Selenium supplementation in patients with peripartum cardiomyopathy: a proof-of-concept trial.

BACKGROUND: We studied the efficacy and safety of selenium supplementation in patients who had peripartum cardiomyopathy (PPCM) and selenium deficiency. METHODS: We randomly assigned 100 PPCM patients with left ventricular ejection fraction (LVEF) < 45% and selenium deficiency (< 70 µg/L) to receive either oral Selenium (L-selenomethionine) 200 µg/day for 3 months or nothing, in addition to recommended therapy, in an open-label randomised trial. The primary outcome was a composite of persistence of heart failure (HF) symptoms, unrecovered LV systolic function (LVEF < 55%) or death from any cause. RESULTS: Over a median of 19 months, the primary outcome occurred in 36 of 46 patients (78.3%) in the selenium group and in 43 of 54 patients (79.6%) in the control group (hazard ratio [HR] 0.69; 95% confidence interval [CI] 0.43-1.09; p = 0.113). Persistence of HF symptoms occurred in 18 patients (39.1%) in the selenium group and in 37 patients (68.5%) in the control group (HR 0.53; 95% CI 0.30-0.93; p = 0.006). LVEF < 55% occurred in 33 patients (71.7%) in the selenium group and in 38 patients (70.4%) in the control group (HR 0.91; 95% CI 0.57-1.45; p = 0.944). Death from any cause occurred in 3 patients (6.5%) in the selenium group and in 9 patients (16.7%) in the control group (HR 0.37; 95% CI 0.10-1.37; p = 0.137). CONCLUSIONS: In this study, selenium supplementation did not reduce the risk of the primary outcome, but it significantly reduced HF symptoms, and there was a trend towards a reduction of all-cause mortality. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03081949.

Response to wax meta-analysis.

The recent Wax et al. meta-analysis (1) review of previously published homebirth research reflects the willingness of some medical journals to publish faulty conclusions based on misinformation regarding the need for more data on maternal mortality and on data long ago dismissed as unreliable, in an attempt to discredit homebirth.

Delivery practices of traditional birth attendants in Dhaka slums, Bangladesh.

This paper describes associations among delivery-location, training of birth attendants, birthing practices, and early postpartum morbidity in women in slum areas of Dhaka, Bangladesh. During November 1993-May 1995, data on delivery-location, training of birth attendants, birthing practices, delivery-related complications, and postpartum morbidity were collected through interviews with 1,506 women, 489 home-based birth attendants, and audits in 20 facilities where the women from this study gave birth. Associations among maternal characteristics, birth practices, delivery-location, and early postpartum morbidity were specifically explored. Self-reported postpartum morbidity was associated with maternal characteristics, delivery-related complications, and some birthing practices. Dais with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home. Postpartum morbidity did not differ by birth-location. Safe motherhood programmes must develop effective strategies to discourage potentially-harmful home-based delivery practices demonstrated to contribute to morbidity.

Socio-cultural factors in maternal morbidity and mortality: a study of a semi-urban community in southern Nigeria.

STUDY OBJECTIVE: To understand community based or socio-cultural factors that determine maternal morbidity and mortality in a semi-urban setting. DESIGN: The study is an exploratory multidisciplinary operations research and the instruments were focus groups and interviews. SETTING: Ekpoma, a semi-urban community with a population of 70,000 in central part of Edo state in southern Nigeria. PARTICIPANTS: Thirteen groups of women, two groups of men, and two groups of traditional birth attendants. RESULTS: There is a fairly good knowledge of haemorrhage but this is circumscibed by attitudes, practices, and situations that keep women away from or delay the decision to seek modern obstetric care. CONCLUSIONS: For a fuller understanding of maternal morbidity and mortality, it is important to consider factors outside the hospital and formal medical practice. Furthermore, a change of existing knowledge, attitudes, practices, and situations can be enhanced through modelling on them.

Beliefs and practices regarding delivery and postpartum maternal morbidity in rural Bangladesh.

Most maternal deaths occur in the puerperium and most maternal morbidities probably also arise at that time. Maternal morbidities occur much more frequently than maternal deaths, but very little is known about their magnitude or causes. This study uses focus-group discussions to explore the experiences of childbirth and postpartum illness among rural Bangladeshi women. The women's beliefs about disease causation, and their use of traditional health care, are explored. The significance of the findings for the training of traditional birth attendants and for programs of postpartum care is discussed.

