Effects of a liquefied petroleum gas stove intervention on stillbirth, congenital anomalies and neonatal mortality: A multi-country household air pollution intervention network trial.

Household air pollution (HAP) from cooking with solid fuels used during pregnancy has been associated with adverse pregnancy outcomes. The Household Air Pollution Intervention Network (HAPIN) trial was a randomized controlled trial that assessed the impact of a liquefied petroleum gas (LPG) stove and fuel intervention on health in Guatemala, India, Peru, and Rwanda. Here we investigated the effects of the LPG stove and fuel intervention on stillbirth, congenital anomalies and neonatal mortality and characterized exposure-response relationships between personal exposures to fine particulate matter (PM2.5), black carbon (BC) and carbon monoxide (CO) and these outcomes. Pregnant women (18 to <35 years of age; gestation confirmed by ultrasound at 9 to <20 weeks) were randomly assigned to intervention or control arms. We monitored these fetal and neonatal outcomes and personal exposure to PM2.5, BC and CO three times during pregnancy, we conducted intention-to-treat (ITT) and exposure-response (E-R) analyses to determine if the HAPIN intervention and corresponding HAP exposure was associated with the risk of fetal/neonatal outcomes. A total of 3200 women (mean age 25.4 ± 4.4 years, mean gestational age at randomization 15.4 ± 3.1 weeks) were included in this analysis. Relative risks for stillbirth, congenital anomaly and neonatal mortality were 0.99 (0.60, 1.66), 0.92 (95 % CI 0.52, 1.61), and 0.99 (0.54, 1.85), respectively, among women in the intervention arm compared to controls in an ITT analysis. Higher mean personal exposures to PM2.5, CO and BC during pregnancy were associated with a higher, but statistically non-significant, incidence of adverse outcomes. The LPG stove and fuel intervention did not reduce the risk of these outcomes nor did we find evidence supporting an association between personal exposures to HAP and stillbirth, congenital anomalies and neonatal mortality.

The impact of the interval between the last meal and the onset of farrowing on the duration of farrowing, stillbirth rates, and colostrum production in highly productive sows in a tropical climate.

The present study investigated impact of the interval between the last meal and the onset of farrowing on the duration of farrowing, stillbirth rates, and colostrum production in highly productive sows in a tropical climate. The study involved a total of 92 Danish Landrace x Yorkshire sows (herd A) and 114 French Landrace × Yorkshire sows (herd B). In herd B, a total of 61 sows had their blood samples collected within 1 hr after the onset of farrowing to evaluate their blood glucose levels. The interval between the last meal and the onset of farrowing averaged 5.9 ± 4.5 and 5.4 ± 4.1 hr in herds A and B, respectively. Neither the duration of farrowing nor the occurrence of stillborn piglets in both herds was affected by the time gap between the last meal and the onset of farrowing. At the onset of farrowing, the average blood glucose level in sows was 77.1 ± 19.3 mg/dL, with a range of 27 to 115 mg/dL. There was a positive correlation observed between the blood glucose concentration and the colostrum yield of the sows (r=0.261, P=0.042). In conclusion, the time interval between the last meal and the onset of farrowing did not have any impact on the farrowing performance of sows. However, a higher concentration of blood glucose at the onset of farrowing was associated with an improvement in the colostrum yield of the sows.

District health management and stillbirth recording and reporting: a qualitative study in the Ashanti Region of Ghana.

BACKGROUND: Despite global efforts to reduce maternal and neonatal mortality, stillbirths remain a significant public health challenge in many low- and middle-income countries. District health systems, largely seen as the backbone of health systems, are pivotal in addressing the data gaps reported for stillbirths. Available, accurate and complete data is essential for District Health Management Teams (DHMTs) to understand the burden of stillbirths, evaluate interventions and tailor health facility support to address the complex challenges that contribute to stillbirths. This study aims to understand stillbirth recording and reporting in the Ashanti Region of Ghana from the perspective of DHMTs. METHODS: The study was conducted in the Ashanti Region of Ghana. 15 members of the regional and district health directorates (RHD/DHD) participated in semi-structured interviews. Sampling was purposive, focusing on RHD/DHD members who interact with maternity services or stillbirth data. Thematic analyses were informed by an a priori framework, including theme 1) experiences, perceptions and attitudes; theme 2) stillbirth data use; and theme 3) leadership and support mechanisms, for stillbirth recording and reporting. RESULTS: Under theme 1, stillbirth definitions varied among respondents, with 20 and 28 weeks commonly used. Fresh and macerated skin appearance was used to classify timing with limited knowledge of antepartum and intrapartum stillbirths. For theme 2, data quality checks, audits, and the district health information management system (DHIMS-2) data entry and review are functions played by the DHD. Midwives were blamed for data quality issues on omissions and misclassifications. Manual entry of data, data transfer from the facility to the DHD, limited knowledge of stillbirth terminology and periodic closure of the DHIMS-2 were seen to proliferate gaps in stillbirth recording and reporting. Under theme 3, perinatal audits were acknowledged as an enabler for stillbirth recording and reporting by the DHD, though audits are mandated for only late-gestational stillbirths (> 28 weeks). Engagement of other sectors, e.g., civil/vital registration and private health facilities, was seen as key in understanding the true population-level burden of stillbirths. CONCLUSION: Effective district health management ensures that every stillbirth is accurately recorded, reported, and acted upon to drive improvements. A large need exists for capacity building on stillbirth definitions and data use. Recommendations are made, for example, terminology standardization and private sector engagement, aimed at reducing stillbirth rates in high-mortality settings such as Ghana.

