Nurses' and auxiliary nurse midwives' adherence to essential birth practices with peer coaching in Uttar Pradesh, India: a secondary analysis of the BetterBirth trial.

BACKGROUND: The BetterBirth trial tested the effect of a peer coaching program around the WHO Safe Childbirth Checklist for birth attendants in primary-level facilities in Uttar Pradesh, India on a composite measure of perinatal and maternal mortality and maternal morbidity. This study aimed to examine the adherence to essential birth practices between two different cadres of birth attendants-nurses and auxiliary nurse midwives (ANMs)-during and after a peer coaching intervention for the WHO Safe Childbirth Checklist. METHODS: This is a secondary analysis of birth attendant characteristics, coaching visits, and behavior uptake during the BetterBirth trial through birth attendant surveys, coach observations, and independent observations. Descriptive statistics were calculated overall, and by staffing cadre (staff nurses and ANMs) for demographic characteristics. Logistic regression using the Pearson overdispersion correction (to account for clustering by site) was used to assess differences between staff nurses and ANMs in the intervention group during regular coaching (2-month time point) and 4 months after the coaching program ended (12-month time point). RESULTS: Of the 570 birth attendants who responded to the survey in intervention and control arms, 474 were staff nurses (83.2%) and 96 were ANMs (16.8%). In the intervention arm, more staff nurses (240/260, 92.3%) received coaching at all pause points compared to ANMs (40/53, 75.5%). At baseline, adherence to practices was similar between ANMs and staff nurses (~ 30%). Overall percent adherence to essential birth practices among ANMs and nurses was highest at 2 months after intervention initiation, when frequent coaching visits occurred (68.1% and 64.1%, respectively, p = 0.76). Practice adherence tapered to 49.2% among ANMs and 56.1% among staff nurses at 12 months, which was 4 months after coaching had ended (p = 0.68). CONCLUSIONS: Overall, ANMs and nurses responded similarly to the coaching intervention with the greatest increase in percent adherence to essential birth practices after 2 months of coaching and subsequent decrease in adherence 4 months after coaching ended. While coaching is an effective strategy to support some aspects of birth attendant competency, the structure, content, and frequency of coaching may need to be customized according to the birth attendant training and competency. TRIAL REGISTRATION: ClinicalTrials.gov: NCT2148952; Universal Trial Number: U1111-1131-5647.

Reduction in Perinatal Mortality after Implementation of HBB Training at a District Hospital in Mali.

BACKGROUND: Mali has a high neonatal mortality rate of 38/1000 live births; in addition the fresh stillbirth rate (FSR) is 23/1000 births and of these one-third are caused by intrapartum events. OBJECTIVES: The aims are to evaluate the effect of helping babies breathe (HBB) on mortality rate at a district hospital in Kati district, Mali. METHODS: HBB first edition was implemented in April 2016. One year later the birth attendants were trained in HBB second edition and started frequent repetition training. This is a before and after study comparing the perinatal mortality during the period before HBB training with the period after HBB training, the period after HBB first edition and the period after HBB second edition. Perinatal mortality is defined as FSR plus neonatal deaths in the first 24 h of life. RESULTS: There was a significant reduction in perinatal mortality rate (PMR) between the period before and after HBB training, from 21.7/1000 births to 6.0/1000 live births; RR 0.27, (95% CI 0.19-0.41; p < 0.0001). Very early neonatal mortality rate (24 h) decreased significantly from 6.3/1000 to 0.8/1000 live births; RR 0.12 (95% CI 0.05-0.33; p = 0.0006). FSR decreased from 15.7/1000 to 5.3/1000, RR 0.33 (95% CI 0.22-0.52; p < 0.0001). No further reduction occurred after introducing the HBB second edition. CONCLUSION: HBB may be effective in a local first-level referral hospital in Mali.

Using statistical process control methods to trace small changes in perinatal mortality after a training program in a low-resource setting.

