Percepção sobre o cuidado à perda gestacional: estudo qualitativo com casais brasileiros / Perceptions on pregnancy loss care: a qualitative study with brazilian couples / Percepción sobre la atención a la pérdida del embarazo: estudio cualitativo con parejas brasileñas

Este artigo analisou a percepção e os sentimentos de casais sobre o atendimento recebido nos serviços de saúde acessados em função de perda gestacional (óbito fetal ante e intraparto). O convite para a pesquisa foi divulgado em mídias sociais (Instagram e Facebook). Dos 66 casais que contataram a equipe, 12 participaram do estudo, cuja coleta de dados ocorreu em 2018. Os casais responderam conjuntamente a uma ficha de dados sociodemográficos e uma entrevista semiestruturada, realizada presencialmente (n=4) ou por videochamada (n=8). Os dados foram gravados em áudio e posteriormente transcritos. A Análise Temática indutiva das entrevistas identificou cinco temas: sentimento de impotência, iatrogenia vivida nos serviços, falta de cuidado em saúde mental, não reconhecimento da perda como evento com consequências emocionais negativas, e características do bom atendimento. Os achados demonstraram situações de violência, comunicação deficitária, desvalorização das perdas precoces, falta de suporte para contato com o bebê falecido e rotinas pouco humanizadas, especialmente durante a internação após a perda. Para aprimorar a assistência às famílias enlutadas, sugere-se qualificação profissional, ampliação da visibilidade do tema entre diferentes atores e reorganização dos serviços, considerando uma diretriz clínica para atenção ao luto perinatal, com destaque para o fortalecimento da inserção de equipes de saúde mental no contexto hospitalar.(AU)

This study analyzed couples' perceptions and feelings about pregnancy loss care (ante and intrapartum fetal death). A research invitation was published on social media (Instagram and Facebook) and data collection took place in 2018. Of the 66 couples who contacted the research team, 12 participated in the study by filling a sociodemographic questionnaire and answering a semi-structured interview in person (n=04) or by video call (n=08). All interviews were audio recorded, transcribed, and examined by Inductive Thematic Analysis, which identified five themes: feelings of impotence, iatrogenic experiences in health services, lack of mental health care, not recognizing pregnancy loss as an emotionally overwhelming event, and aspects of good healthcare. Analysis showed experiences of violence, poor communication, devaluation of early losses, lack of support for contact with the deceased baby, and dehumanizing routines, especially during hospitalization after loss. Professional qualification, extended pregnancy loss visibility among different stakeholders, and reorganization of health services are needed to improve the care offered to grieving families, considering a clinical guideline for perinatal grief care with emphasis on strengthening the insertion of mental health teams in the hospital context.(AU)

Este estudio analizó las percepciones y sentimientos de parejas sobre la atención recibida en los servicios de salud a los que accedieron debido a la pérdida del embarazo (muerte fetal ante e intraparto). La invitación al estudio se publicó en las redes sociales (Instagram y Facebook). De las 66 parejas que se contactaron con el equipo, 12 participaron en el estudio, cuya recolección de datos se realizó en 2018. Las parejas respondieron un formulario de datos sociodemográficos y realizaron una entrevista semiestructurada presencialmente (n=4) o por videollamada (n=08). Los datos se grabaron en audio para su posterior transcripción. El análisis temático inductivo identificó cinco temas: Sentimiento de impotencia, experiencias iatrogénicas en los servicios, falta de atención a la salud mental, falta de reconocimiento de la pérdida como un evento con consecuencias emocionales negativas y características de buena atención. Los hallazgos evidenciaron situaciones de violencia, comunicación deficiente, desvalorización de las pérdidas tempranas, falta de apoyo para el contacto con el bebé fallecido y rutinas poco humanizadas, especialmente durante la hospitalización tras la pérdida. Para mejorar la atención a las familias en duelo, se sugiere capacitación profesional, ampliación de la visibilidad del tema entre los diferentes actores y reorganización de los servicios, teniendo en cuenta una guía clínica para la atención del duelo perinatal, enfocada en fortalecer la inserción de los equipos de salud mental en el contexto hospitalario.(AU)

Comportamiento de algunos indicadores del Programa Materno Infantil en Campechuela durante los años 1980-2018 / Behavior of some indicators of the Maternal and Child Program in Campechuela during the years 1980-2018