Maternal and fetal factors associated with stillbirth in singleton pregnancies in 13 hospitals across six states in India: A prospective cohort study.

OBJECTIVE: This study aimed to investigate the incidence of and risk factors for stillbirth in an Indian population. METHODS: We conducted a secondary data analysis of a hospital-based cohort from the Maternal and Perinatal Health Research collaboration, India (MaatHRI), including pregnant women who gave birth between October 2018-September 2023. Data from 9823 singleton pregnancies recruited from 13 hospitals across six Indian states were included. Univariable and multivariable Poisson regression analysis were performed to examine the relationship between stillbirth and potential risk factors. Model prediction was assessed using the area under the receiver-operating characteristic (AUROC) curve. RESULTS: There were 216 stillbirths (48 antepartum and 168 intrapartum) in the study population, representing an overall stillbirth rate of 22.0 per 1000 total births (95% confidence interval [CI]: 19.2-25.1). Modifiable risk factors for stillbirth were: receiving less than four antenatal check-ups (adjusted relative risk [aRR]: 1.75, 95% CI: 1.25-2.47), not taking any iron and folic acid supplementation during pregnancy (aRR: 7.23, 95% CI: 2.12-45.33) and having severe anemia in the third trimester (aRR: 3.37, 95% CI: 1.97-6.11). Having pregnancy/fetal complications such as hypertensive disorders of pregnancy (aRR: 1.59, 95% CI: 1.03-2.36), preterm birth (aRR: 4.41, 95% CI: 3.21-6.08) and birth weight below the 10th percentile for gestational age (aRR: 1.35, 95% CI: 1.02-1.79) were also associated with an increased risk of stillbirth. Identified risk factors explained 78.2% (95% CI: 75.0%-81.4%) of the risk of stillbirth in the population. CONCLUSION: Addressing potentially modifiable antenatal factors could reduce the risk of stillbirths in India.

Factors affecting birth weight and stillbirth in sows housed in a tropical environment.

This study analysed data from a commercial swine herd in Thailand equipped with a free-farrowing housing system, comprising 17,196 piglets from 1318 litters, to explore the impact of sow and litter characteristics on the piglet birth weight and the incidence of stillbirth. The piglets were classified into four groups based on the total number of piglets born per litter (TB): ≤9 (n = 1434), 10-12 (n = 3232), 13-15 (n = 6537) and ≥16 (n = 5993). Sows were classified into four groups based on parity number: 1, 2-4, 5-7 and ≥8. The piglets were categorized into quartiles based on their birth order ranking: Q1 (n = 4786), Q2 (n = 4143), Q3 (n = 3808) and Q4 (n = 4456). Piglet birth weight was individually measured before colostrum ingestion. On average, TB, the number of live-born piglets and the incidence of stillbirth were 13.1 ± 3.7, 11.5 ± 3.8 and 6.3%, respectively. Among these litters, 26.6% had TB numbers ≥16. The average piglet birth weight was 1.37 ± 0.36 kg, with 18.3% of piglets weighing ≤1.0 kg at birth. Piglet birth weight was influenced by birth order ranking, as Q4 piglets were found to be heavier than piglets born in Q1-Q3 (p < .001). Moreover, the percentage of piglets with a birth weight of ≤1.0 kg increased from 5.9% in litters with TB of ≤9-25.3% in litters with TB of ≥16 (p < .001). Additionally, primiparous sows had lower piglet birth weights compared to sows with parity numbers 2-4, 5-7 and ≥8 (p < .001). Piglets born in the fourth quartile (Q4) had a higher risk of stillbirth compared to those born in the first (Q1), second (Q2) and third (Q3) quartiles (12.5% vs. 2.2%, 4.1% and 6.6%, respectively, p < .001). The incidence of stillbirth in litters with TB ≥16 was also higher than that in litters with TB ≤9 and 10-12 (p < .05). Furthermore, sows with parity numbers ≥8 had a higher incidence of stillbirth (9.7%) compared to primiparous sows (4.0%, p < .001), sows with 2-4 parity (5.2%, p < .001) and sows with 5-7 parity (7.6%, p = .003). In summary, a high incidence of stillbirth was found in piglets born in the last quartile of litters, in litters with >16 piglets and for sows with parity numbers ≥8. Piglets born in the last quartile of litters were heavier than those born in the first to third quartiles.

Prenatal Health Care Outcomes Before and During the COVID-19 Pandemic Among Pregnant Individuals and Their Newborns in an Integrated US Health System.

