Cluster randomised trial of an active, multifaceted educational intervention based on the WHO Reproductive Health Library to improve obstetric practices.

OBJECTIVE: We conducted a trial to evaluate the effect of an active, multifaceted educational strategy to promote the use of the WHO Reproductive Health Library (RHL) on obstetric practices. DESIGN: Cluster randomised trial. The trial was assigned the International Standardised Randomised Controlled Trial Number ISRCTN14055385. SETTINGS: Twenty-two hospitals in Mexico City and 18 in the Northeast region of Thailand. METHODS: The intervention consisted primarily of three interactive workshops using RHL over a period of 6 months. The focus of the workshops was to provide access to knowledge and enable its use. A computer and support for using both the computer and RHL were provided at each hospital. The control hospitals did not receive any intervention. MAIN OUTCOME MEASURES: The main outcome measures were changes in ten selected clinical practices as recommended in RHL starting approximately four to six months after the third workshop. Clinical practice data were collected at each hospital from 1000 consecutively delivered women or for a 6-month period whichever was reached sooner. RESULTS: The active, multifaceted educational intervention we employed did not affect the ten targeted practices in a consistent and substantive way. Iron/folate supplementation, uterotonic use after birth and breastfeeding on demand were already frequently practiced, and we were unable to measure external cephalic version. Of the remaining six practices, selective, as opposed to routine episiotomy policy increased in the intervention group (difference in adjusted mean rate = 5.3%; 95% CI -0.1 to 10.7%) in Thailand, and there was a trend towards an increased use of antibiotics at caesarean section in Mexico (difference in adjusted mean rate = 19.0%; 95% CI: -8.0 to 46.0%). There were no differences in the use of labour companionship, magnesium sulphate use for eclampsia, corticosteroids for women delivering before 34 weeks and vacuum extraction. RHL awareness (24.8-65.5% in Mexico and 33.9-83.3% in Thailand) and use (4.8-34.9% in Mexico and 15.5-76.4% in Thailand) increased substantially after the intervention in both countries. CONCLUSION: The multifaceted, active strategy to provide health workers with the knowledge and skills to use RHL to improve their practice led to increased access to and use of RHL, however, no consistent or substantive changes in clinical practices were detected within 4-6 months after the third workshop.

The etiology of maternal mortality in developing countries: what do verbal autopsies tell us?

OBJECTIVE: To reassess the practical value of verbal autopsy data, which, in the absence of more definitive information, have been used to describe the causes of maternal mortality and to identify priorities in programmes intended to save women's lives in developing countries. METHODS: We reanalysed verbal autopsy data from a study of 145 maternal deaths that occurred in Guerrero, Querétaro and San Luis Potosí, Mexico, in 1995, taking into account other causes of death and the WHO classification system. The results were also compared with information given on imperfect death certificates. FINDINGS: The reclassification showed wide variations in the attribution of maternal deaths to single specific medical causes. CONCLUSION: The verbal autopsy methodology has inherent limitations as a means of obtaining histories of medical events. At best it may reconfirm the knowledge that mortality among poor women with little access to medical care is higher than that among wealthier women who have better access to such care.

WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care.

BACKGROUND: We undertook a multicentre randomised controlled trial that compared the standard model of antenatal care with a new model that emphasises actions known to be effective in improving maternal or neonatal outcomes and has fewer clinic visits. METHODS: Clinics in Argentina, Cuba, Saudi Arabia, and Thailand were randomly allocated to provide either the new model (27 clinics) or the standard model currently in use (26 clinics). All women presenting for antenatal care at these clinics over an average of 18 months were enrolled. Women enrolled in clinics offering the new model were classified on the basis of history of obstetric and clinical conditions. Those who did not require further specific assessment or treatment were offered the basic component of the new model, and those deemed at higher risk received the usual care for their conditions; however, all were included in the new-model group for the analyses, which were by intention to treat. The primary outcomes were low birthweight (<2500 g), pre-eclampsia/eclampsia, severe postpartum anaemia (<90 g/L haemoglobin), and treated urinary-tract infection. There was an assessment of quality of care and an economic evaluation. FINDINGS: Women attending clinics assigned the new model (n=12568) had a median of five visits compared with eight within the standard model (n=11958). More women in the new model than in the standard model were referred to higher levels of care (13.4% vs 7.3%), but rates of hospital admission, diagnosis, and length of stay were similar. The groups had similar rates of low birthweight (new model 7.68% vs standard model 7.14%; stratified rate difference 0.96 [95% CI -0.01 to 1.92]), postpartum anaemia (7.59% vs 8.67%; 0.32), and urinary-tract infection (5.95% vs 7.41%; -0.42 [-1.65 to 0.80]). For pre-eclampsia/eclampsia the rate was slightly higher in the new model (1.69% vs 1.38%; 0.21 [-0.25 to 0.67]). Adjustment by several confounding variables did not modify this pattern. There were negligible differences between groups for several secondary outcomes. Women and providers in both groups were, in general, satisfied with the care received, although some women assigned the new model expressed concern about the timing of visits. There was no cost increase, and in some settings the new model decreased cost. INTERPRETATIONS: Provision of routine antenatal care by the new model seems not to affect maternal and perinatal outcomes. It could be implemented without major resistance from women and providers and may reduce cost.