OBJECTIVE: To trace and document smaller changes in perinatal survival over time. DESIGN: Prospective observational study, with retrospective analysis. SETTING: Labor ward and operating theater at Haydom Lutheran Hospital in rural north-central Tanzania. PARTICIPANTS: All women giving birth and birth attendants. INTERVENTION: Helping Babies Breathe (HBB) simulation training on newborn care and resuscitation and some other efforts to improve perinatal outcome. MAIN OUTCOME MEASURE: Perinatal survival, including fresh stillbirths and early (24-h) newborn survival. RESULT: The variable life-adjusted plot and cumulative sum chart revealed a steady improvement in survival over time, after the baseline period. There were some variations throughout the study period, and some of these could be linked to different interventions and events. CONCLUSION: To our knowledge, this is the first time statistical process control methods have been used to document changes in perinatal mortality over time in a rural Sub-Saharan hospital, showing a steady increase in survival. These methods can be utilized to continuously monitor and describe changes in patient outcomes.

A pre-post study of a multi-country scale up of resuscitation training of facility birth attendants: does Helping Babies Breathe training save lives?

BACKGROUND: Whether facility-based implementation of Helping Babies Breathe (HBB) reduces neonatal mortality at a population level in low and middle income countries (LMIC) has not been studied. Therefore, we evaluated HBB implementation in this context where our study team has ongoing prospective outcome data on all pregnancies regardless of place of delivery. METHODS: We compared outcomes of birth cohorts in three sites in India and Kenya pre-post implementation of a facility-based intervention, using a prospective, population-based registry in 52 geographic clusters. Our hypothesis was that HBB implementation would result in a 20 % decrease in the perinatal mortality rate (PMR) among births ≥1500 g. RESULTS: We enrolled 70,704 births during two 12-month study periods. Births within each site did not differ pre-post intervention, except for an increased proportion of <2500 g newborns and deliveries by caesarean section in the post period. There were no significant differences in PMR among all registry births; however, a post-hoc analysis stratified by birthweight documented improvement in <2500 g mortality in Belgaum in both registry and in HBB-trained facility births. No improvement in <2500 g mortality measures was noted in Nagpur or Kenya and there was no improvement in normal birth weight survival. CONCLUSIONS: Rapid scale up of HBB training of facility birth attendants in three diverse sites in India and Kenya was not associated with consistent improvements in mortality among all neonates ≥1500 g; however, differential improvements in <2500 g survival in Belgaum suggest the need for careful implementation of HBB training with attention to the target population, data collection, and ongoing quality monitoring activities. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov: NCT01681017 .

Global Burden, Epidemiologic Trends, and Prevention of Intrapartum-Related Deaths in Low-Resource Settings.

Intrapartum-related neonatal deaths include live-born infants who die in the first 28 days of life from neonatal encephalopathy or die before onset of neonatal encephalopathy and have evidence of intrapartum injury. A smaller portion of the population in poorer countries has access to basic obstetric and postnatal care causing neonatal mortality rates to be higher. Presence of a skilled birth attendant and provision of basic emergency obstetric care can reduce intrapartum birth asphyxia by 40%. With the announcement of Sustainable Development Goals and global Every Newborn Action Plan, there is hope that interventions around continuum of care will save lives.

Factores sociodemográficos y seguimiento prenatal asociados a la mortalidad perinatal en gestantes de Colombia / Sociodemographic factors and adequacy of prenatal care associated perinatal mortality in Colombian pregnant women