Importance: The COVID-19 pandemic accelerated the use of telemedicine. However, data on the integration of telemedicine in prenatal health care and health outcomes are sparse. Objective: To evaluate a multimodal model of in-office and telemedicine prenatal health care implemented during the COVID-19 pandemic and its association with maternal and newborn health outcomes. Design, Setting, and Participants: This cohort study of pregnant individuals using longitudinal electronic health record data was conducted at Kaiser Permanente Northern California, an integrated health care system serving a population of 4.5 million people. Individuals who delivered a live birth or stillbirth between July 1, 2018, and October 21, 2021, were included in the study. Data were analyzed from January 2022 to May 2023. Exposure: Exposure levels to the multimodal prenatal health care model were separated into 3 intervals: unexposed (T1, birth delivery between July 1, 2018, and February 29, 2020), partially exposed (T2, birth delivery between March 1, 2020, and December 5, 2020), and fully exposed (T3, birth delivery between December 6, 2020, and October 31, 2021). Main Outcomes and Measures: Primary outcomes included rates of preeclampsia and eclampsia, severe maternal morbidity, cesarean delivery, preterm birth, and neonatal intensive care unit (NICU) admission. The distributions of demographic and clinical characteristics, care processes, and health outcomes for birth deliveries within each of the 3 intervals of interest were assessed with standardized mean differences calculated for between-interval contrasts. Interrupted time series analyses were used to examine changes in rates of perinatal outcomes and its association with the multimodal prenatal health care model. Secondary outcomes included gestational hypertension, gestational diabetes, depression, venous thromboembolism, newborn Apgar score, transient tachypnea, and birth weight. Results: The cohort included 151 464 individuals (mean [SD] age, 31.3 [5.3] years) who delivered a live birth or stillbirth. The mean (SD) number of total prenatal visits was similar in T1 (9.41 [4.75] visits), T2 (9.17 [4.50] visits), and T3 (9.15 [4.66] visits), whereas the proportion of telemedicine visits increased from 11.1% (79 214 visits) in T1 to 20.9% (66 726 visits) in T2 and 21.3% (79 518 visits) in T3. NICU admission rates were 9.2% (7014 admissions) in T1, 8.3% (2905 admissions) in T2, and 8.6% (3615 admissions) in T3. Interrupted time series analysis showed no change in NICU admission risk during T1 (change per 4-week interval, -0.22%; 95% CI, -0.53% to 0.09%), a decrease in risk during T2 (change per 4-week interval, -0.91%; 95% CI, -1.77% to -0.03%), and an increase in risk during T3 (change per 4-week interval, 1.75%; 95% CI, 0.49% to 3.02%). There were no clinically relevant changes between T1, T2, and T3 in the rates of risk of preeclampsia and eclampsia (change per 4-week interval, 0.76% [95% CI, 0.39% to 1.14%] for T1; -0.19% [95% CI, -1.19% to 0.81%] for T2; and -0.80% [95% CI, -2.13% to 0.55%] for T3), severe maternal morbidity (change per 4-week interval , 0.12% [95% CI, 0.40% to 0.63%] for T1; -0.39% [95% CI, -1.00% to 1.80%] for T2; and 0.99% [95% CI, -0.88% to 2.90%] for T3), cesarean delivery (change per 4-week interval, 0.06% [95% CI, -0.11% to 0.23%] for T1; -0.03% [95% CI, -0.49% to 0.44%] for T2; and -0.05% [95% CI, -0.68% to 0.59%] for T3), preterm birth (change per 4-week interval, 0.23% [95% CI, -0.11% to 0.57%] for T1; -0.37% [95% CI, -1.29% to 0.55%] for T2; and -0.15% [95% CI, -1.41% to 1.13%] for T3), or secondary outcomes. Conclusions and Relevance: These findings suggest that a multimodal prenatal health care model combining in-office and telemedicine visits performed adequately compared with in-office only prenatal health care, supporting its continued use after the pandemic.

Antenatal depression and adverse birth outcomes among pregnant women living with HIV in Dar es Salaam, Tanzania.

BACKGROUND: Women who experience antenatal depression may be at increased risk of adverse birth outcomes. Few studies have examined this association among women living with HIV (WHIV). METHODS: We conducted a prospective cohort study of 2298 pregnant WHIV on antiretroviral therapy (ART) in Dar es Salaam, Tanzania, who were participants in a randomized trial of vitamin D3 supplementation. Depressive symptoms were assessed at 12-27 weeks gestation using the Hopkins Symptoms Checklist (HSCL-25). Generalized estimating equations to account for twins were used to assess the relative risks of adverse birth outcomes. RESULTS: Approximately 67 % of the women in our study population reported symptoms consistent with depression. We observed a 4.0 % prevalence of stillbirth and a 25.1 % prevalence of preterm birth. We found that low social support, higher education, and more recent initiation of ART were associated with a greater risk of antenatal depression. There was no association of antenatal depression with risk of fetal loss, stillbirth, low birth weight, birth weight, preterm birth, gestational age at delivery, or small-for-gestational age. LIMITATIONS: Depression was self-reported and only collected at one timepoint in pregnancy. Our findings may not be generalizable to all WHIV. CONCLUSIONS: Our findings illustrate the high risk of both depression and adverse birth outcomes among WHIV and underscore the need for interventions to improve their mental health and the health of their infants; however, the relationship between depression and birth outcomes remains unclear. Further research on this topic is merited, particularly examining the chronicity and timing of depression in pregnancy.

Is there a relation between stillbirth and low levels of vitamin D in the population? A bi-national follow-up study of vitamin D fortification.

