group at each study week. Differences became statistically significant for umbilical artery RI and PI from 32 and 36 weeks, respectively. Estimated probabilities of bilateral uterine artery diastolic notching trended toward lower values in calcium-supplemented women., Conclusion: Calcium supplementation of pregnant women with deficient calcium intake may affect uteroplacental and fetoplacental blood flow by preserving the vasodilation of normal gestation., (2010 Mosby, Inc.)

Background: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care., Discussion: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings., Summary: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.

Objectives: To examine the association between high prepregnancy maternal body mass index (BMI) and the risk of preterm birth (PTB)., Methods: A systematic review of the literature. We included cohorts and case-control studies published since 1968 that examined the association between BMI and PTB of all types, spontaneous (s), elective and with ruptured membranes (PPROM) in three gestational age categories: general (<37 weeks), moderate (32-36 weeks) and very (<32 weeks) PTB., Results: 20,401 citations were screened and 39 studies (1,788,633 women) were included. Preobese (BMI, 25-29.9) and obese I (BMI, 30-34.9) women have a reduced risk for sPTB: AOR = 0.85 (95% CI: 0.80-0.92) and 0.83 (95% CI: 0.75-0.92), respectively. Their risk for moderate PTB was 1.20 (95% CI: 1.04-1.38) and 1.60 (95% CI: 1.32-1.94), respectively. Obese II women (BMI, 35-40) have an increased risk for PTB in general (AOR = 1.33, 95% CI: 1.12-1.57) moderate (AOR = 2.43, 95% CI: 1.46-4.05) and very PTB (AOR = 1.96, 95% CI: 1.66-2.31). Obese III women (BMI > 40) have an even higher risk for very PTB (AOR = 2.27, 95%CI: 1.76-2.94). High BMI does not modify the risk for PPROM and increases the risk for elective PTB., Conclusions: High maternal BMI may have different effects on different types of PTB.

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.

Objectives: We analyzed trends in maternal, newborn, and child mortality in Chile between 1990 and 2004, after the introduction of national interventions and reforms, and examined associations between trends and interventions., Methods: Data were provided by the Chilean Ministry of Health on all pregnancies between 1990 and 2004 (approximately 4,000,000). We calculated yearly maternal mortality ratios, stillbirth rates, and mortality rates for neonates, infants (aged > 28 days and < 1 year), and children aged 1 to 4 years. We also calculated these statistics by 5-year intervals for Chile's poorest to richest district quintiles., Results: During the study period, the maternal mortality ratio decreased from 42.1 to 18.5 per 100,000 live births. The mortality rate for neonates decreased from 9.0 to 5.7 per 1000 births, for infants from 7.8 to 3.1 per 1000 births, and for young children from 3.1 to 1.7 per 1000 live births. The stillbirth rate declined from 6.0 to 5.0 per 1000 births. Disparities in these mortality statistics between the poorest and richest district quintiles also decreased, with the largest mortality reductions in the poorest quintile., Conclusions: During a period of socioeconomic development and health sector reforms, Chile experienced significant mortality and inequity reductions.

Objective: To study pathophysiologic pathways in spontaneous preterm birth and possibly the racial disparity associating with maternal and fetal genetic variations, using bioinformatics tools., Methods: A large scale candidate gene association study was performed on 1442 SNPs in 130 genes in a case (preterm birth < 36 weeks) control study (term birth > 37 weeks). Both maternal and fetal DNA from Caucasians (172 cases and 198 controls) and 279 African-Americans (82 cases and 197 controls) were used. A single locus association (genotypic) analysis followed by hierarchical clustering was performed, where clustering was based on p values for significant associations within each race. Using Ingenuity Pathway Analysis (IPA) software, known pathophysiologic pathways in both races were determined., Results: From all SNPs entered into the analysis, the IPA mapped genes to specific disease functions. Gene variants in Caucasians were implicated in disease functions shared with other known disorders; specifically, dermatopathy, inflammation, and hematological disorders. This may reflect abnormal cervical ripening and decidual hemorrhage. In African-Americans inflammatory pathways were the most prevalent. In Caucasians, maternal gene variants showed the most prominent role in disease functions, whereas in African Americans it was fetal variants. The IPA software was used to generate molecular interaction maps that differed between races and also between maternal and fetal genetic variants., Conclusion: Differences at the genetic level revealed distinct disease functions and operational pathways in African Americans and Caucasians in spontaneous preterm birth. Differences in maternal and fetal contributions in pregnancy outcome are also different between African Americans and Caucasians. These results present a set of explicit testable hypotheses regarding genetic associations with preterm birth in African Americans and Caucasians.

