Uneven progress in maternal health worldwide but some countries setting good example

Uneven progress in maternal health worldwide but some countries setting good example: "The authors say: The continued scarcity of progress in maternal health over the past two decades in several parts of the world is disturbing, The little progress is especially of concern for south Asia and sub-Saharan Africa, which have consistently presented the worst maternal health in the world. They add that the connection between maternal mortality, poverty, and status of women is no coincidence, and as such countries which have improved their investment in education and employment for women have also improved their investment in maternal care. They say: Thus, the examples of countries like Thailand and Malaysia suggest that MDG5 is achievable with appropriate financial and political commitment."

Event

I thought the class may find this interesting.....

The Heilbrunn Department of Population and Family Health Fall 2007
Seminar Series

Presents:

Nassim Assefi, MD
Physician and Author

Discussing:

"Maternal Mortality in Afghanistan"


Description:

Afghanistan has one of the highest rates of maternal mortality ever
measured: on average one in six-to-nine women die of pregnancy
related causes. This talk will focus on:

- How we measure mortality in a country with no vital statistics,
insecurity, and destroyed infrastructure;

- The causes of maternal mortality in Afghanistan;

- Associated socioeconomic risks; and

- Solutions.

The speaker is a women's health specialist who spent 2004 and 2005
in Afghanistan constructing programs to decrease maternal and child
mortality.


October 15, 2007

12:30 PM - 1:45 PM

60 Haven Avenue, B2 Conference Room


Drinks will be provided. Please bring your own lunch.

Action needed on maternal deathsAction needed on maternal deaths

Experts have condemned the "appalling" lack of progress made in reducing the number of women worldwide dying during pregnancy and childbirth.

Analysis in The Lancet medical journal shows half a million women die every year - little change from 20 years ago.

And 20 million unsafe abortions - a major factor in maternal deaths and illness - are done annually.

Read the article here: http://news.bbc.co.uk/2/hi/health/7039647.stm

Vaccine-linked polio hits Nigeria

Nigeria is fighting a rare outbreak of a vaccine-derived form of polio, says the UN's World Health Organization.

It says 69 children in the north have caught the paralysing disease from others who had already been immunised.

The WHO says such rare outbreaks have occurred where immunisation campaigns did not reach enough of the population.

In 2003 Islamic leaders brought a temporary halt to the vaccine campaign in the north saying it was a Western conspiracy to sterilise Muslim women.

The WHO says this rare outbreak of vaccine-derived polio demonstrates the need for more vaccination, not less.

But the concern is that the cause of the outbreak could be misinterpreted by people here and reinforce their scepticism of the whole vaccine campaign.

Scare stories

The WHO says the outbreak occurred when some of those who had received the oral polio vaccine excreted a mutated form of the virus which infected those who were not immunised who had not completed the vaccination programme.

It says the outbreak is ongoing but slowing because of the continuing vaccination campaign, and the last reported case was in August.

The WHO says the outbreak occurred because not enough people were receiving the polio vaccine in the first place.

Northern Nigeria still has a low coverage rate for the vaccination campaign, a legacy of a temporary halt to the programme in 2003.

Those scare stories built on existing traditional scepticism of Western medicine.

But more recently the vaccination programme has made some progress.

Polio cases as a whole are down on last year, in part because of a new programme of polio victims accompanying immunisation teams to demonstrate to parents the risks of not having their children vaccinated.

http://news.bbc.co.uk/2/hi/africa/7037462.stm

Can We Acheive Millenium Development Goal 4?

A very interesting, but controversial article.

http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673607614780.pdf

Who's Making Money From Microcredit? . NOW | PBS

Dr. Brown asked me to post this episode of NOW. If you go to this page you can either listen to or watch the full story:

Who's Making Money From Microcredit? . NOW | PBS: "Microcredit has been hailed as a breakthrough in combating global poverty by giving small loans to impoverished people in the hopes of transforming their lives. But one very profitable Mexican lending program is now under intense scrutiny. NOW takes a close look at Compartamos bank, which started as a nonprofit organization lending small sums of money to poor indigenous Mexican women to help them start their own businesses. Today, it's a for-profit bank with more than 600,000 Mexican clients, often paying very high interest rates. Interviewing both grateful loan recipients and vocal critics-like Nobel prize-winning microcredit pioneer Muhammad Yunus-NOW investigates if Compartamos is truly serving the poor, or exploiting them."