Introducción: el adecuado seguimiento clínico y el cumplimiento de los requerimientos nutricionales, son aspectos esenciales para el adecuado desarrollo fetal y la culminación exitosa del embarazo. El objetivo de este estudio fue determinar la asociación entre los factores sociodemográficos y el seguimiento prenatal asociados a la mortalidad perinatal en gestantes de Colombia. Material y métodos: estudio descriptivo y transversal secundario a la información obtenida en la Encuesta Nacional de la Situación Nutricional 2010 (ENSIN 2010) y la Encuesta Nacional de Demografía y Salud (ENDS 2010), en 14.754 mujeres gestantes de entre 13 y 44 años de edad. Los factores sociodemográficos: sexo del recién nacido, región geográfica (atlántica, oriental, central, pacífica, Bogotá, territorios nacionales), nivel socioeconómico- Sisbén (I al VI) y área geográfica (cabecera municipal, centro poblado, población dispersa), el seguimiento prenatal (control de peso, altura uterina, presión arterial, fetocardia, bioquímica sanguínea, análisis de orina) y la suplementación con hierro, calcio y ácido fólico se recogieron a través de una encuesta estructurada. Se establecieron asociaciones mediante la construcción de modelos de regresión logística binaria simple y multivariable. Resultados: de las variables sociodemográficas, residir en centros poblados, región oriental o pacífica, y pertenecer al nivel Sisbén I, son las que mostraron mayor frecuencia de muerte perinatal, con valores de 1,7%, 1,5%, 1,4% y 1,4%, respectivamente. Tras ajustar por sexo del recién nacido, área, región geográfica y puntaje de Sisbén, se encontró que un inadecuado seguimiento en el control del peso (OR 5,12), la presión arterial (OR 5,18), la bioquímica sanguínea (OR 2,19) y la suplementación con hierro (OR 2,09), calcio (OR 1,73) y ácido fólico (OR 2,73) se asociaron como factores predisponentes a la mortalidad perinatal. Conclusiones: la mortalidad perinatal cambia según los factores sociodemográficos y el seguimiento prenatal estudiados. El Estado podría usar los resultados de este estudio para fomentar intervenciones que mejoren el seguimiento prenatal durante la gestación (AU)

Background: an adequate monitoring and the compliance of the nutritional requirements are essential for fetal development and successful control of pregnancy outcomes. This study aimed to determine the association between sociodemographic factors and the pre-birth monitoring associated with perinatal mortality in pregnant women from Colombia. Methods: this was a cross-sectional analysis from the 2010 Colombian Demographic and Health Survey and the National Nutritional Survey that included 14 754 pregnant women between 13 and 44 years old. Sociodemographic factors included: new born sex, geographic region, socioeconomic status (SISBEN), pre-birth monitoring (weight control, uterus height, blood pressure, fetal cardiac activity, biochemistry essays, urine analysis) and the supplementation of iron, calcium and folic acid, were collected by structured questionnaire. Associations were established through multivariable and binary regression models. Results: sociodemographic factors such as living in high-density cities, pacific and western regions and low socioeconomic status (SISBEN I) showed a highest perinatal mortality with rates of 1.7%, 1.5%, 1.4% and 1.4%, respectively. After adjustment by new born sex, geographic region and SISBEN score, an adequate monitoring of weight control (OR = 5.12), blood pressure (OR = 5.18), biochemistry essays (OR = 2.19), supplementation of iron (OR = 2.09), calcium (OR=1.73) and folic acid (OR = 2.73) were associated as facilitators of perinatal mortality. Conclusions: perinatal mortality is determined by the sociodemographic factors and pre-birth follow-up included in this study. Government and decision makers can take these results to garbage actions aiming to improve pregnancy monitoring (AU)

Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes.