BACKGROUND: Stillbirth has been associated with low plasma vitamin D. Both Sweden and Finland have a high proportion of low plasma vitamin D levels (< 50 nmol/L). We aimed to assess the odds of stillbirth in relation to changes in national vitamin D fortification. METHODS: We surveyed all pregnancies in Finland between 1994 and 2021 (n = 1,569,739) and Sweden (n = 2,800,730) with live or stillbirth registered in the Medical Birth Registries. The mean incidences before and after changes in the vitamin D food fortification programs in Finland (2003 and 2009) and Sweden (2018) were compared with cross-tabulation with 95% confidence intervals (CI). RESULTS: In Finland, the stillbirth rate declined from ~ 4.1/1000 prior to 2003, to 3.4/1000 between 2004 and 2009 (odds ratio [OR] 0.87, 95% CI 0.81-0.93), and to 2.8/1000 after 2010 (OR 0.84, 95% CI 0.78-0.91). In Sweden, the stillbirth rate decreased from 3.9/1000 between 2008 and 2017 to 3.2/1000 after 2018 (OR 0.83, 95% CI 0.78-0.89). When the level of the dose-dependent difference in Finland in a large sample with correct temporal associations decreased, it remained steady in Sweden, and vice versa, indicating that the effect may be due to vitamin D. These are observational findings that may not be causal. CONCLUSION: Each increment of vitamin D fortification was associated with a 15% drop in stillbirths on a national level. If true, and if fortification reaches the entire population, it may represent a milestone in preventing stillbirths and reducing health inequalities.

Mendelian randomization study of maternal coffee consumption and its influence on birthweight, stillbirth, miscarriage, gestational age and pre-term birth.

BACKGROUND: Coffee consumption has been associated with several adverse pregnancy outcomes, although data from randomized-controlled trials are lacking. We investigate whether there is a causal relationship between coffee consumption and miscarriage, stillbirth, birthweight, gestational age and pre-term birth using Mendelian randomization (MR). METHODS: A two-sample MR study was performed using summary results data from a genome-wide association meta-analysis of coffee consumption (N = 91 462) from the Coffee and Caffeine Genetics Consortium. Outcomes included self-reported miscarriage (N = 49 996 cases and 174 109 controls from a large meta-analysis); the number of stillbirths [N = 60 453 from UK Biobank (UKBB)]; gestational age and pre-term birth (N = 43 568 from the 23andMe, Inc cohort) and birthweight (N = 297 356 reporting own birthweight and N = 210 248 reporting offspring's birthweight from UKBB and the Early Growth Genetics Consortium). Additionally, a one-sample genetic risk score (GRS) analysis of coffee consumption in UKBB women (N up to 194 196) and the Avon Longitudinal Study of Parents and Children (N up to 6845 mothers and 4510 children) and its relationship with offspring outcomes was performed. RESULTS: Both the two-sample MR and one-sample GRS analyses showed no change in risk of sporadic miscarriages, stillbirths, pre-term birth or effect on gestational age connected to coffee consumption. Although both analyses showed an association between increased coffee consumption and higher birthweight, the magnitude of the effect was inconsistent. CONCLUSION: Our results suggest that coffee consumption during pregnancy might not itself contribute to adverse outcomes such as stillbirth, sporadic miscarriages and pre-term birth or lower gestational age or birthweight of the offspring.

Epidemiology of Caesarean section on maternal request in Australia: A population-based study.

OBJECTIVE: To explore the trends, determinants, and short-term maternal and neonatal health outcomes of Caesarean section on maternal request (CSMR). DESIGN: Population-based record linkage study. SETTING: Birth registry data for all births in Queensland, Australia, from 2008 to 2017. PARTICIPANTS: Pregnancies resulting in live or intrapartum stillbirth with >=20 gestational weeks and/or >=400 gm birth weight were the study population. The analytic sample was restricted to low-risk pregnancies by excluding preterm, non-cephalic pregnancies with medical risk factors. MEASUREMENTS: CSMR was defined as a first-time C-section in singleton, term pregnancies with an ICD-10-AM code of O-82/O-47. CSMR trend was reported in age-standardised rate using a join-point regression model. The determinants and perinatal outcomes of CSMR were tested against Spontaneous vaginal births (VBs) and planned VBs including assisted VBs and emergency C-sections in this group. The generalised estimating equation technique was used for regression analysis and reported in the odds ratio (OR) at a 95% Confidence Interval (CI). FINDINGS: Of total C-sections (n = 204,863), the average annual change in CSMR rate was 4.4% (95% CI: 2.1-6.7%, p<0.01) for the total pregnancies (N=613,375) Of the analytic sample (N=365568), nulliparous women with age ≥35 years (OR: 2.32,95% CI: 2.09-2.57), delivered at private hospitals (OR:4.90; 95% CI: 4.65-5.18); with mood disorders (OR: 2.15; 95% CI: 1.88-2.43) were positive and midwives birth attendant (OR 0.28; 95% CI: 0.26 to 0.30) was negative influencing factors for CSMR. In a propensity score matched sample; CSMR observed an increasedrisk of anaesthetic complications (OR: 8.00; 95% CI:1.95-32.82) and slightly reduced odds of birth asphyxia (OR:0.20;95%CI:0.06-0.60)against planned VBs while the overall incidence of birth-asphyxia was low (1.29%) However, neonatal morbidities (OR:1.61; 95% CI:1-2.59) and special care admission (OR:2.15; 95% CI:1.03-4.5) were higher after CSMR in comparison to SVBs CONCLUSION: Despite being linked with adverse perinatal health outcomes, the incidence of CSMR increased 1.75-fold during the past 10 years. Maternal educational interventions to provide adequate information, including the long-term risks and benefits of C-sections, can help reduce the growing rates of CSMR.