The power of information and contraceptive choice in a family planning setting in Mexico.

OBJECTIVES: This study measured the effect of information about family planning methods and STD risk factors and prevention, together with personal choice on the selection of intrauterine devices (IUDs) by clients with cervical infection. METHODS: We conducted a randomised, controlled trial in which family planning clients were assigned to one of two groups, the standard practice (control) group in which the provider selected the woman's contraceptive and the information and choice (intervention) group. The study enrolled 2107 clients in a family planning clinic in Mexico City. RESULTS: Only 2.1% of the clients had gonorrhoea or chlamydial infections. Significantly fewer women in the intervention group selected the IUD than the proportion for whom the IUD was recommended in the standard care group by clinicians (58.2% v 88.2%, p = 0.0000). The difference was even more pronounced among infected women: 47.8% v 93.2% (intervention v control group, p = 0.0006). CONCLUSIONS: The intervention increased the selection of condoms and reduced the selection of IUDs, especially among women with cervical infections, for whom IUD insertion is contraindicated.

A study on maternal mortality in Mexico through a qualitative approach.

This report presents the main qualitative results of a verbal autopsy study carried out in three states of Mexico, which aimed at identifying the factors associated with maternal mortality that could be subject to modifications through concrete interventions. By reviewing death certificates issued in 1995, it was possible to identify 164 households where a maternal death had occurred. One hundred forty-five of these households were visited, and a precoded questionnaire was completed to explore socioeconomic and living conditions, as well as causes of death. An open-ended question to prompt the relatives to narrate all the facts that led to the maternal deaths was included in the questionnaire. This study presents an analysis of that question, focusing on the delays in the care-seeking process and organized according to the model of the three delays: in deciding to seek care, in reaching a care facility, and in actually receiving care after arrival. Additionally, problems related to quality of care are examined. For analysis of the accounts, structural, interactional/community, and subjective variables were identified that allowed refining of our understanding of the problem of maternal deaths. Finally, based on the findings of the study, this article presents a series of recommendations, highlighting that interventions should address the early stages of a complication and focus on decreasing the various forms of inequality (gender and socioeconomic) associated with the occurrence of maternal deaths.

Health sector reform and reproductive health in Latin America and the Caribbean: strengthening the links.

Many countries in Latin America and the Caribbean (LAC) are currently reforming their national health sectors and also implementing a comprehensive approach to reproductive health care. Three regional workshops to explore how health sector reform could improve reproductive health services have revealed the inherently complex, competing, and political nature of health sector reform and reproductive health. The objectives of reproductive health care can run parallel to those of health sector reform in that both are concerned with promoting equitable access to high quality care by means of integrated approaches to primary health care, and by the involvement of the public in setting health sector priorities. However, there is a serious risk that health reforms will be driven mainly by financial and/or political considerations and not by the need to improve the quality of health services as a basic human right. With only limited changes to the health systems in many Latin American and Caribbean countries and a handful of examples of positive progress resulting from reforms, the gap between rhetoric and practice remains wide.

[Emergency contraception: a simple, safe, effective and economical method for preventing undesired pregnancy]. / Anticoncepción de emergencia: un método simple, seguro, efectivo y económico para prevenir embarazos no deseados.