Objective: In the context of the planned International Society of Ultrasound in Obstetrics and Gynecology-World Health Organization multicenter study for the development of fetal growth standards for international application, we conducted a systematic review and meta-analysis to evaluate the safety of human exposure to ultrasonography in pregnancy., Methods: A systematic search of electronic databases, reference lists and unpublished literature was conducted for trials and observational studies that assessed short- and long-term effects of exposure to ultrasonography, involving women and their fetuses exposed to ultrasonography, using B-mode or Doppler sonography during any period of pregnancy, for any number of times. The outcome measures were: (1) adverse maternal outcome; (2) adverse perinatal outcome; (3) abnormal childhood growth and neurological development; (4) non-right handedness; (5) childhood malignancy; and (6) intellectual performance and mental disease., Results: The electronic search identified 6716 citations, and 19 were identified from secondary sources. A total of 61 publications reporting data from 41 different studies were included: 16 controlled trials, 13 cohort and 12 case-control studies. Ultrasonography in pregnancy was not associated with adverse maternal or perinatal outcome, impaired physical or neurological development, increased risk for malignancy in childhood, subnormal intellectual performance or mental diseases. According to the available clinical trials, there was a weak association between exposure to ultrasonography and non-right handedness in boys (odds ratio 1.26; 95% CI, 1.03-1.54)., Conclusion: According to the available evidence, exposure to diagnostic ultrasonography during pregnancy appears to be safe.

Objective: To determine if vitamin C and E supplementation in high-risk pregnant women with low nutritional status reduces pre-eclampsia., Design: Multicentred, randomised, controlled, double-blinded trial., Setting: Antenatal care clinics and Hospitals in four countries., Population: Pregnant women between 14 and 22 weeks' gestation., Method: Randomised women received 1000 mg vitamin C and 400 iu of vitamin E or placebo daily until delivery., Main Outcome Measures: Pre-eclampsia, low birthweight, small for gestational age and perinatal death., Results: Six hundred and eighty-seven women were randomised to the vitamin group and 678 to the placebo group. Groups had similar gestational ages (18.1; SD 2.4 weeks), socio-economic, clinical and demographical characteristics and blood pressure at trial entry. Risk factors for eligibility were similar, except for multiple pregnancies: placebo group (14.7%), vitamins group (11.8%). Previous pre-eclampsia, or its complications, was the most common risk factor at entry (vitamins 41.6%, placebo 41.3%). Treatment compliance was 87% in the two groups and loss to follow-up was low (vitamins 2.0%, placebo 1.3%). Supplementation was not associated with a reduction of pre-eclampsia (RR: 1.0; 95% CI: 0.9-1.3), eclampsia (RR: 1.5; 95% CI: 0.3-8.9), gestational hypertension (RR: 1.2; 95% CI: 0.9-1.7), nor any other maternal outcome. Low birthweight (RR: 0.9; 95% CI: 0.8-1.1), small for gestational age (RR: 0.9; 95% CI: 0.8-1.1) and perinatal deaths (RR: 0.8; 95% CI: 0.6-1.2) were also unaffected., Conclusion: Vitamins C and E at the doses used did not prevent pre-eclampsia in these high-risk women.

Objective: Afghanistan is one of the countries with highest maternal and perinatal mortality in the world. Lack of reliable data, however, makes it difficult to select and prioritise the interventions that would be most cost effective. To gain some evidence, we review and analyse perinatal outcomes in facilities in Kabul and examine the role of patient risk and clinical practice factors., Methods: We used data for 2006 from a facility-based maternal and newborn surveillance system based on labour and delivery logbooks in the four government hospitals with maternity services in Kabul to analyse perinatal mortality and understanding potentially modifiable factors., Results: Data was collected for 53,524 births during 2006. Perinatal mortality was 43.5 per 1000 total births and the stillbirth rate was 38. For babies with a birthweight of > or =2500 g, the risk of perinatal death if delivered by cesarean section was 3.57 (CI = 3.08-4.13) times the risk of those delivered vaginally. Babies born of mothers with risk factors were 6.49 (CI = 5.64-7.48) times more likely to die. The perinatal mortality rate in babies of women with risk factors undergoing cesarean section was 220.5 per 1000 total births., Conclusions: Facility-based monitoring of perinatal health is possible in resource-limited settings. The situation in hospitals in Kabul is precarious with high levels of perinatal mortality. Improved intrapartum care, especially for women with risk factors, is needed to positively impact perinatal health.