Effect of the Helping Babies Breathe Program on Newborn Outcomes: Systematic Review and Meta-Analysis.

Background and objectives: In low- and middle-income countries, the leading cause of neonatal mortality is perinatal asphyxia. Training in neonatal resuscitation has been shown to decrease this cause of mortality. The program "Helping Babies Breathe" (HBB) is a program to teach basic neonatal resuscitation focused on countries and areas with limited economic resources. The aim of the study was to determine the effect of the implementation of the HBB program on newborn outcomes: mortality and morbidity. Material and Methods: A systematic review was carried out on observational studies and clinical trials that reported the effect of the implementation in low- and middle-income countries of the HBB program on neonatal mortality and morbidity. We carried out a meta-analysis of the extracted data. Random-effect models were used to evaluate heterogeneity, using the Cochrane Q and I2 tests, and stratified analyses were performed by age and type of outcome to determine the sources of heterogeneity. Results: Eleven studies were identified. The implementation of the program includes educational strategies focused on the training of doctors, nurses, midwives, and students of health professions. The poled results showed a decrease in overall mortality (OR 0.67; 95% CI 0.57, 0.80), intrapartum stillbirth mortality (OR 0.62; 95% CI 0.51, 0.75), and first-day mortality (OR 0.70; 95% IC 0.64, 0.77). High heterogeneity was found, which was partly explained by differences in the gestational age of the participants. Conclusions: The implementation of the program HBB in low- and medium-income countries has a significant impact on reducing early neonatal mortality.

The effects of completion of continuum of care in maternal health services on adverse birth outcomes in Northwestern Ethiopia: a prospective follow-up study.

BACKGROUND: Globally, around 4 million babies die within the first month of birth annually with more than 3 million stillbirths. Of them, 99% of newborn deaths and 98% of stillbirths occur in developing countries. Despite giving priority to maternal health services, adverse birth outcomes are still major public health problems in the study area. Hence, a continuum of care (CoC) is a core key strategy to overcome those challenges. The study conducted on the effectiveness of continuum of care in maternal health services was scarce in developing countries and not done in the study area. We aimed to assess the effectiveness of continuum of care and determinants of adverse birth outcomes. METHODS: Community and health facility-linked prospective follow-up study designs were employed from March 2020 to January 2021 in Northwestern Ethiopia. A multistage clustered sampling technique was used to recruit 2198 pregnant women. Data were collected by using a semi-structured and pretested questionnaire. Collected data were coded, entered, cleaned, and analyzed by STATA 14. Multilevel logistic regression model was used to identify community and individual-level factors. Finally, propensity score matching was applied to determine the effectiveness of continuum of care. RESULTS: The magnitude of adverse birth outcomes was 12.4% (95% CI 12.2-12.7): stillbirth (2.8%; 95% CI 2.7-3.0), neonatal mortality (3.1%; 95% CI 2.9-3.2), and neonatal morbidity (6.8%; 95% CI 6.6-7.0). Risk factors were poor household wealth (AOR = 3.3; 95% CI 1.07-10.23), pregnant-related maternal complications during pregnancy (AOR = 3.29; 95% CI 1.68-6.46), childbirth (AOR = 6.08; 95% CI 2.36-15.48), after childbirth (AOR = 5.24; 95% CI 2.23-12.33), an offensive odor of amniotic fluid (AOR = 3.04; 95% CI 1.37-6.75) and history of stillbirth (AOR = 4.2; 95% CI 1.78-9.93). Whereas, receiving iron-folic acid (AOR = 0.44; 95% CI 0.14-0.98), initiating breastfeeding within 1 h (AOR = 0.22; 95% CI 0.10-0.50) and immunizing newborn (AOR = 0.33; 95% CI 0.12-0.93) were protective factors. As treatment effect, completion of continuum of care via time dimension (ß = - 0.03; 95% CI - 0.05, - 0.01) and space dimension (ß = - 0.03; 95% CI - 0.04, - 0.01) were significantly reduce perinatal death. CONCLUSIONS: Adverse birth outcomes were high as compared with national targets. Completion of continuum of care is an effective intervention for reducing perinatal death. Efforts should be made to strengthen the continuum of care in maternal health services, iron supplementation, immunizing and early initiation of breastfeeding.

Adverse birth outcomes are a major public health problem and a big challenge in Ethiopia, particularly in the study area. They encompass stillbirth, neonatal death, and neonatal illness within 28 days after birth. Globally, about 4 million babies die within the first month of birth annually with more than 3 million stillbirths. Of these, about 99% of newborn deaths and 98% of stillbirths occur in developing countries. As a solution to overcome those problems, a continuum of care in maternal health services is a core strategy. Therefore, this study was planned to determine how effective continuum of care in maternal health service is in reducing perinatal death and factors contributing to the adverse birth outcomes. In this study, 2198 pregnant women were recruited and followed for 11 months. The health condition of women was frequently assessed and recorded during pregnancy, childbirth and the period until 42 days after childbirth, as well as the health condition of the babies until 28 days after the birth, the package of maternal health services received, and adverse birth outcomes. Among the 2198 pregnant women enrolled in the study, 248 women encountered adverse birth outcomes (52 had stillbirths, 58 had neonatal death and 138 had neonatal illness). Risk factors of adverse birth outcomes were a poor household wealth index quintile, pregnancy-related maternal complications, offensive odor amniotic fluid, and history of stillbirth. On the other hand, protective interventions against adverse birth outcomes were receiving iron supplementation during pregnancy, initiating breastfeeding within 1 h, and immunizing the newborn. Moreover, completions of continuum of care in maternal health services via time and space dimensions reduced perinatal death. In conclusion, neonatal and perinatal deaths were high in the study areas. Completions of continuum of care in maternal health services via time and space dimensions reduced perinatal death, neonatal death, and stillbirth. The results of this study can inform national health policymakers, maternal and child programmers, and other stakeholders to prioritize and strengthen protective intervention and continuum of care in maternal health services.