In the following article, the most recent knowledge on emergency contraception (EC) is reviewed. EC is defined as those contraceptive methods that may be used to prevent an unwanted pregnancy up to 3 days after unprotected intercourse, contraceptive failure or rape. In case of non-hormonal methods (IUD), the time window for pregnancy prevention goes up to 5 days after intercourse. The different regimens now available, hormonal and non-hormonal methods, indications, contraceptive effectiveness, side effects and safety profile, possible mechanisms of action and counseling strategies will be reviewed. The potential benefits on reproductive health of wide-spread knowledge and easy, non-restrictive access to this methodology are emphasized. An extensive list of recent references is enclosed.

Reduction of the cesarean delivery rate in Ecuador.

OBJECTIVE: This quasi-experimental study tested a method to safely reduce the rate of cesarean delivery in Ecuador. METHOD: Hospital policy was modified to provide co-management for cesarean candidates at the major maternity hospital in Quito. Cesarean rates before (n=14743) and after (n=12351) the intervention were compared by chi-square and multiple logistic regression with other major maternity hospitals (before, n=12514; after, n=9590). Characteristics of cesarean candidates who had vaginal or cesarean deliveries in the intervention hospital were compared by chi-square (n=1584). RESULT: Cesarean rates declined by 4.5% (P<0.001) in the intervention hospital. A smaller (2.1%, P<0.01) reduction occurred in the other major public hospital in Quito where students of the co-principal investigator attempted to reduce cesarean delivery. Cesarean rates were unchanged in the public maternity hospitals of other major cities. CONCLUSION: Case co-management, a simple, locally appropriate, and inexpensive intervention, safely reduced surgical delivery, hospital stay and cost of care.

How do researchers influence decision-makers? Case studies of Mexican policies.

Though the problems translating or applying research in policy-making are legion, solutions are rare. As developing countries increase their capacities to develop effective local solutions to their health problems, they confront the research/policy dilemma. Yet few descriptive studies of research-policy links can be found from developing countries, and the relevance of European and North American models and data is questionable. We report the results of a descriptive study from Mexico of the relationship between health research and policy in four vertical programmes (AIDS, cholera, family planning, immunization). We interviewed 67 researchers and policy-makers from different institutions and levels of responsibility. We analyzed interviewee responses looking for factors that promoted or impeded exchanges between researchers and policy-makers. These were, in turn, divided into emphases on content, actors, process, and context. Many of the promoting factors resembled findings from studies in industrialized countries. Some important differences across the four programmes, which also distinguish them from industrialized country programmes, included extent of reliance on formal communication channels, role of the mass media in building social consensus or creating discord, levels of social consensus, role of foreign donors, and extent of support for biomedical versus social research. We recommend various ways to increase the impact of research on health policy-making in Mexico. Some of the largest challenges include the fact that researchers are but one of many interest groups, and research but one input among many equally legitimate elements to be considered by policy-makers. Another important challenge in Mexico is the relatively small role played by the public in policy-making. Further democratic changes in Mexico may be the most important incentive to increase the use of research in policy-making.

Emergency contraception in Mexico City: what do health care providers and potential users know and think about it?

Emergency contraception promises to reduce Mexico's high unwanted pregnancy and unsafe abortion rates. Because oral contraceptives are sold over-the-counter, several emergency contraceptive regimens are already potentially available to those women who know about the method. Soon, specially packaged emergency contraceptives may also arrive in Mexico. To initiate campaigns promoting emergency contraception, we interviewed health care providers and clients at health clinics in Mexico City, ascertaining knowledge, attitudes, and practices concerning the method. We found limited knowledge, but nevertheless cautious support for emergency contraception in Mexico. Health care providers and clients greatly overestimated the negative health effects of emergency contraception, although clients overwhelmingly reported that they would use or recommend it if needed. Although providers typically advocated medically controlled distribution, clients believed emergency contraception should be more widely available, including in schools and vending machines with information prevalent in the mass media and elsewhere.

PIP: An interview was conducted to ascertain knowledge, attitudes, and practices concerning emergency contraception (EC) among health care providers and potential EC users in metropolitan Mexico. Findings showed that there was a limited knowledge about EC per se and its method, but nevertheless, most of the participants were cautious to support EC in Mexico. Health care providers and clients greatly overestimated the negative health effects of EC, although clients overwhelmingly reported that they would use or recommend it if needed. Although providers typically advocated medically controlled distribution, clients believe EC should be more widely available, including in schools and vending machines, with information prevalent in the mass media and elsewhere.