Feedback for Maternal Health, Family Planning, and Safe Birth

• Excellent presentation covering a very broad set of issues. Over dependency on PowerPoint at times. Good class discussion with issues and questions, well handled. Jeopardy game was great fun!
• We did great – What else am I supposed to say?
• Good balance of student participation, professor commentary and presenter facilitation.
• Very well planned and thought-out. Good responses with own knowledge to questions and inquiries.
• Awesome presentation!
• Well thought out and presented. C-section discussion strayed towards domestic (developed countries concerns) but overall excellent. Game was fund and involved the class.
• Great presentation.
• Presenter #1: Excellent delivery – defined key concepts, engaged class and I think did a great job of connecting comments made to her slides (throughout). A bit graph heavy, but that said appropriately picked graphs.
• Presenter #2: Good delivery – very us focused when discussing requirements for clinical workers – would have been good to see comparison. Would have liked to hear a bit about the men’s role in family planning. Would have liked to also learn more about ways to incorporate post-natal and pre-natal care options (clinical & not).
• Presenter #1: Excellent overall delivery.
• Presenter #2: Great presentation, excellent delivery; however, too much medical info.
• Great speakers! Funny game too.

Make Every Mother and Child Count

The full WHO report is full of useful background info and stats on maternal and child health. It's a free download here:

WHO | The World Health Report 2005 - Make Every Mother and Child Count

One useful grouping of stats to keep in mind for tomorrow's class is the top leading causes globally of maternal mortality: "severe bleeding/hemorrhage (25%), infections (13%), eclampsia (12%), obstructed labour (8%), complications of abortion (13%), other direct causes (8%), and indirect causes (20%). Indirect causes such as malaria, anaemia, HIV/AIDS and cardiovascular disease, complicate pregnancy or are aggravated by it."

Distribution of Nets Splits Malaria Fighters

MAENDELEO, Kenya — Veronica Njeri, 45, says she has “never healed” since losing two of her six children to malaria 20 years ago, and she still feels vulnerable. While her oldest are adults or teenagers, and have presumably built up immunity to the disease, she worries about her youngest, Anthony, who is 4.

Would be interested to know what folks thought of social marketing vs. free nets...

The Quiet Scandal of 10 Million Deaths

HEALTH: The Quiet Scandal of 10 Million Deaths : "...95 percent of all maternal and newborn deaths worldwide occur in 75 countries in Africa, Asia and Latin America [...]"

Home Births vs. Hospital Births

Here is some data for home births versus hospital births in the US and Australia - the data cover the entire country. The article is complaining about the lack of such data for Britain...

BMJ 1999;319:1008 ( 9 October )

Letters

Data on babies' safety during hospital births are being ignored

EDITORZander and Chamberlain state that "no evidence exists to support the claim that a hospital is the safest place for women to have normal births."¹ They cite the report Where to be Born, published in 1994 by the National Epidemiology Unit.

In 1997 the Confidential Enquiry into Stillbirths and Deaths in Infancy published a survey of 19 348 deaths in Britain occurring during 1994 and 1995, including 873 deaths due to intrapartum events.² At that time 98.16% of all deliveries occurred in hospital. The chance of a normal baby dying during labour at term was 1 in 1561. The Royal Colleges of Obstetricians and Gynaecologists and of Midwives regard this risk as unacceptably high and are working to reduce it still further.

Data on home deliveries in the United States were published in 1995,³ and data for home deliveries in Australia were published in 1998.⁴ In the American study (a retrospective review of 11 788 planned home births) the intrapartum and neonatal mortality among women intending to have a home birth at the onset of labour was 1 in 500. In a prospective American study of 1404 home births in 1994-5 the figure was 1 in 400, and the authors regarded this outcome as good.⁵ In the Australian study, which included 7002 planned home births during 1985-90, the risk of intrapartum fetal death was 1 in 371.