BACKGROUND: While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions (such as tetanus toxoid immunisation to mothers, clean and skilled care at delivery, newborn resuscitation, exclusive breastfeeding, clean umbilical cord care, and/or management of infections in newborns), many require facility-based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packaged interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. OBJECTIVES: To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2014), World Bank's JOLIS (25 May 2014), BLDS at IDS and IDEAS database of unpublished working papers (25 May 2014), Google and Google Scholar (25 May 2014). SELECTION CRITERIA: All prospective randomised, cluster-randomised and quasi-randomised trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities, and improving neonatal outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, assessed trial quality and extracted the data. Data were checked for accuracy. MAIN RESULTS: The review included 26 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from three trials. Assessment of risk of bias in these studies suggests concerns regarding insufficient information on sequence generation and regarding failure to adequately address incomplete outcome data, particularly from randomised controlled trials. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio (RR) estimates were used along with the standard error of the logarithms of RR estimates.Our review showed a possible effect in terms of a reduction in maternal mortality (RR 0.80; 95% confidence interval (CI) 0.64 to 1.00, random-effects (11 studies, n = 167,311; random-effects, Tau² = 0.03, I² 20%). However, significant reduction was observed in maternal morbidity (average RR 0.75; 95% CI 0.61 to 0.92; four studies, n = 138,290; random-effects, Tau² = 0.02, I² = 28%); neonatal mortality (average RR 0.75; 95% CI 0.67 to 0.83; 21 studies, n = 302,646; random-effects, Tau² = 0.06, I² = 85%) including both early and late mortality; stillbirths (average RR 0.81; 95% CI 0.73 to 0.91; 15 studies, n = 201,181; random-effects, Tau² = 0.03, I² = 66%); and perinatal mortality (average RR 0.78; 95% CI 0.70 to 0.86; 17 studies, n = 282,327; random-effects Tau² = 0.04, I² = 88%) as a consequence of implementation of community-based interventional care packages.Community-based intervention packages also increased the uptake of tetanus immunisation by 5% (average RR 1.05; 95% CI 1.02 to 1.09; seven studies, n = 71,622; random-effects Tau² = 0.00, I² = 52%); use of clean delivery kits by 82% (average RR 1.82; 95% CI 1.10 to 3.02; four studies, n = 54,254; random-effects, Tau² = 0.23, I² = 90%); rates of institutional deliveries by 20% (average RR 1.20; 95% CI 1.04 to 1.39; 14 studies, n = 147,890; random-effects, Tau² = 0.05, I² = 80%); rates of early breastfeeding by 93% (average RR 1.93; 95% CI 1.55 to 2.39; 11 studies, n = 72,464; random-effects, Tau² = 0.14, I² = 98%), and healthcare seeking for neonatal morbidities by 42% (average RR 1.42; 95% CI 1.14 to 1.77, nine studies, n = 66,935, random-effects, Tau² = 0.09, I² = 92%). The review also showed a possible effect on increasing the uptake of iron/folic acid supplementation during pregnancy (average RR 1.47; 95% CI 0.99 to 2.17; six studies, n = 71,622; random-effects, Tau² = 0.26; I² = 99%).It has no impact on improving referrals for maternal morbidities, healthcare seeking for maternal morbidities, iron/folate supplementation, attendance of skilled birth attendance on delivery, and other neonatal care-related outcomes. We did not find studies that reported the impact of community-based intervention package on improving exclusive breastfeeding rates at six months of age. We assessed our primary outcomes for publication bias and observed slight asymmetry on the funnel plot for maternal mortality. AUTHORS' CONCLUSIONS: Our review offers encouraging evidence that community-based intervention packages reduce morbidity for women, mortality and morbidity for babies, and improves care-related outcomes particularly in low- and middle-income countries. It has highlighted the value of integrating maternal and newborn care in community settings through a range of interventions, which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.

Implementation and evaluation of the Helping Babies Breathe curriculum in three resource limited settings: does Helping Babies Breathe save lives? A study protocol.

BACKGROUND: Neonatal deaths account for over 40% of all under-5 year deaths; their reduction is increasingly critical for achieving Millennium Development Goal 4. An estimated 3 million newborns die annually during their first month of life; half of these deaths occur during delivery or within 24 hours. Every year, 6 million babies require help to breathe immediately after birth. Resuscitation training to help babies breathe and prevent/manage birth asphyxia is not routine in low-middle income facility settings. Helping Babies Breathe (HBB), a simulation-training program for babies wherever they are born, was developed for use in low-middle income countries. We evaluated whether HBB training of facility birth attendants reduces perinatal mortality in the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Global Network research sites. METHODS/DESIGN: We hypothesize that a two-year prospective pre-post study to evaluate the impact of a facility-based training package, including HBB and essential newborn care, will reduce all perinatal mortality (fresh stillbirth or neonatal death prior to 7 days) among the Global Network's Maternal Neonatal Health Registry births ≥1500 grams in the study clusters served by the facilities. We will also evaluate the effectiveness of the HBB training program changing on facility-based perinatal mortality and resuscitation practices. Seventy-one health facilities serving 52 geographically-defined study clusters in Belgaum and Nagpur, India, and Eldoret, Kenya, and 30,000 women will be included. Primary outcome data will be collected by staff not involved in the HBB intervention. Additional data on resuscitations, resuscitation debriefings, death audits, quality monitoring and improvement will be collected. HBB training will include training of MTs, facility level birth attendants, and quality monitoring and improvement activities. DISCUSSION: Our study will evaluate the effect of a HBB/ENC training and quality monitoring and improvement package on perinatal mortality using a large multicenter design and approach in 71 resource-limited health facilities, leveraging an existing birth registry to provide neonatal outcomes through day 7. The study will provide the evidence base, lessons learned, and best practices that will be essential to guiding future policy and investment in neonatal resuscitation. TRIAL REGISTRATION: Trial registration ClinicalTrials.gov Identifier: NCT01681017.