The objective of this study was to identify influences on longitudinal changes in autonomic function during pregnancy. We studied 195 low-income Peruvian women who were subjects in a randomized controlled trial of zinc supplementation and fetal neurobehavioral development. Maternal cardiorespiratory status and electrodermal activity were assessed at 20, 24, 28, 32, 36, and 38 weeks' gestation over a 50-min session. At baseline (10-16 weeks), and at 28 and 36 weeks' gestation, mass and height, arm and calf circumferences, and skinfold thicknesses were assessed, and blood was taken to measure hemoglobin, hematocrit, and plasma zinc concentration. Measures of heart period (HP), respiratory period (RP), respiratory sinus arrhythmia (RSA), skin conductance level (SCL), and mean arterial pressure (MAP) were analyzed using longitudinal models. Having a hemoglobin concentration <10.5 g.dL-1 at 28 weeks was associated with shorter HP and RP and lower RSA, and change in hemoglobin from baseline to 36 weeks was associated with decreased SCL. Further, 3 measures were associated with variation in fat or fat-free mass in the calf; RSA was negatively associated with changes in calf muscle area over pregnancy, while changes in calf fat area were positively associated with MAP and SCL. Variability in autonomic function during the second half of pregnancy is associated with hematologic status and changes in lower limb body composition across pregnancy.

Objective: To evaluate whether prenatal calcium supplementation affects fetal and infant growth during the first year of life., Methods: Ninety-one pregnant women and 159 mothers and their infants enrolled beginning before 20 weeks gestation, and women received daily supplements containing either 1.5 g calcium or placebo. Women were examined by ultrasound at 20, 24, 28, 32 and 36 weeks to evaluate fetal biometry. During the first year after delivery, sub-groups of infants born from mothers participating in the trial were examined to assess infant growth. Anthropometric measurements of the infants were assessed. Mothers were inquired about lactation patterns, morbidities of the infants, separation from the mother, and admission to hospital., Results: Ultrasound measurements of fetal biometry did not show any differences between fetuses whose mothers received calcium supplementation during pregnancy and those who received placebo. Concerning infant growth, the mean weight and head circumference of infants born to calcium-supplemented mothers were similar to those born to placebo-supplemented mothers during the first year of life. The mean mid-arm circumference and mean length were significantly higher in the infants of the calcium group at sixth and ninth month, respectively. But, at 12 months, there were no significant differences in any of the anthropometric measurements., Conclusion: Calcium supplementation during pregnancy of women with low calcium intake does not have a noticeable impact on fetal and infant growth during the first year of life.

Objective: A dipslide is a plastic paddle coated with agar that is attached to a plastic cap that screws onto a sterile plastic vial. Our objective was to estimate the diagnostic accuracy of the dipslide culture technique to detect asymptomatic bacteriuria during pregnancy and to evaluate the accuracy of nitrate and leucocyte esterase dipslides for screening., Methods: This was an ancillary study within a trial comparing single-day with 7-day therapy in treating asymptomatic bacteriuria. Clean-catch midstream samples were collected from pregnant women seeking routine care. Positive and negative likelihood ratios and sensitivity and specificity for the culture-based dipslide to detect and chemical dipsticks (nitrites, leukocyte esterase, or both) to screen were estimated using traditional urine culture as the "gold standard.", Results: : A total of 3,048 eligible pregnant women were screened. The prevalence of asymptomatic bacteriuria was 15%, with Escherichia coli the most prevalent organism. The likelihood ratio for detecting asymptomatic bacteriuria with a positive dipslide test was 225 (95% confidence interval [CI] 113-449), increasing the probability of asymptomatic bacteriuria to 98%; the likelihood ratio for a negative dipslide test was 0.02 (95% CI 0.01-0.05), reducing the probability of bacteriuria to less than 1%. The positive likelihood ratio of leukocyte esterase and nitrite dipsticks (when both or either one was positive) was 6.95 (95% CI 5.80-8.33), increasing the probability of bacteriuria to only 54%; the negative likelihood ratio was 0.50 (95% CI 0.45-0.57), reducing the probability to 8%., Conclusion: A pregnant woman with a positive dipslide test is very likely to have a definitive diagnosis of asymptomatic bacteriuria, whereas a negative result effectively rules out the presence of bacteriuria. Dipsticks that measure nitrites and leukocyte esterase have low sensitivity for use in screening for asymptomatic bacteriuria during gestation., Clinical Trial Registration: ISRCTN, isrctn.org, 1196608, Level of Evidence: II.