Conceptual bases and methodology for the evaluation of women's and providers' perception of the quality of antenatal care in the WHO Antenatal Care Randomised Controlled Trial.

In this paper, we describe the conceptual bases and methodology used to assess women's and providers' perception of the quality of antenatal care, as part of a large randomised trial in four developing countries. Information has been obtained by applying both qualitative and quantitative methodologies. The focus group discussions and in-depth interviews have contributed useful insights into the cultural milieu in which care is provided, users' and providers' expectations, and their concept of quality. Based on these findings, we developed two standardised questionnaires, one being administered to a representative sample of pregnant women (n = 1600) and the other for all care providers. In this paper we present some of the findings of the focus group discussions and in-depth interviews with women in one country as an example of the kind of information we have obtained. Women expressed their point of view concerning a reduced number of visits, type of provider, information that they get during clinical encounters and interpersonal relations with health professionals. The qualitative information, together with the data we obtain from the surveys, will highlight the aspects that will have be to considered if the new model of care is to be introduced on a routine basis.

PIP: Measurement of the subjective dimension of the quality of health care, including the perceptions of patients and providers, is seldom attempted. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial, underway in 53 clinics in Argentina, Cuba, Thailand, and Saudi Arabia, will apply both quantitative and qualitative methodologies to an assessment of client and staff satisfaction with a new prenatal care program. Specifically, the study addresses user and provider perceptions of quality in the context of a wide spectrum of ethnic backgrounds, social strata, organization of health services, and medical cultures. The research instrument consists of questions that explore the preferences of 1600 women and their providers in terms of the number of prenatal care visits, provider type and gender, time spent in the waiting room and with the provider, and amount and appropriateness of information received during the visits. Preliminary results from focus groups and in-depth interviews indicate that women are concerned about the safety of the reduced number of visits during pregnancy (four for low-risk women) inherent in the experimental regimen, prefer to receive care from specialists rather than family practitioners, are confused by the technical language used by providers, and want more information on the psychosocial aspects of pregnancy. Such qualitative information, together with data obtained from questionnaires, will highlight areas that must be addressed if the new prenatal care model is to be introduced on a routine basis.

Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial.

OBJECT: To evaluate the effects of psychosocial support during labour, delivery and the immediate postpartum period provided by a female companion (doula). DESIGN: The effects of the intervention were assessed by means of a randomised clinical trial. Social support by a doula was provided to women in the intervention group, while women in the control arm received routine care. SETTING: A large social security hospital in Mexico City. PARTICIPANTS: Seven hundred and twenty-four women with a single fetus, no previous vaginal delivery, < 6 cm of cervical dilatation, and no indications for an elective caesarean section were randomly assigned to be accompanied by a doula, or to receive routine care. OUTCOME MEASURES: Breastfeeding practices, duration of labour, medical interventions, mother's emotional conditions, and newborn's health. METHODS: Blinded interviewers obtained data from the clinical records, during encounters with women in the immediate postpartum period, and at their homes 40 days after birth. Relative risks and confidence intervals were estimated for all relevant outcomes. RESULTS: The frequency of exclusive breastfeeding one month after birth was significantly higher in the intervention group (RR 1.64; I-C: 1.01-2.64), as were the behaviours that promote breastfeeding. However, the programme did not achieve a significant effect on full breastfeeding. More women in the intervention group perceived a high degree of control over the delivery experience, and the duration of labour was shorter than in the control group (4.56 hours vs 5.58 hours; RR 1.07 CI (95%) = 1.52 to -0.51). There were no effects either on medical interventions, mothers' anxiety, self-esteem, perception of pain and satisfaction, or in newborns' conditions. CONCLUSIONS: Psychosocial support by doulas had a positive effect on breastfeeding and duration of labour. It had a more limited impact on medical interventions, perhaps because of the strict routine in hospital procedures, the cultural background of the women, the short duration of the intervention, and the profile of the doulas. It is important to include psychosocial support as a component of breastfeeding promotion strategies.