ENC training reduces perinatal mortality in Karnataka, India.

OBJECTIVE: To evaluate the effect of World Health Organization Essential Newborn Care course and the American Academy of Pediatrics Neonatal Resuscitation Program training on perinatal mortality in rural India. METHODS: This study was part of a multi-country prospective, community-based cluster randomized controlled trial. Birth, 7-day and 28-day neonatal outcomes for all women with pregnancies greater than 28 weeks in the 26 study communities in Karnataka, India were included. Mortality rates pre- and post-Essential Newborn Care training were collected prospectively and then communities randomized to either receive neonatal resuscitation or refresher newborn care training in the control clusters. RESULTS: Consent was obtained on 99% of the 25,096 births. Perinatal mortality for infants ≥500 g decreased from 52 to 36/1000 after newborn care training (RR 0.7; 95% CI 0.5, 0.9); stillbirth decreased from 23 to 14/1000 (RR 0.62; 95% CI 0.46, 0.83) and early neonatal mortality decreased from 29 to 22/1000 (RR 0.74; 95% CI 0.53, 1.03). Mortality was not reduced further with resuscitation training. CONCLUSIONS: Using a pre-post design, World Health Organization Essential Newborn Care community birth attendant training resulted in a significant reduction in perinatal mortality. In low-resource settings, the newborn care training package appears to be an effective intervention to decrease perinatal mortality.

Effectiveness of an integrated approach to reduce perinatal mortality: recent experiences from Matlab, Bangladesh.

BACKGROUND: Improving perinatal health is the key to achieving the Millennium Development Goal for child survival. Recently, several reviews suggest that scaling up available effective perinatal interventions in an integrated approach can substantially reduce the stillbirth and neonatal death rates worldwide. We evaluated the effect of packaged interventions given in pregnancy, delivery and post-partum periods through integration of community- and facility-based services on perinatal mortality. METHODS: This study took advantage of an ongoing health and demographic surveillance system (HDSS) and a new Maternal, Neonatal and Child Health (MNCH) Project initiated in 2007 in Matlab, Bangladesh in half (intervention area) of the HDSS area. In the other half, women received usual care through the government health system (comparison area). The MNCH Project strengthened ongoing maternal and child health services as well as added new services. The intervention followed a continuum of care model for pregnancy, intrapartum, and post-natal periods by improving established links between community- and facility-based services. With a separate pre-post samples design, we compared the perinatal mortality rates between two periods--before (2005-2006) and after (2008-2009) implementation of MNCH interventions. We also evaluated the difference-of-differences in perinatal mortality between intervention and comparison areas. RESULTS: Antenatal coverage, facility delivery and cesarean section rates were significantly higher in the post- intervention period in comparison with the period before intervention. In the intervention area, the odds of perinatal mortality decreased by 36% between the pre-intervention and post-intervention periods (odds ratio: 0.64; 95% confidence intervals: 0.52-0.78). The reduction in the intervention area was also significant relative to the reduction in the comparison area (OR 0.73, 95% CI: 0.56-0.95; P = 0.018). CONCLUSION: The continuum of care approach provided through the integration of service delivery modes decreased the perinatal mortality rate within a short period of time. Further testing of this model is warranted within the government health system in Bangladesh and other low-income countries.