PIP: In August 1991 in rural central Bangladesh, researchers conducted focus group discussions with mothers of all ages and trained and untrained traditional birth attendants (TBAs) to examine the experiences of childbirth, postpartum morbidity, local beliefs, and practices. They intended to use the information to design a prospective study of postpartum morbidity and its relation to delivery practices. Postpartum morbidity was common. Most frequently described postpartum conditions were breast problems, perineal problems, infections, and prolapse. Participants mentioned a wide range of local treatments, but few mentioned antibiotics as a treatment for infections. They believed in supernatural causes of disease. Training did not substantially change the belief systems or practices of TBAs. Harmful traditional practices included internal manipulations and massage, introduction of oils into the vagina, use of fundal pressure or tight abdominal bands during labor, pulling on the umbilical cord, choking or inducing vomiting in the mother to facilitate placental delivery, and not using uterine massage to prevent and treat postpartum hemorrhage. Beneficial practices were adopting an upright position and walking during labor, squatting for delivery, noninterferring with the membranes, having psychological support from attendants, and being in familiar surroundings. The custom of seclusion was a key obstacle to health-care seeking after delivery. Thus, home visits during the first two weeks after delivery are needed. Relatives rather than TBAs performed many deliveries. Food taboos were not as significant as earlier believed. These discussions revealed that the preventive aspect of modern prenatal care has not been incorporated into the women's belief system. They also suggest that the need for health care is not being addressed.

Maternal mortality in rural Bangladesh: the Tangail District.

A study was conducted from September 1982 to August 1983 in the Tangail district of Bangladesh to estimate the maternal mortality level there and identify its causes and correlates. A rate of 56.6 per 10,000 live births was found, with abortion-related deaths contributing nearly 10 deaths per 10,000 live births. The major causes of maternal mortality were found to be obstructed labor and sepsis caused by improperly performed abortion. Those at high risk were mothers below age 20 and above age 30 and those above parity four. No inverse relationship was found between maternal mortality and socioeconomic status, as might be expected. Community-level pregnancy monitoring programs, increased attention on the part of family planning workers toward teenaged, older, and high parity mothers, and nutrition supplement programs for anemic mothers are recommended.

PIP: A study was conducted in the Tangail district of Bangladesh from Sept. 1982 to Aug. 1983 to estimate the maternal mortality level there and identify its causes and correlates. 3 questionnaires: 1 for maternal deaths, 1 for deaths other than maternal deaths, and 1 for live births were used to collect data. A rate of 56.6/10,000 live births was found, with abortion related deaths contributing nearly 10 deaths/10,000 live births. The major causes of maternal mortality were found to be obstructed labor and sepsis caused by improperly performed abortion. Those at high risk were mothers below age 20 and above age 30 and those above parity 4. No inverse relationship was found between maternal mortality and socioeconomic status. Community level pregnancy monitoring programs, increased attention on the part of family planning workers toward teenaged, older, and high parity mothers, and nutrition supplement programs for anemic mothers are recommended. This study was faced with a number of methodological limitations that have implications for future research on maternal mortallity in Bangladesh. The number of live births was underestimated, and some types of maternal deaths might not have been detected. These methodological limitations could be corrected by following a 2-step data collection procedure.

Maternal mortality in rural Bangladesh: the Jamalpur District.

During the 12-month period from September 1982 to August 1983, 9,317 live births and 58 maternal deaths were recorded in Melanda and Islampur upazilas in the Jamalpur district of rural Bangladesh, giving a maternal mortality rate of 62.3 per 10,000 live births. Maternal mortality was positively related to maternal age and parity, with the mortality risk rising very sharply beyond age 35 years, and beyond parity four among women aged 25-34 years in particular. The most common causes of maternal death were eclampsia (20.7 percent), septic abortion (20.7 percent), postpartum sepsis (10.3 percent), obstructed labor (10.3 percent), and antepartum and postpartum hemorrhage (10.3 percent). These findings indicate that family planning, by decreasing the likelihood of pregnancy after age 35 and parity four, can help reduce the proportion of women at risk of maternal mortality.

PIP: This study was conducted to determine: the present rate, demographic correlates, and major causes of maternal mortality in rural Bangladesh; the pattern of health practices in relation to maternal mortality; the rate and pattern of neonatal mortality in rural areas; and the reliability of traditional birth attendants as reporters of maternal mortality-related data. During the 12-month period from September 1982 to August 1983, 9,317 live births and 58 maternal deaths were recorded in Melanda and Islampur upazilas in the Jamalpur district of rural Bangladesh, giving a maternal mortality rate of 62.3/10,000 live births. The age-specific maternal mortality rate is lowest in the 20-24 year old age group. Mortality risk increases with age after 29 years, particularly in the 35-39 and the 40-and-over groups. For all ages combined, mortality rates show a positive relation to parity. Although a positive relationship between parity and mortality is visible in the 25-34 group, the relationship is negative in the 35-and-over group. The single most common cause of death was septic abortion. Other causes include eclampsia (20.7%), delivery complications including obstructed labor, retained placenta (17.2%), postpartum sepsis (10.3%), and hemorrhage (10.3%). The classic triad of causes of infection--eclampsia--hemorrhage, accounted for 68.9% of all maternal deaths in the study area; direct obstetric causes accounted for 86.2% of all maternal deaths. The positive correlation between maternal age and maternal mortality risk found in the study indicates that childbearing in women aged above 35 years is significantly more hazardous than in younger women. A high mortality risk was also found among high parity (4) women. Family planning can reduce the risk of maternal mortality.