Introducción: el Programa Materno Infantil es un programa muy sensible en el sector de la salud ya que declara la atención integral tanto a la embarazada, a la madre, al niño y al adolescente. Las tasas de mortalidad fetal, en menores de un año y el bajo peso al nacer son indicadores que reflejan las condiciones de vida de la mujer; la morbilidad subyacente y la calidad de vida de una sociedad. Objetivo: determinar el comportamiento de estos dos indicadores en el municipio de Campechuela durante los años 1980 a 2018, período de 39 años. Métodos: se realizó un estudio observacional descriptivo, retrospectivo. El universo comprendió todos los nacimientos en Campechuela en los años de estudio, las muertes en menores de 1 año, las muertes fetales y el bajo peso al nacer. Se representaron los resultados expresados en frecuencias absolutas, frecuencias relativas y tasas. Mediante el empleo de las técnicas de la estadística descriptiva. Resultados: la natalidad ha disminuido a lo largo del período en estudio con variaciones en el tiempo, la tasa de mortalidad infantil ha tenido una disminución considerable, no siendo así, el bajo peso que han tenido fluctuaciones, y las defunciones fetales se ha comportado de forma desfavorable, los resultados permiten valorar que hay que intensificar aún más el control y seguimiento a este grupo priorizado, e incrementar las pesquisas de los factores de riesgo que conllevan a estos indicadores no favorables. Conclusiones: los indicadores del Programa Materno Infantil miden la calidad de vida de una nación, a pesar de todas las estrategias tomadas por el Ministerio de Salud Pública existen algunos resultados que hay que revertir como las muertes fetales, por lo que se requiere de más trabajo desde la Atención Primaria de Salud haciendo énfasis en la promoción y la prevención, trabajar con intención los protocolos de actuación en dicho programa(AU)

Introduction: the Maternal and Child Program is a very sensitive program in the health sector since it declares comprehensive care for pregnant women, mothers, children and adolescents. Fetal mortality rates in children under one year of age and low birth weight are indicators that reflect the living conditions of women; the underlying morbidity and quality of life of a society. Objective: to determine the behavior of these two indicators in the municipality of Campechuela during the years 1980 to 2018, a period of 39 years. Methods: a retrospective, descriptive, observational study was carried out. The universe included all the births in Campechuela in the study years, deaths in children under 1 year of age, fetal deaths and low birth weight. The results expressed in absolute frequencies, relative frequencies and rates were represented. Through the use of descriptive statistics techniques. Results: the birth rate has decreased throughout the period under study with variations over time, the infant mortality rate has had a considerable decrease, not being the case, the low weight that has fluctuated, and fetal deaths have behaved in a different way. In an unfavorable way, the results allow us to assess that it is necessary to further intensify the control and monitoring of this prioritized group, and to increase the investigation of the risk factors that lead to these unfavorable indicators. Conclusions: the indicators of the Maternal and Child Program measure the quality of life of a nation, despite all the strategies taken by the Ministry of Public Health there are some results that must be reversed, such as fetal deaths, so more work is required from Primary Health Care, emphasizing promotion and prevention, working with intention the protocols of action in said program(EU)

Why do community members believe mothers and babies are dying? Behavioral versus situational attribution in rural northern Ghana.

OBJECTIVE: Rates of maternal and neonatal death remain high in the Global South, especially in Sub-Saharan Africa. In addition, indicators vary significantly by geography. This study aimed to understand what communities in northern Ghana with frequent maternal and newborn deaths or near deaths (near-misses) perceive to be the causes. As part of a larger study, four communities in Ghana's Northern Region were identified as areas with high concentrations of deaths and near-misses of mothers and babies. DESIGN: Stakeholders were interviewed using in-depth interviews (IDIs) and focus-group discussions (FGDs). Field workers conducted 12 FGDs and 12 IDIs across a total of 126 participants. SETTING: This exploratory descriptive study was conducted in the East Mamprusi District in the Northern Region of Ghana, in the communities of Jawani, Nagboo, Gbangu and Wundua. PARTICIPANTS: FGDs were led by trained field workers and attended by traditional chiefs and their elders, members of women's groups, and traditional birth attendants in each of the four study communities. IDIs, or one-on-one interviews, were conducted with traditional healers who manage maternal and neonatal cases, community health nurses, and midwives. MEASUREMENTS AND FINDINGS: Qualitative data were audio-recorded, transcribed, and thematically analyzed using the Attride-Sterling analytical framework. Discussions focused on where blame should be attributed for the negative outcomes of mothers and babies - with blame either being directed at the actions or inactions of the mothers (behavioral), or at the larger factors associated with poverty (situational) that necessitate mothers' behavior. For example, some respondents blamed women for their poor diets, while others blamed the lack of money or household support to buy nutritious foods. Blame was rarely attributed to the fathers despite local gender norms of males being the household decision-makers with regard to spending and care-seeking. KEY CONCLUSIONS: These findings contribute to a small but growing body of literature on the blaming of mothers for their own deaths and those of their newborns - a phenomenon also described in high-income countries - and is supported by blame attribution theories that explain the self-protective nature of victim-blaming. IMPLICATIONS FOR PRACTICE: These results carry important implications for education and intervention design related to maternal and neonatal mortality, including more focused efforts at incorporating men and the larger community. More research is warranted on blame attribution for these adverse outcomes and its effects on the victims.