PIP: Studies in numerous countries have documented the positive contributions of doulas--women experienced in childbirth who provide continuous physical, emotional, and informational support to women before, during, and just after childbirth. The present study, conducted in a Mexican Institute of Social Security public hospital, explored the hypothesis that psychosocial support from a doula increases exclusive and full breast feeding by improving the mother's emotional status, shortening the duration of labor, and decreasing medical intervention. 724 women with no previous vaginal delivery and no indications for cesarean section delivery were randomly assigned to be accompanied by a doula (n = 361) or to receive routine care (n = 363). Blinded interviewers obtained outcome data from the clinical records, encounters with mothers in the immediate postpartum period, and home visits 40 days after delivery. The frequency of exclusive breast feeding 1 month after birth was significantly higher in the intervention group than the control group (12% vs. 7%; relative risk (RR), 1.64; 95% confidence interval (CI), 1.01-2.64). However, the program did not achieve a significant effect on full breast feeding (37% and 36%, respectively). The duration of labor was shorter in the intervention group than the control group (4.56 vs. 5.58 hours; RR, 1.07; 95% CI, -1.52-0.51). A significantly larger proportion of women in the intervention group than the control group perceived a high level of control over labor (79.8% vs. 77.1%; RR, 1.14; 95% CI, 1.03-1.27). There were no effects on medical interventions, maternal anxiety, self-esteem, perception of pain, maternal satisfaction, or newborn Apgar scores. Although the prevalence of exclusive breast feeding was low in both groups, these findings suggest that psychosocial support during labor and the immediate postpartum period should be part of a comprehensive strategy to promote breast feeding.

"Alone, I wouldn't have known what to do": a qualitative study on social support during labor and delivery in Mexico.

This article presents some of the most relevant qualitative results of a trial to evaluate the effects of the provision of psychosocial support to first-time mothers during labor, childbirth and in the immediate postpartum period in a social security hospital in Mexico City. The article focuses on the experiences of mothers who have received psychosocial support from a doula (the term doula is used to identify a woman who provides continuous support to a woman during labor. delivery and the immediate postpartum period) and compares them with the experiences of those women who gave birth following normal hospital routine. Sixteen in-depth interviews were held with women in the immediate post partum period (eight of whom had been accompanied by a doula and eight who had not) before they were discharged from hospital, and the results were analyzed using qualitative techniques. The interviews showed that the women accompanied by a doula had a more positive childbirth experience. The differences between both groups related to their perceptions of the childbirth experience; the treatment they received from hospital staff; the information they were given and how well they understood it; their perception of hospital routines; their feelings about cesarean sections and, spatial and temporal perceptions. The most important difference between the two groups was the way they expressed their feelings about their own labor, their sense of control and their self-perception.

Ethnography of fertility and menstruation in rural Mexico.

In rural populations in Mexico, the system of ideas in relation to the reproductive cycle is built on a mestizo base, with pre-Colombian and Western elements. The objective of the study was the analysis of concepts and resources related to human reproduction in Morelos, in order to design a primary reproductive health care program. The use of ethnographic methods helped identify bio-cultural constructs on which the communities base their reproductive patterns. Our main research results reveal that these populations attribute great value to the extension of the family through descendants. Women's sexuality is directly linked to reproduction and blood is the supremely feminine substance. Great importance is consistently attributed to menstruation about which well-defined concepts exist in the community, where as pre-menarche changes are perceived as a state of bio-psychosocial maturity. Menarche beyond 14 years of age is considered abnormal and is attributed to an 'excess of cold' in the body, therapy is usually administered by traditional birth attendants. In the mythical explanations given for bleeding, the moon plays a fundamental role, as the first rupture of the hymen is attributed to it. A general lack of knowledge about ovulation and its relation to reproduction was observed, resulting in incorrect contraceptive practices.

Impact of health education during pregnancy on behavior and utilization of health resources. Latin American Network for Perinatal and Reproductive Research.

OBJECTIVE: Our purpose was to assess whether an intervention in the education of the mother and the support person involves a change in health-related behavior and use of health facilities. STUDY DESIGN: A randomized, controlled trial was conducted in four cities of Latin America on pregnant women at risk. Half of them (n = 1115) received a home intervention of four to six visits dealing with psychosocial support and education about health-related habits, alarm signs, hospital facilities, antismoking and antialcohol programs, and a reinforcement of adequate health services utilization for the pregnant woman and a support person. The control group (n = 1120) received routine prenatal care. RESULTS: The distribution of risk factors and demographic, obstetric, and psychologic characteristics at baseline was similar in both groups. Women in the intervention group showed a statistically significant better knowledge of seven of the nine alarm signs considered and of two of the three labor-onset signs required. No differences between groups were observed in improvement on diet, cigarette and alcohol consumption, maternal physical strain, lactation at 40 days postpartum, and utilization of health facilities. CONCLUSIONS: An intervention of psychosocial support and health education during pregnancy failed to show any benefit on perinatal outcome, health-related behavior, or utilization of health facilities.