It is disappointing that no similar recent audit of the safety of home delivery in Britain is available. The figures from the United States and Australia are, however, strikingly similar; in the absence of current data from the United Kingdom they indicate that, for a normal birth, hospital delivery is now three to four times safer than home delivery for the baby.

Women should be able to choose between home and hospital delivery. They also have a right to accurate and up to date information.

James Drife, professor of obstetrics and gynaecology.
University of Leeds, Leeds LS2 9NS j.o.drife@leeds.ac.uk

---

1.	Zander L, Chamberlain G. ABC of labour care: Place of birth. BMJ 1999; 318: 721-723[Free Full Text]. (13 March.)
2.	Confidential Enquiry into Stillbirths and Deaths in Infancy. Fourth annual report: concentrating on intrapartum deaths 1994-95. London: Maternal and Child Health Research Consortium, 1997.
3.	Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study. J Nurse Midwifery 1995; 40: 483-492[Medline].
4.	Bastian H, Keirse MJNC, Lancaster PL. Perinatal deaths associated with planned home births in Australia: population based study. BMJ 1998; 317: 384-388[Abstract/Free Full Text].
5.	Murphy PA, Fullerton J. Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol 1998; 92: 461-470[Abstract].

World Leaders Address Lagging Maternal and Child Health Goals

I assumed this was on everyone's radar since CGI was here in NY, but I found a few of you that hadn't heard! Funding is one of this field's biggest problems, so last weeks' events are very big news:

World Leaders Address Lagging Maternal and Child Health Goals - Feminist Wire Daily Newsbriefs: U.S. and Global News Coverage: "Norwegian Prime Minister Jens Stoltenberg recently unveiled a new World Health Organization (WHO)-led collaboration of governments and organizations designed to improve maternal and child health worldwide. Deliver Now for Women Children aims to spur progress on UN%u2019s Millennium Development Goals 4 and 5, which call for a two-thirds reduction in child deaths and a three-quarters reduction in maternal mortality by 2015. Deliver Now was founded in reaction to slow progress on these goals, as well as those of the World Bank's Safe Motherhood Initiative of 1987. More than ten million women and children still die each year due to preventable causes%u2014more than the resulting deaths of AIDS and TB combined, according to the WHO."

Kano Records Low Maternal Mortality Rate in Two Years (Page 1 of 1)

great case study of successful program:

allAfrica.com: Nigeria: Kano Records Low Maternal Mortality Rate in Two Years (Page 1 of 1): "...Dr Sani Jibrin also said within the communities in the state Emergency Loan Funds Scheme had been introduced to assist pregnant women while taken to hospital for delivery of other pregnancy related problems. He said under the programme the communities are motivated to deposit funds so that when ever there is case of pregnant woman needing money for emergency treatment such funds would be used for the purpose [...]"

Home Births in the US

There are many studies looking at the results of home birth versus hospital delivery. When using an intent to treat analysis (as a good study should - if the home baby dies when it gets to the hospital - it should not be placed in the 'hospital delivery' group) the home group always has higher mortality - presumably in the delay of getting care to critically ill mothers and infants.

Below are abstracts from 2 articles from a respected journal - looking at large numbers of patients. As seen below there are a high number of women that are transferred to the hospital - before, during, or after birth. It is also important to note that the 'hospital' group includes all the women with high risk pregnancies, that are known to have worse outcomes (pre-ecalmpsia, women with large babies, preterm labor, breech, Vaginal Birth After Cesarean, etc.).

Outcomes of Planned Home Births in Washington State: 1989–1996

Jenny W. Y. Pang, MD, MPH, James D. Heffelfinger, MD, MPH, Greg J. Huang, DMD, MPH, Thomas J. Benedetti, MD, MHA and Noel S. Weiss, MD, DrPH

From the Department of Epidemiology, University of Washington School of Public Health and Community Medicine; Department of Obstetrics and Gynecology, University of Washington School of Medicine; Department of Pediatrics, Children’s Hospital and Regional Medical Center, Seattle, Washington; and Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia.