A case-control study of risk factors for fetal and early neonatal deaths in a tertiary hospital in Kenya.

BACKGROUND: It is important to understand the risk factors for fetal and neonatal mortality which is a major contributor to high under five deaths globally. Fetal and neonatal mortality is a sensitive indicator of maternal health in society. This study aimed to examine the risk factors for fetal and early neonatal mortality at the Moi Teaching and Referral Hospital in Kenya. METHODS: This was a case-control study. Cases were fetal and early neonatal deaths (n = 200). The controls were infants born alive immediately preceding and following the cases (n = 400). Bivariate comparisons and multiple logistic regression analyses were undertaken. RESULTS: The odds of having 0-1 antenatal visits relative to 2-3 visits were higher for cases than controls (Adjusted Odds Ratio (AOR) = 4.5; 95% CI: 1.2-16.7; p = 0.03)). There were lower odds among cases of having a doctor rather than a midwife as a birth attendant (AOR = 0.2; 95% CI: 0.1-0.6; p < 0.01). The odds of mothers having Premature Rupture of Membranes (AOR = 4.1; 95% CI: 1.4-12.1; p = 0.01), haemorrhage (AOR = 4.8; 95% CI: 1.1-21.9; p = 0.04) and dystocia (AOR = 3.6; 95% CI: 1.2-10.9; p = 0.02) were higher for the cases compared with the controls. The odds of gestational age less than 37 weeks (AOR = 7.0; 95% CI 2.4-20.4) and above 42 weeks (AOR = 16.2; 95% CI 2.8-92.3) compared to 37-42 weeks, were higher for cases relative to controls (p < 0.01). Cases had higher odds of being born with congenital malformations (AOR = 6.3; 95% CI: 1.2-31.6; p = 0.04) and with Apgar scores of below six at five minutes (AOR = 26.4; 95% CI: 6.1-113.8; p < 0.001). CONCLUSION: Interventions that focus on educating mothers on antenatal attendance, screening, monitoring and management of maternal conditions during the antenatal period should be strengthened. Doctor attendance at each birth and for emergency admissions is important to ensure early neonatal survival and avert potential risk factors for mortality.

Global estimates of syphilis in pregnancy and associated adverse outcomes: analysis of multinational antenatal surveillance data.

BACKGROUND: The World Health Organization initiative to eliminate mother-to-child transmission of syphilis aims for ≥ 90% of pregnant women to be tested for syphilis and ≥ 90% to receive treatment by 2015. We calculated global and regional estimates of syphilis in pregnancy and associated adverse outcomes for 2008, as well as antenatal care (ANC) coverage for women with syphilis. METHODS AND FINDINGS: Estimates were based upon a health service delivery model. National syphilis seropositivity data from 97 of 193 countries and ANC coverage from 147 countries were obtained from World Health Organization databases. Proportions of adverse outcomes and effectiveness of screening and treatment were from published literature. Regional estimates of ANC syphilis testing and treatment were examined through sensitivity analysis. In 2008, approximately 1.36 million (range: 1.16 to 1.56 million) pregnant women globally were estimated to have probable active syphilis; of these, 80% had attended ANC. Globally, 520,905 (best case: 425,847; worst case: 615,963) adverse outcomes were estimated to be caused by maternal syphilis, including approximately 212,327 (174,938; 249,716) stillbirths (>28 wk) or early fetal deaths (22 to 28 wk), 91,764 (76,141; 107,397) neonatal deaths, 65,267 (56,929; 73,605) preterm or low birth weight infants, and 151,547 (117,848; 185,245) infected newborns. Approximately 66% of adverse outcomes occurred in ANC attendees who were not tested or were not treated for syphilis. In 2008, based on the middle case scenario, clinical services likely averted 26% of all adverse outcomes. Limitations include missing syphilis seropositivity data for many countries in Europe, the Mediterranean, and North America, and use of estimates for the proportion of syphilis that was "probable active," and for testing and treatment coverage. CONCLUSIONS: Syphilis continues to affect large numbers of pregnant women, causing substantial perinatal morbidity and mortality that could be prevented by early testing and treatment. In this analysis, most adverse outcomes occurred among women who attended ANC but were not tested or treated for syphilis, highlighting the need to improve the quality of ANC as well as ANC coverage. In addition, improved ANC data on syphilis testing coverage, positivity, and treatment are needed. Please see later in the article for the Editors' Summary.