Prenatal fortified balanced energy-protein supplementation and birth outcomes in rural Burkina Faso: A randomized controlled efficacy trial.

BACKGROUND: Providing balanced energy-protein (BEP) supplements is a promising intervention to improve birth outcomes in low- and middle-income countries (LMICs); however, evidence is limited. We aimed to assess the efficacy of fortified BEP supplementation during pregnancy to improve birth outcomes, as compared to iron-folic acid (IFA) tablets, the standard of care. METHODS AND FINDINGS: We conducted an individually randomized controlled efficacy trial (MIcronutriments pour la SAnté de la Mère et de l'Enfant [MISAME]-III) in 6 health center catchment areas in rural Burkina Faso. Pregnant women, aged 15 to 40 years with gestational age (GA) <21 completed weeks, were randomly assigned to receive either fortified BEP supplements and IFA (intervention) or IFA (control). Supplements were provided during home visits, and intake was supervised on a daily basis by trained village-based project workers. The primary outcome was prevalence of small-for-gestational age (SGA) and secondary outcomes included large-for-gestational age (LGA), low birth weight (LBW), preterm birth (PTB), gestational duration, birth weight, birth length, Rohrer's ponderal index, head circumference, thoracic circumference, arm circumference, fetal loss, and stillbirth. Statistical analyses followed the intention-to-treat (ITT) principle. From October 2019 to December 2020, 1,897 pregnant women were randomized (960 control and 937 intervention). The last child was born in August 2021, and birth anthropometry was analyzed from 1,708 pregnancies (872 control and 836 intervention). A total of 22 women were lost to follow-up in the control group and 27 women in the intervention group. BEP supplementation led to a mean 3.1 percentage points (pp) reduction in SGA with a 95% confidence interval (CI) of -7.39 to 1.16 (P = 0.151), indicating a wide range of plausible true treatment efficacy. Adjusting for prognostic factors of SGA, and conducting complete cases (1,659/1,708, 97%) and per-protocol analysis among women with an observed BEP adherence ≥75% (1,481/1,708, 87%), did not change the results. The intervention significantly improved the duration of gestation (+0.20 weeks, 95% CI 0.05 to 0.36, P = 0.010), birth weight (50.1 g, 8.11 to 92.0, P = 0.019), birth length (0.20 cm, 0.01 to 0.40, P = 0.044), thoracic circumference (0.20 cm, 0.04 to 0.37, P = 0.016), arm circumference (0.86 mm, 0.11 to 1.62, P = 0.025), and decreased LBW prevalence (-3.95 pp, -6.83 to -1.06, P = 0.007) as secondary outcomes measures. No differences in serious adverse events [SAEs; fetal loss (21 control and 26 intervention) and stillbirth (16 control and 17 intervention)] between the study groups were found. Key limitations are the nonblinded administration of supplements and the lack of information on other prognostic factors (e.g., infection, inflammation, stress, and physical activity) to determine to which extent these might have influenced the effect on nutrient availability and birth outcomes. CONCLUSIONS: The MISAME-III trial did not provide evidence that fortified BEP supplementation is efficacious in reducing SGA prevalence. However, the intervention had a small positive effect on other birth outcomes. Additional maternal and biochemical outcomes need to be investigated to provide further evidence on the overall clinical relevance of BEP supplementation. TRIAL REGISTRATION: ClinicalTrials.gov NCT03533712.

Evaluation of neural tube defects from 2014 to 2019 in Turkey.

OBJECTIVE: The aim of this study is to determine the frequency of neural tube defects (NTDs) and to examine the epidemiological characteristics of NTD related deaths in Turkey. METHODS: This nationwide descriptive study was included NTD related infant deaths, termination of pregnancy for fetal anomaly (ToPFA) and stillbirth cases registered in Death Notification System between 2014 and 2019, and patients diagnosed with NTD in the 2018 birth cohort. FINDINGS: In the 2018 birth cohort, there were 3475 cases of NTD at birth (27.5 per 10,000). The fatality rates for live-born babies with NTD in this cohort were 13.5% at first year, and 15.6% at the end of March, 2022. NTDs were associated with 11.7% of ToPFA cases, 2.5% of stillbirths and 2.8% of infant deaths in 2014-2019. NTD related stillbirth rate was 1.74 per 10,000 births, while NTD related ToPFA rate and infant mortality rate were 0.61 and 2.70 per 10,000 live births respectively. NTD-related stillbirth and infant mortality rate were highest in the Eastern region (3.64 per 10,000 births; 4.65 per 10,000 live births respectively), while ToPFA rate was highest in the North and West regions (1.17 and 0.79 per 10,000 live births respectively) (p < 0.05). Prematurity and low birth weight were the variables with the highest NTD related rates for stillbirths (11.26 and 16.80 per 10,000 birth), ToPFA (9.25 and 12.74) per 10,000 live birth), and infant deaths (13.91 and 20.11 per 10,000 live birth) (p < 0.05). CONCLUSION: NTDs are common and have an important place among the mortality causes in Turkey. Primary prevention through mandatory folic acid fortification should be considered both to reduce the frequency of NTD and related mortality rates.