Address reprint requests to: Jenny Pang, MD, MPH, University of Washington School of Public Health, Department of Epidemiology, Box 357236, Seattle, Washington 98195; E-mail: jwpang@u.washington.edu.

OBJECTIVE: To determine whether there was a difference between planned home births and planned hospital births in Washington State with regard to certain adverse infant outcomes (neonatal death, low Apgar score, need for ventilator support) and maternal outcomes (prolonged labor, postpartum bleeding).

METHODS: We examined birth registry information from Washington State during 1989–1996 on uncomplicated singleton pregnancies of at least 34 weeks’ gestation that either were delivered at home by a health professional (N = 5854) or were transferred to medical facilities after attempted delivery at home (N = 279). These intended home births were compared with births of singletons planned to be born in hospitals (N = 10,593) during the same years.

RESULTS: Infants of planned home deliveries were at increased risk of neonatal death (adjusted relative risk [RR] 1.99, 95% confidence interval [CI] 1.06, 3.73), and Apgar score no higher than 3 at 5 minutes (RR 2.31, 95% CI 1.29, 4.16). These same relationships remained when the analysis was restricted to pregnancies of at least 37 weeks’ gestation. Among nulliparous women only, these deliveries also were associated with an increased risk of prolonged labor (RR 1.73, 95% CI 1.28, 2.34) and postpartum bleeding (RR 2.76, 95% CI 1.74, 4.36).

CONCLUSION: This study suggests that planned home births in Washington State during 1989–1996 had greater infant and maternal risks than did hospital births.

Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study

PA Murphy and J Fullerton

OBJECTIVE: To describe the outcomes of intended home birth in the practices of certified nurse-midwives. METHODS: Twenty-nine US nurse-midwifery practices were recruited for the study in 1994. Women presenting for intended home birth in these practices were enrolled in the study from late 1994 to late 1995. Outcomes for all enrolled women were ascertained. Validity and reliability of submitted data were established. RESULTS: Of 1404 enrolled women intending home births, 6% miscarried, terminated the pregnancy or changed plans. Another 7.4% became ineligible for home birth prior to the onset of labor at term due to the development of perinatal problems and were referred for planned hospital birth. Of those women beginning labor with the intention of delivering at home, 102 (8.3%) were transferred to the hospital during labor. Ten mothers (0.8%) were transferred to the hospital after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000. CONCLUSION: Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.

Link to article on reducing maternal and neonatal mortality in developing countries

Here is the link:

http://www.bmj.com/cgi/content/full/329/7475/1166

Brooklyn midwife's practice thrives as expectant moms seek natural deliveries

NY Daily News: Brooklyn midwife's practice thrives as expectant moms seek natural deliveries: "...Midwifery, the time-honored profession of helping women through childbirth, has evolved into a health care profession in which practitioners offer prenatal and post-partum care and carry malpractice insurance [...] 'Midwives try to conform to what the woman wants to do, not the other way around,' said Mairi Breen Rothman, a spokeswoman for the American College of Nurse-Midwives..."

In preparation for tomorrow's presentation, students can take a look at the UNFPA report: Meeting the Need, Strengthening Family Planning Programs. The document is available at:

http://www.unfpa.org/upload/lib_pub_file/648_filename_meeting.pdf

Family Planning: Methods of Contraception

Hello All,

For Tuesday's Presentation we will not go over the methods of contraception in great depth. If you are interested in learning more about the various types, their effectiveness, side effects, advantages and disadvantages, please take a look at the resources provided on these websites:

World Health Organization: Family Planning Resources: Decision-Making Tool for Family Planning Clients and Providers
http://www.who.int/reproductive-health/publications/dmt/index.htm

Advocates for Youth: Rights, Respect, Responsibility. Contraceptives: What are your choices?
http://www.advocatesforyouth.org/youth/health/contraceptives/

-Temple & Carolyn