Louisiana implementation of the National Fetal and Infant Mortality Review (NFIMR) program model: successes and opportunities.

Common features of successful, local-level, Fetal Infant Mortality Review (FIMR) Programs are identified by the National Fetal and Infant Mortality Review (NFIMR) Program, including medical records abstraction and home interviews, case reviews by a case review team (CRT), and community systems action recommendations implemented by a community action team (CAT). This paper presents Louisiana's FIMR program, an adaptation of NFIMR recommendations. In 2001, the Louisiana Maternal and Child Health Program began a statewide FIMR Network (LaFIMR) based on the NFIMR model. Geographic areas of focus, case identification, staffing, data collection methods, and CRT and CAT membership and activities include modifications of the NFIMR recommendations unique to LaFIMR implementation. Adaptations made to the NFIMR model were advantageous to LaFIMR's success. Specifically, LaFIMR geographic areas of interest cover multiple natural communities. Compared with independent FIMR programs elsewhere, LaFIMR represents a Title V Program-based coordinated network of regional LaFIMR teams offering opportunities for expanded partnerships. Primary sources for LaFIMR case identification include obituaries and hospital logs, with secondary identification available through vital records. Improvements in vital records data systems are expected to enhance future LaFIMR case identification. LaFIMR-identified records that are linked with vital event certificates provide enhanced contextual findings for reviews and support continuous quality improvement processes. These differences in the LaFIMR implementation reinforce the NFIMR-supported uniqueness of FIMR programs across the United States, and may encourage other FIMR programs to consider how adaptations to NFIMR recommendations could benefit their programs.

Home birth attendants in low income countries: who are they and what do they do?

BACKGROUND: Nearly half the world's babies are born at home. We sought to evaluate the training, knowledge, skills, and access to medical equipment and testing for home birth attendants across 7 international sites. METHODS: Face-to-face interviews were done by trained interviewers to assess level of training, knowledge and practices regarding care during the antenatal, intrapartum and postpartum periods. The survey was administered to a sample of birth attendants conducting home or out-of-facility deliveries in 7 sites in 6 countries (India, Pakistan, Guatemala, Democratic Republic of the Congo, Kenya and Zambia). RESULTS: A total of 1226 home birth attendants were surveyed. Less than half the birth attendants were literate. Eighty percent had one month or less of formal training. Most home birth attendants did not have basic equipment (e.g., blood pressure apparatus, stethoscope, infant bag and mask manual resuscitator). Reporting of births and maternal and neonatal deaths to government agencies was low. Indian auxilliary nurse midwives, who perform some home but mainly clinic births, were far better trained and differed in many characteristics from the birth attendants who only performed deliveries at home. CONCLUSIONS: Home birth attendants in low-income countries were often illiterate, could not read numbers and had little formal training. Most had few of the skills or access to tests, medications and equipment that are necessary to reduce maternal, fetal or neonatal mortality.

Integrated approaches to improve birth outcomes: perinatal periods of risk, infant mortality review, and the Los Angeles Mommy and Baby Project.