Maternal first trimester iron status and its association with obstetric and perinatal outcomes.

PURPOSE: To assess the following in singleton pregnant women: (1) associations between first trimester iron deficiency and obstetric and perinatal outcomes, (2) overall first trimester iron status and (3) post-treatment iron status after intensified iron supplementation. METHODS: A prospective cohort study was conducted with linkage of first trimester hemoglobin and plasma ferritin with obstetric and perinatal data from a hospital database. Blood sample data were obtained from a Danish University Hospital. The cohort was divided into groups according to ferritin and hemoglobin: (1) iron-deficient anemic (ferritin < 30 ng/mL and Hb < 110 g/L), (2) iron-deficient non-anemic (ferritin < 30 ng/mL and Hb ≥ 110 g/L), and (3) iron-replete non-anemic (ferritin 30-200 ng/mL and Hb ≥ 110 g/L). Obstetric and perinatal outcomes in each iron-deficient group were compared to the iron-replete non-anemic group using multivariable logistic regression. The effect of 4 weeks intensified iron supplementation on hemoglobin and ferritin was assessed by groupwise comparisons. RESULTS: The cohort comprised 5763 singleton pregnant women, of which 14.2% had non-anemic iron deficiency, and 1.2% had iron-deficiency anemia. Compared to iron-replete non-anemic women, iron-deficient anemic women had a higher risk of gestational diabetes (aOR 3.8, 95% CI 1.4-9.0), and iron-deficient non-anemic women had a higher risk of stillbirth (aOR 4.0, 95% CI 1.0-14.3). In group 1 and 2, 81.5% and 67.7% remained iron-deficient after intensified iron supplementation. CONCLUSION: Iron-deficiency anemia was associated with gestational diabetes, and non-anemic iron deficiency with stillbirth, although risk estimates were imprecise due to few events. Iron deficiency was present in 15.4% and often persisted despite 4 weeks intensified iron supplementation.

Descriptive epidemiology of external structural birth defects in Enugu State, Nigeria.

Objectives: To determine the birth prevalence, trend, and characteristics of external structural birth defects occurrence in Enugu Metropolis, Nigeria. Design: Cross-sectional study involving review of delivery records. Setting: The study was conducted at three tertiary hospitals, one public and two missionary, in Enugu Metropolis. Participants: Mothers and their babies delivered between 1 January 2009 and 31 December 2016 in the study facilities. Main outcome measures: Birth prevalence of defects presented as frequency/10,000 births. Other descriptive variables are presented as frequencies and percentages. Results: There were 21530 births with 133 birth defects (birth prevalence: 61.8/10,000 births) and 1176 stillbirths (stillbirth rate: 54.6/1000 births). The frequencies and birth prevalence (/10,000 births) of recorded defects were: Limb deformities 60(27.9), Neural tube defects (NTDs): 36(16.7), Urogenital system defects: 12(5.6), Gastrointestinal system defects 10(4.6) and Orofacial clefts 4(1.9). Birth defects occurrence showed a rising trend from 2009 to 2016. The mean (SD) age of mothers whose babies had Birth defects was 29.1(4.7) years. Only 62(46.6%) of 133 antenatal clinic folders of these women were traceable for further review. Eighteen (29.0%) had febrile illness in early pregnancy, 9(14.5%) had Malaria, 17(27.4%) had <4 antenatal clinic attendance, 7(11.3%) did not take folic acid and 6(9.7%) took herbal medications during pregnancy. Conclusions: Birth defects occurrence showed a rising trend with limb deformities and NTDs having the highest prevalence. Record keeping was poor at the facilities. Birth defects preventive interventions like folic acid supplementation for women-of-childbearing age should be promoted in Enugu Metropolis. Funding: This work was supported by the non-communicable disease Minigrant from the Task Force for Global Health, Decatur, Georgia, USA (TPN-FE-NCD-C2-IFO-9).

Zinc supplementation for improving pregnancy and infant outcome.