E pluribus unum: using group model building with many interdependent organizations to create integrated health-care networks.

This chapter reports on an action research case study of integrated obstetric care in the Netherlands. Efficient and patient-friendly patient flows through integrated care networks are of major societal importance. How to design and develop such interorganizational patient flows is still a nascent research area, especially when dealing with a large number (n>3) of stakeholders. We have shown that a modification of an existing method to support interorganizational collaboration by system dynamics-based group model building (GMB) (the Renga method, Akkermans, 2001) may be effective in achieving such collaboration.

Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect.

BACKGROUND: In many developing countries, the majority of births are attended by traditional birth attendants, who lack formal training in neonatal resuscitation and other essential care required by the newly born infant. In these countries, the major causes of neonatal mortality are birth asphyxia, infection, and low-birth-weight/prematurity. Death from these causes is potentially modifiable using low-cost interventions, including neonatal resuscitation training. The purpose of this study was to evaluate the effect on perinatal mortality of training birth attendants in a rural area of the Democratic Republic of Congo (DRC) using two established programs. METHODS: This study, a secondary analysis of DRC-specific data collected during a multi-country study, was conducted in two phases. The effect of training using the WHO Essential Newborn Care (ENC) program was evaluated using an active baseline design, followed by a cluster randomized trial of training using an adaptation of a neonatal resuscitation program (NRP). The perinatal mortality rates before ENC, after ENC training, and after randomization to additional NRP training or continued care were compared. In addition, the influence of time following resuscitation training was investigated by examining change in perinatal mortality during sequential three-month increments following ENC training. RESULTS: More than two-thirds of deliveries were attended by traditional birth attendants and occurred in homes; these proportions decreased after ENC training. There was no apparent decline in perinatal mortality when the outcome of all deliveries prior to ENC training was compared to those after ENC but before NRP training. However, there was a gradual but significant decline in perinatal mortality during the year following ENC training (RR 0.73; 95% CI: 0.56-0.96), which was independently associated with time following training. The decline was attributable to a decline in early neonatal mortality. NRP training had no demonstrable effect on early neonatal mortality. CONCLUSION: Training DRC birth attendants using the ENC program reduces perinatal mortality. However, a period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. ENC training has the potential to be a low cost, high impact intervention in developing countries. TRIAL REGISTRATION: This trial has been registered at http://www.clinicaltrials.gov (identifier NCT00136708).

Intrapartum-related stillbirths and neonatal deaths in rural bangladesh: a prospective, community-based cohort study.

OBJECTIVE: Using a low-cost community surveillance system, we aimed to estimate intrapartum stillbirth and intrapartum-related neonatal death rates for a low-income community setting. PATIENTS AND METHODS: From 2005 to 2008, information on all deliveries in 18 unions of 3 districts of Bangladesh was ascertained by using traditional birth attendants as key informants. Outcomes were measured using a structured interview with families 6 weeks after delivery. RESULTS: We ascertained information on 31 967 deliveries, of which 26 173 (82%) occurred at home. For home deliveries, the mean cluster-adjusted stillbirth rate was 26 (95% confidence interval [CI[: 24-28) per 1000 births, and the perinatal mortality rate was 51 per 1000 births (95% CI: 47-55). The NMR was 33 per 1000 live births (95% CI: 30-37). There were 3186 (12.5%) home-born infants who did not breathe immediately. Of these, 53% underwent some form of resuscitation. Of 1435 infants who were in poor condition at 5 minutes (5% of all deliveries), 286 (20%) died; 35% of all causes of neonatal mortality. Of 201 fresh stillbirths, 40 (14%) of the infants had major congenital abnormalities. Our estimate of the intrapartum-related crude mortality rate among home-born infants is 17 in 1000 (95% CI: 16-19), 6 in 1000 stillborn and 11 in 1000 neonatal deaths after difficulties at birth. CONCLUSIONS: Difficulty initiating respiration among infants born at home in rural Bangladesh is common, and resuscitation is frequently attempted. Newborns who remain in poor condition at 5 minutes have a 20% mortality rate. Evaluation of resuscitation methods, early intervention trials including antibiotic regimes, and follow-up studies of survivors of community-based resuscitation are needed.