This article provides an example of how Perinatal Periods of Risk (PPOR) can provide a framework and offer analytic methods that move communities to productive action to address infant mortality. Between 1999 and 2002, the infant mortality rate in the Antelope Valley region of Los Angeles County increased from 5.0 to 10.6 per 1,000 live births. Of particular concern, infant mortality among African Americans in the Antelope Valley rose from 11.0 per 1,000 live births (7 cases) in 1999 to 32.7 per 1,000 live births (27 cases) in 2002. In response, the Los Angeles County Department of Public Health, Maternal, Child, and Adolescent Health Programs partnered with a community task force to develop an action plan to address the issue. Three stages of the PPOR approach were used: (1) Assuring Readiness; (2) Data and Assessment, which included: (a) Using 2002 vital records to identify areas with the highest excess rates of feto-infant mortality (Phase 1 PPOR), and (b) Implementing Infant Mortality Review (IMR) and the Los Angeles Mommy and Baby (LAMB) Project, a population-based study to identify potential factors associated with adverse birth outcomes. (Phase 2 PPOR); and (3) Strategy and Planning, to develop strategic actions for targeted prevention. A description of stakeholders' commitments to improve birth outcomes and monitor infant mortality is also given. The Antelope Valley community was engaged and ready to investigate the local rise in infant mortality. Phase 1 PPOR analysis identified Maternal Health/Prematurity and Infant Health as the most important periods of risk for further investigation and potential intervention. During the Phase 2 PPOR analyses, IMR found a significant proportion of mothers with previous fetal loss (45%) or low birth weight/preterm (LBW/PT) birth, late prenatal care (39%), maternal infections (47%), and infant safety issues (21%). After adjusting for potential confounders (maternal age, race, education level, and marital status), the LAMB case-control study (279 controls, 87 cases) identified additional factors associated with LBW births: high blood pressure before and during pregnancy, pregnancy weight gain falling outside of the recommended range, smoking during pregnancy, and feeling unhappy during pregnancy. PT birth was significantly associated with having a previous LBW/PT birth, not taking multivitamins before pregnancy, and feeling unhappy during pregnancy. In response to these findings, community stakeholders gathered to develop strategic actions for targeted prevention to address infant mortality. Subsequently, key funders infused resources into the community, resulting in expanded case management of high-risk women, increased family planning services and local resources, better training for nurses, and public health initiatives to increase awareness of infant safety. Community readiness, mobilization, and alignment in addressing a public health concern in Los Angeles County enabled the integration of PPOR analytic methods into the established IMR structure and [the design and implementation of a population-based l study (LAMB)] to monitor the factors associated with adverse birth outcomes. PPOR proved an effective approach for identifying risk and social factors of greatest concern, the magnitude of the problem, and mobilizing community action to improve infant mortality in the Antelope Valley.

Preconception care.

UNLABELLED: Our objective was to provide the clinician with easy-to-use evidence-based guidelines, based on the best available literature, for offering effective preconception care, aimed at decreasing maternal and fetal/neonatal morbidity and mortality. We searched the Cochrane Library, MEDLINE, and PUBMED from 1966 until January 2009. We used the search terms "preconception," "preconception care," "prepregnancy," and "inter-pregnancy." We focused on level I publications, randomized studies, and meta-analyses of these studies in particular. We included non-English publications, if pertinent. We searched the reference lists of manuscripts identified, and selected those we judged relevant. Preconception care has been defined as a set of interventions that aim to identify and modify risks to a woman's health or pregnancy outcome through prevention and management. It should occur any time any healthcare provider sees a reproductive age woman. Personal and family history, physical exam, laboratory screening, reproductive plan, nutrition, supplements, weight, exercise, vaccinations, and injury prevention should be reviewed in all women. Folic acid 400 mcg per day, as well as proper diet and exercise should be encouraged. Women should receive the influenza vaccine if planning pregnancy during flu season; the rubella and varicella vaccines if there's no evidence of immunity to these viruses; and tetanus/diphtheria/pertussis if lacking adult vaccination. Specific interventions to reduce morbidity and mortality for both the woman and her baby should be offered to those identified with chronic diseases, or exposed to teratogens or illicit substances. There are several interventions that have been proven to effectively improve pregnancy outcome when provided as preconception care. These should be consistently provided to reproductive-age women. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEANING OBJECTIVES: After completion of this educational activity, the participant should be better able to assess potential benefits for women and their offspring that result from preconception care, translate specific evidence-based preconception strategies into clinical practice, and select resources for practitioners and patients that are print media or online related to preconception health.

Effects of maternal zinc supplementation on pregnancy and lactation outcomes.