BACKGROUND: It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy, such as prolonged labour, atonic postpartum haemorrhage, pregnancy-induced hypertension, preterm labour and post-term pregnancies, although these associations have not yet been established. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. OBJECTIVES: 1. To compare the effects on maternal, fetal, neonatal and infant outcomes in healthy pregnant women receiving zinc supplementation versus no zinc supplementation, or placebo. 2. To assess the above outcomes in a subgroup analysis reviewing studies performed in women who are, or are likely to be, zinc-deficient. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 July 2020), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials of zinc supplementation versus no zinc supplementation or placebo administration during pregnancy, earlier than 27 weeks' gestation. We excluded quasi-randomised controlled trials. We intended to include studies presented only as abstracts, if they provided enough information or, if necessary, by contacting authors to analyse them against our criteria; we did not find any such studies. DATA COLLECTION AND ANALYSIS: Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. We assessed the certainty of the evidence using GRADE. MAIN RESULTS: For this update, we included 25 randomised controlled trials (RCTs) involving over 18,000 women and their babies. The overall risk of bias was low in half of the studies. The evidence suggests that zinc supplementation may result in little or no difference in reducing preterm births (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.74 to 1.03; 21 studies, 9851 participants; low-certainty evidence). Further, zinc supplementation may make little or no difference in reducing the risk of stillbirth (RR 1.22, 95% CI 0.80 to 1.88; 7 studies, 3295 participants; low-certainty evidence), or perinatal deaths (RR 1.10, 95% CI 0.81 to 1.51; 2 studies, 2489 participants; low-certainty evidence). It is unclear whether zinc supplementation reduces neonatal death, because the certainty of the evidence is very low. Finally, for other birth outcomes, zinc supplementation may make little or no difference to mean birthweight (MD 13.83, 95% CI -15.81 to 43.46; 22 studies, 7977 participants; low-certainty evidence), and probably makes little or no difference in reducing the risk of low birthweight (RR 0.94, 95% CI 0.79 to 1.13; 17 studies, 7399 participants; moderate-certainty evidence) and small-for-gestational age babies when compared to placebo or no zinc supplementation (RR 1.02, 95% CI 0.92 to 1.12; 9 studies, 5330 participants; moderate-certainty evidence). We did not conduct subgroup analyses, as very few studies used normal zinc populations. AUTHORS' CONCLUSIONS: There is not enough evidence that zinc supplementation during pregnancy results in improvements in maternal or neonatal outcomes. Future research to address ways of improving the overall nutritional status of pregnant women, particularly in low-income regions, and not looking at zinc in isolation, should be an urgent priority.

Neonatal admission and mortality in babies born in UK alongside midwifery units: a national population-based case-control study using the UK Midwifery Study System (UKMidSS).

OBJECTIVES: To determine the incidence of and risk factors for neonatal unit admission, intrapartum stillbirth or neonatal death without admission, and describe outcomes, in babies born in an alongside midwifery unit (AMU). DESIGN: National population-based case-control study. METHOD: We used the UK Midwifery Study System to identify and collect data about 1041 women who gave birth in AMUs, March 2017 to February 2018, whose babies were admitted to a neonatal unit or died (cases) and 1984 controls from the same AMUs. We used multivariable logistic regression, generating adjusted OR (aOR) with 95% CIs, to investigate maternal and intrapartum factors associated with neonatal admission or mortality. RESULTS: The incidence of neonatal admission or mortality following birth in an AMU was 1.2%, comprising neonatal admission (1.2%) and mortality (0.01%). White 'other' ethnicity (aOR=1.28; 95% CI=1.01 to 1.63); nulliparity (aOR=2.09; 95% CI=1.78 to 2.45); ≥2 previous pregnancies ≥24 weeks' gestation (aOR=1.38; 95% CI=1.10 to 1.74); male sex (aOR=1.46; 95% CI=1.23 to 1.75); maternal pregnancy problem (aOR=1.40; 95% CI=1.03 to 1.90); prolonged (aOR=1.42; 95% CI=1.01 to 2.01) or unrecorded (aOR=1.38; 95% CI=1.05 to 1.81) second stage duration; opiate use (aOR=1.31; 95% CI=1.02 to 1.68); shoulder dystocia (aOR=5.06; 95% CI=3.00 to 8.52); birth weight <2500 g (aOR=4.12; 95% CI=1.97 to 8.60), 4000-4999 g (aOR=1.64; 95% CI=1.25 to 2.14) and ≥4500 g (aOR=2.10; 95% CI=1.17 to 3.76), were independently associated with neonatal admission or mortality. Among babies admitted (n=1038), 18% received intensive care. Nine babies died, six following neonatal admission. Sepsis (52%) and respiratory distress (42%) were the most common discharge diagnoses. CONCLUSIONS: The results of this study are in line with other evidence on risk factors for neonatal admission, and reassuring in terms of the quality and safety of care in AMUs.

Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review.

BACKGROUND: Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required. METHODS: A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted. RESULTS: 179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions. CONCLUSIONS: Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.

Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study.

BACKGROUND: Strengthening the capacity of midwives to deliver high-quality maternal and newborn health services has been highlighted as a priority by global health organisations. To support low-income and middle-income countries (LMICs) in their decisions about investments in health, we aimed to estimate the potential impact of midwives on reducing maternal and neonatal deaths and stillbirths under several intervention coverage scenarios. METHODS: For this modelling study, we used the Lives Saved Tool to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up in 88 countries that account for the vast majority of the world's maternal and neonatal deaths and stillbirths. We used four scenarios to assess the effects of increasing the coverage of midwife-delivered interventions by a modest amount (10% every 5 years), a substantial amount (25% every 5 years), and the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). We grouped countries in three equal-sized groups according to their Human Development Index. Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries. FINDINGS: We estimated that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths, equating to 1·3 million deaths averted per year by 2035. Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths, allowing 4·3 million lives to be saved annually by 2035. These deaths averted would be particularly concentrated in the group B countries, which currently account for a large proportion of the world's population and have high mortality rates compared with group C. INTERPRETATION: Midwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions. FUNDING: New Venture Fund.