Background: The third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60-70%. Active management consists of several interventions packaged together and the relative contribution of each of the components is unknown. Controlled cord traction is one of those components that require training in manual skill for it to be performed appropriately. If it is possible to dispense with controlled cord traction without losing efficacy it would have major implications for effective management of the third stage of labour at peripheral levels of health care., Objective: The primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV is not less effective than the full AMTSL package., Methods: A hospital-based, multicentre, individually randomized controlled trial is proposed. The hypothesis tested will be a non-inferiority hypothesis. The aim will be to determine whether the simplified package without CCT, with the advantage of not requiring training to acquire the manual skill to perform this task, is not less effective than the full AMTSL package with regard to reducing blood loss in the third stage of labour.The simplified package will include uterotonic (oxytocin 10 IU IM) injection after delivery of the baby and cord clamping and cutting at approximately 3 minutes after birth. The full package will include the uterotonic injection (oxytocin 10 IU IM), controlled cord traction following observation of uterine contraction and cord clamping and cutting at approximately 3 minutes after birth. The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. The secondary outcomes are blood transfusion, the use of additional uterotonics and measure of severe morbidity and maternal death.We aim to recruit 25,000 women delivering vaginally in health facilities in eight countries within a 12 month recruitment period., Management: Overall trial management will be from HRP/RHR in Geneva. There will be eight centres located in Argentina, Egypt, India, Kenya, Philippines, South Africa, Thailand and Uganda. There will be an online data entry system managed from HRP/RHR. The trial protocol was developed following a technical consultation with international organizations and leading researchers in the field., Expected Outcomes: The main objective of this trial is to investigate whether a simplified package of third stage management can be recommended without increasing the risk of PPH. By avoiding the need for a manual procedure that requires training, the third stage management can be implemented in a more widespread and cost-effective way around the world even at the most peripheral levels of the health care system. This trial forms part of the programme of work to reduce maternal deaths due to postpartum haemorrhage within the RHR department in collaboration with other research groups and organizations active in the field., Trial Registration: ACTRN12608000434392.

Objective: To use an active facility-based maternal and newborn surveillance system to describe cesarean delivery practices and outcomes in a resource-poor setting., Methods: Using data from operating room logbooks, 392 cesarean deliveries were evaluated between April 1 and June 30 2006 at a large public maternity hospital in Kabul, Afghanistan., Results: The perinatal mortality rate was 89 per 1000 births: 57% antepartum and 37% intrapartum stillbirths. Fetuses with normal birth weight comprised 85% of intrapartum stillbirths. Obstructed labor, uterine rupture, and malpresentation accounted for more than 50% of perinatal deaths. The cesarean delivery rate was 10.2% and there were 2 maternal deaths., Conclusion: The high percentage of intrapartum stillbirths among normal birth weight fetuses suggests a need for improved labor monitoring and surgical obstetric practices. The use of a facility-based perinatal surveillance system is critical in guiding such quality assurance initiatives.

Objective: We describe the levels and patterns of change in red blood cell (RBC) metallothionein (MT) during pregnancy and the neonate and relate RBCMT to other indicators of zinc and iron status., Methods: As part of a double-masked controlled trial of prenatal zinc supplementation among 242 Peruvian pregnant women, we determined RBCMT at enrollment (10-16 wk), at 28 and 36 wk of gestation, and in the cord blood at delivery in 158 women (86 who received daily supplements containing 60 mg of iron and 250 microg of folic acid and 72 whose supplements also contained 25 mg of zinc). In addition, we measured plasma and urinary zinc concentrations, hemoglobin and serum ferritin, and, on a limited sample, RBC zinc and placental MT., Results: RBCMT increased during pregnancy, and levels in the cord blood approximated maternal values at 36 wk. Only RBC zinc at 36 wk differed by supplement type (P < 0.05). Increases in RBCMT over pregnancy were, however, related to early pregnancy RBC zinc and inversely with the decline in plasma zinc from baseline to 36 wk of gestation., Conclusion: Changes in RBCMT throughout pregnancy were consistent with the hypothesized role of MT in regulating zinc homeostasis. RBCMT appears to not be responsive during pregnancy to changes in zinc status achieved with supplements.

Good public-health decisionmaking is dependent on reliable and timely statistics on births and deaths (including the medical causes of death). All high-income countries, without exception, have national civil registration systems that record these events and generate regular, frequent, and timely vital statistics. By contrast, these statistics are not available in many low-income and lower-middle-income countries, even though it is in such settings that premature mortality is most severe and the need for robust evidence to back decisionmaking most critical. Civil registration also has a range of benefits for individuals in terms of legal status, and the protection of economic, social, and human rights. However, over the past 30 years, the global health and development community has failed to provide the needed technical and financial support to countries to develop civil registration systems. There is no single blueprint for establishing and maintaining such systems and ensuring the availability of sound vital statistics. Each country faces a different set of challenges, and strategies must be tailored accordingly. There are steps that can be taken, however, and we propose an approach that couples the application of methods to generate better vital statistics in the short term with capacity-building for comprehensive civil registration systems in the long run.

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.