Observational studies in human populations suggest that maternal zinc deficiency during pregnancy may cause adverse pregnancy outcomes for the mother and fetus. Therefore, we reviewed the current evidence from studies of zinc supplementation, with or without other micronutrients, during pregnancy and lactation to assess its impact on maternal, fetal, and infant health. A meta-analysis of supplementation trials indicates a 14% reduction in premature delivery among zinc-supplemented women. Most studies found no significant impact of maternal zinc supplementation on infant birthweight, but a subset of studies conducted in underweight or zinc-deficient women suggests that there may be a positive effect of zinc supplementation in such women. However, the number of relevant studies is limited, and more information is needed to confirm these observations. The results for other pregnancy outcomes are inconsistent, and the number of available studies is small. Likewise, the impact of maternal zinc supplementation during pregnancy on infant postnatal growth and risk of infection is variable, and few studies are available. Thus, more research will be needed to allow definitive conclusions to be drawn, especially for the second half of infancy and later childhood. Studies found no adverse effects of maternal zinc supplementation on iron status during pregnancy. More information is required on other potential adverse effects, particularly with regard to a possible modifying effect of preexisting maternal zinc status. In view of the possible benefits of zinc supplementation for reducing the risk of premature delivery, the possible positive impact of zinc supplementation on infant birthweight among undernourished women, and the lack of reported adverse effects, zinc should be included in maternal supplements given during pregnancy in populations at risk for zinc deficiency.

Multiple micronutrient supplementation during pregnancy in developing-country settings: policy and program implications of the results of a meta-analysis.

BACKGROUND: An independent Systematic Review Team performed a meta-analysis of 12 randomized, controlled trials comparing multiple micronutrients with daily iron-folic acid supplementation during pregnancy. OBJECTIVE: To provide an independent interpretation of the policy and program implications of the results of the meta-analysis. METHODS: A group of policy and program experts performed an independent review of the meta-analysis results, analyzing internal and external validity and drawing conclusions on the program implications. RESULTS: Although iron content was often lower in the multiple micronutrient supplement than in the iron-folic acid supplement, both supplements were equally effective in tackling anemia. Community-based supplementation ensured high adherence, but some mothers still remained anemic, indicating the need to concomitantly treat infections. The small, significant increase in mean birthweight among infants of mothers receiving multiple micronutrients compared with infants of mothers receiving iron-folic acid is of similar magnitude to that produced by food supplementation during pregnancy. Larger micronutrient doses seem to produce greater impact. Meaningful improvements have also been observed in height and cognitive development of the children by 2 years of age. There were no significant differences in the rates of stillbirth, early neonatal death, or neonatal death between the supplemented groups. The nonsignificant trend toward increased early neonatal mortality observed in the groups receiving multiple micronutrients may be related to differences across trials in the rate of adolescent pregnancies, continuing iron deficiency, and/or adequacy of postpartum health care and merits further investigation. CONCLUSIONS: Replacing iron-folic acid supplements with multiple micronutrient supplements in the package of health and nutrition interventions delivered to mothers during pregnancy will improve the impact of supplementation on birthweight and on child growth and development.

Multiple micronutrient supplementation during pregnancy in low-income countries: a meta-analysis of effects on stillbirths and on early and late neonatal mortality.

BACKGROUND: Multiple micronutrient deficiencies are common among women in low-income countries and may adversely affect pregnancy outcomes. OBJECTIVE: To conduct a meta-analysis of the effects on stillbirths and on early and late neonatal mortality of supplementation during pregnancy with multiple micronutrients compared with iron-folic acid in recent randomized, controlled trials. METHODS: Twelve randomized, controlled trials were included in the analysis (Bangladesh; Burkina Faso; China; Guinea-Bissau; Indramayu and Lombok, Indonesia; Mexico; Sarlahi and Janakur, Nepal; Niger; Pakistan; and Zimbabwe), all providing approximately 1 recommended dietary allowance (RDA) of multiple micronutrients or iron-folic acid to presumed HIV-negative women. RESULTS: Supplementation providing approximately I RDA of multiple micronutrients did not decrease the risk of stillbirth (OR = 1.01; 95% CI, 0.88 to 1.16), early neonatal mortality (OR = 1.23; 95% CI, 0.95 to 1.59), late neonatal mortality (OR = 0.94; 95% CI, 0.73 to 1.23), or perinatal mortality (OR = 1.11; 95% CI, 0.93 to 1.33). CONCLUSIONS: Our meta-analysis provides consistent evidence that supplementation providing approximately 1 RDA of multiple micronutrients during pregnancy does not result in any reduction in stillbirths or in early or late neonatal deaths compared with iron-folic acid alone.