The Latin American Multicenter Trial on psychosocial support during pregnancy: methodology and baseline comparability. Latin American Network for Perinatal and Reproductive Research (LANPER).

This article presents the methodology and baseline findings of a large multicenter trial involving four countries from Latin America (Argentina, Brazil, Cuba, and Mexico). The study was a randomized, controlled, single-masked trial to investigate the impact of social support during pregnancy on perinatal outcomes. Pregnant women with gestational ages between 15 and 22 weeks were screened in health facilities in the four countries. Those presenting with one or more risk factors for having a low-birthweight baby were invited to join the trial. A total of 2235 women--between 500 and 600 in each country--were randomized into an intervention (n = 1110) or a control (n = 1125) group. Both groups were comparable in terms of nearly all baseline variables. The intervention group received a minimum of four visits at home by a trained health worker who provided direct emotional support, health education, and an attempt to enhance the woman's social support network. Over 90% of all women were evaluated at 36 weeks of pregnancy and soon after delivery, and 85% at the 40th day postpartum. The outcomes under study included intrauterine growth retardation, gestational age, perinatal and maternal morbidity and mortality, labor interventions, psychological distress and characteristics of the social support network, among others. This trial showed that it was possible to select, screen, randomize, visit, and evaluate a large number of women in four Latin American countries using a standardized methodology.

Estimating maternal mortality in rural areas of Mexico: the application of an indirect demographic method.

OBJECTIVE: To measure maternal mortality levels in rural areas of Mexico. METHODS: In a cross-sectional study, a census of 13,378 households was carried out in the municipalities of Yecapixtla and Tlaltizapan, Morelos, Mexico. Information on 10,443 subjects from 12 to 49 years old was included in the analysis. An indirect method of measuring maternal mortality--the sisterhood method--was used to estimate maternal mortality. Information about the number of sisters of the interviewees who died due to maternal causes was collected in the census. With this information, estimates of maternal mortality related to a period of 10-12 years before the application of the census were obtained. An innovation to the original method was the calculation of a confidence interval for the estimated maternal mortality rate (MMR). RESULTS: The MMR in this region was 18.68/10,000 live births (95% CI 15.79-21.58/10,000 live births). The average risk of dying due to maternal causes was 1 in 87 for women between 12 and 49 years of age. CONCLUSIONS: The sisterhood method was effective for estimating maternal mortality in a small region, with no previous information about this indicator. The method proved to be useful for identifying a priority region for the implementation of maternal mortality reduction programs. Furthermore, the method was particularly convenient since it was applied as part of a multipurpose survey.

[The factors associated with hospital maternal death in the state of Morelos, Mexico]. / Factores asociados a la muerte materna hospitalaria en el estado de Morelos, México.

The objective of this case-control study was to assess some risk factors related to hospital maternal mortality in the state of Morelos, Mexico. The cases were all maternal deaths which occurred in Morelos between 1989 and 1991 (n = 35), and the controls were women who presented the same complications and were taken care for at the same hospitals than the cases, but survived pregnancy and delivery (n = 35). The results showed that living with a partner is a protective factor (OR = 0.08), as well as using family planning methods (OR = 0.15). Not receiving care at the first place where it was requested was a risk factor (OR = 6.6). Maternal deaths had the same number of prenatal care visits than controls, but their first visit occurred, in average, one month later. The implications of the small sample size, characteristic of the studies on maternal mortality, are discussed at length. The results pinpoint the need to strengthen high-risk pregnancies screening programs through early prenatal care, and promote intersectorial strategies to provide care to pregnant women.

Engineering considerations in the development of the automatic implantable cardioverter defibrillator.

Each of the authors played a significant role in the design and development of one or more of the Medrad/Intec/Cardiac Pacemakers Inc defibrillators. In so doing, each has contributed to the realization of Dr Mirowski's dream. That tens of thousands of patients have now benefitted from his leadership and that many AICDs will soon be competing in the marketplace is testimony to his truly remarkable vision and persistence.