Particularidades del tratamiento de la gestante con diabetes mellitus tipo 2 / Special considerations in the treatment of pregnant women with type 2 diabetes mellitus

La prevalencia de diabetes mellitus tipo 2 (DM2) en la gestación está en aumento y puede superar la de la diabetes mellitus tipo 1 (DM1).En general, el tratamiento es similar, con algunas particularidades. Las pacientes con DM2 son de mayor edad, son más obesas, tienen hipertensión crónica con mayor frecuencia, reciben asistencia pregestacional específica con menor frecuencia, consultan más tarde durante la gestación y están más expuestas a fármacos potencialmente teratógenos. En contrapartida, el tiempo de evolución de la enfermedad y la frecuencia de complicaciones son inferiores y el control metabólico es mejor. Aunque hay controversia, la evolución perinatal es similar, a excepción de la prematuridad, que es inferior en DM2.El fármaco recomendado para el tratamiento de la hiperglucemia es la insulina. Antes del embarazo, el énfasis debe ponerse en aumentar la asistencia pregestacional, mejorar el control glucémico, reforzándola educación diabetológica, y evitar la exposición a fármacos potencialmente teratógenos. Durante la gestación, los últimos objetivos continúan vigentes. Después del parto, se debe replantear el programa terapéutico teniendo en cuenta el paso de los fármacos a la leche materna (AU)

The prevalence of type 2 diabetes mellitus(DM2) in pregnancy is increasing and can exceed that of type 1 DM (DM1). In general, treatment is similar with some special considerations. Patients with DM2 are older and heavier, more likely to have chronic hypertension, less likely to receive specific prepregnancy care, consult later inpregnancy, and are more frequently exposed to potentially teratogenic drugs. In contrast, diabetes duration and the complications rate are lower and metabolic control is better. Although there is some controversy on the topic, perinatal outcomes are similar, except for the prematurity rate, which is lower in DM2. The recommended drug for the treatment of hyperglycemia is insulin. Before pregnancy, emphasis shouldbe placed on increasing attendance at prepregnancy care, improving glycemiccontrol, reinforcing diabetes instruction and avoiding exposure to potentially teratogenicdrugs. During pregnancy, the latter aims remain applicable. After delivery, the treatment regimen should be reconsidered, taking into account transfer of different drugs through breast milk (AU)

The use of herbal medicines during pregnancy and perinatal mortality in Tumpat District, Kelantan, Malaysia.

The objective of this case-control study was to determine the association between herbal medicine use during pregnancy and perinatal mortality in Tumpat District, Kelantan, Malaysia. Cases were mothers who gave birth from June 2002 to June 2005 with a history of perinatal mortality, while controls were those without a history of perinatal infant mortality. A total of 316 mothers (106 cases and 210 controls) were interviewed. The use of unidentified herbs prepared by traditional midwives and other types of herbal medicines during the first trimester of pregnancy were positively associated with perinatal mortality (OR = 5.24, 95% CI = 1.13; 24.23 and OR = 8.90, 95%, CI = 1.35; 58.53, respectively). The use of unidentified "Orang Asli" herbs and coconut oil during the third trimester of pregnancy were negatively associated with perinatal mortality in Tumpat (OR = 0.10, 95% CI = 0.02; 0.59 and OR = 0.48, 95% CI = 0.25; 0.92, respectively). These findings suggest the use of unidentified "Orang Asli" herbs and coconut oil in late pregnancy are protective against perinatal mortality, while the use of unidentified herbs prepared by traditional midwives and other types of herbal medicines in early pregnancy has an increased risk of perinatal infant mortality. Pharmacological studies to confirm and identify the compounds in these herbs and their effects on the fetus should be conducted in the future.