Coffee and fetal death: a cohort study with prospective data.

The authors conducted a cohort study within the Danish National Birth Cohort to determine whether coffee consumption during pregnancy is associated with late fetal death (spontaneous abortion and stillbirth). A total of 88,482 pregnant women recruited from March 1996 to November 2002 participated in a comprehensive interview on coffee consumption and potentially confounding factors in pregnancy. Information on pregnancy outcome was obtained from the National Hospital Discharge Register and medical records. The authors detected 1,102 fetal deaths. High levels of coffee consumption were associated with an increased risk of fetal death. Relative to nonconsumers of coffee, the adjusted hazard ratios for fetal death associated with coffee consumption of 1/2-3, 4-7, and > or =8 cups of coffee per day were 1.03 (95% confidence interval (CI): 0.89, 1.19), 1.33 (95% CI: 1.08, 1.63), and 1.59 (95% CI: 1.19, 2.13), respectively. Reverse causation due to unrecognized fetal demise may explain the association between coffee intake and risk of fetal death prior to 20 completed weeks' gestation but not the association with fetal loss following 20 completed weeks' gestation. Consumption of coffee during pregnancy was associated with a higher risk of fetal death, especially losses occurring after 20 completed weeks of gestation.

Enfermedad hemolítica feto-neonatal: nuestra experiencia en transfusiones intra-uterinas intraperitoneales / Feto-neonatal haemolytic disease: our experience intraperitoneal intra-uterine transfusions

Desde enero de 1985 a diciembre de 1992 se realizaron 250 transfusiones intra-útero bajo control ecográfico en 106 pacientes con enfermedad hemolítica feto-neonatal severa (grado III) que es aproximadamente la cuarta parte (23,7 por ciento) de la población sensibilizada. Detallamos técnicas y metodología utilizada. Se analizan los resultados obtenidos (nacidos vivos o nacidos muertos) según semanas de iniciación del tratamiento y presencia o no de ascitis. La proporción de nacidos vivos fue significativamente superior cuando iniciamos el tratamiento en la semana 25 o después. La proporción de nacidos vivos fue significativamente menor cuando existió ascitis al inicio del tratamiento

Enfermedad hemolítica feto-neonatal: nuestra experiencia en transfusiones intra-uterinas intraperitoneales / Feto-neonatal haemolytic disease: our experience intraperitoneal intra-uterine transfusions

Desde enero de 1985 a diciembre de 1992 se realizaron 250 transfusiones intra-útero bajo control ecográfico en 106 pacientes con enfermedad hemolítica feto-neonatal severa (grado III) que es aproximadamente la cuarta parte (23,7 por ciento) de la población sensibilizada. Detallamos técnicas y metodología utilizada. Se analizan los resultados obtenidos (nacidos vivos o nacidos muertos) según semanas de iniciación del tratamiento y presencia o no de ascitis. La proporción de nacidos vivos fue significativamente superior cuando iniciamos el tratamiento en la semana 25 o después. La proporción de nacidos vivos fue significativamente menor cuando existió ascitis al inicio del tratamiento

Evaluación de la salud fetal: situación perinatal organización / Evaluatión of fetal health: perinatal situation and organization

El objeto de este libro es dar a conocer los resultados de una estrategia ante una problemática de salud pública; mortalidad perinatal debido a hipoxia fetal, incluyendo investigación y evaluación tecnológica para el diagnóstico precoz de esos daños, conocer su verdadera utilidad y finalmente llegar a la implementación de un esquema de estudio o árbol de decisiones en la atención de embarazadas de riesgos. Este libro tiene tres finalidades; la primera es exponer una respuesta asistencial a una situación de salud, la segunda divulgar un procedimiento investigativo usando evaluación de técnicas diagnóstico y la tercera una finalidad docente al difundir aspectos de base en el área materno infantil para todo el equipo de salud. Se puede dividir esta Obra en tres grandes partes: la primera muestra la situación perinatal, la segunda detalla el proceso de investigación con sus resultados, conclusiones y un esquema de asistencia o arbol de decisiones aplicándola a la problematica de salud fetal, y una tercera, organización perinatal