Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of Maternal and Newborn Health.

OBJECTIVE: To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low- and middle-income countries. DESIGN: Secondary analysis of a multi-country cross-sectional study. SETTING: 29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health. POPULATION: 258 215 singleton deliveries in 286 hospitals. METHODS: We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries. MAIN OUTCOME MEASURES: Preterm delivery. RESULTS: In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2-34.6%)] compared with medium (4.3%, 3.0-6.7%), and high-HDI countries (4.8%, 4.4-5.5%). CONCLUSION: Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low-HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary. TWEETABLE ABSTRACT: Inclusion of stillbirths increases preterm birth rates estimates, especially in low-HDI countries.

Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study.

OBJECTIVE: To investigate the risk of adverse pregnancy outcomes among adolescents in 29 countries. DESIGN: Secondary analysis using facility-based cross-sectional data of the World Health Organization Multicountry Survey on Maternal and Newborn Health. SETTING: Twenty-nine countries in Africa, Latin America, Asia and the Middle East. POPULATION: Women admitted for delivery in 359 health facilities during 2-4 months between 2010 and 2011. METHODS: Multilevel logistic regression models were used to estimate the association between young maternal age and adverse pregnancy outcomes. MAIN OUTCOME MEASURES: Risk of adverse pregnancy outcomes among adolescent mothers. RESULTS: A total of 124 446 mothers aged ≤24 years and their infants were analysed. Compared with mothers aged 20-24 years, adolescent mothers aged 10-19 years had higher risks of eclampsia, puerperal endometritis, systemic infections, low birthweight, preterm delivery and severe neonatal conditions. The increased risk of intra-hospital early neonatal death among infants born to adolescent mothers was reduced and statistically insignificant after adjustment for gestational age and birthweight, in addition to maternal characteristics, mode of delivery and congenital malformation. The coverage of prophylactic uterotonics, prophylactic antibiotics for caesarean section and antenatal corticosteroids for preterm delivery at 26-34 weeks was significantly lower among adolescent mothers. CONCLUSIONS: Adolescent pregnancy was associated with higher risks of adverse pregnancy outcomes. Pregnancy prevention strategies and the improvement of healthcare interventions are crucial to reduce adverse pregnancy outcomes among adolescent women in low- and middle-income countries.

Advanced maternal age and pregnancy outcomes: a multicountry assessment.

OBJECTIVE: To assess the association between advanced maternal age (AMA) and adverse pregnancy outcomes. DESIGN: Secondary analysis of the facility-based, cross-sectional data of the WHO Multicountry Survey on Maternal and Newborn Health. SETTINGS: A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East. SAMPLE: A total of 308 149 singleton pregnant women admitted to the participating health facilities. METHODS: We estimated the prevalence of pregnant women with advanced age (35 years or older). We calculated adjusted odds ratios of individual severe maternal and perinatal outcomes in these women, compared with women aged 20-34 years, using a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. The confounding factors included facility and individual characteristics, as well as country (classified by maternal mortality ratio level). MAIN OUTCOME MEASURES: Severe maternal adverse outcomes, including maternal near miss (MNM), maternal death (MD), and severe maternal outcome (SMO), and perinatal outcomes, including preterm birth (<37 weeks of gestation), stillbirths, early neonatal mortality, perinatal mortality, low birthweight (<2500 g), and neonatal intensive care unit (NICU) admission. RESULTS: The prevalence of pregnant women with AMA was 12.3% (37 787/308 149). Advanced maternal age significantly increased the risk of maternal adverse outcomes, including MNM, MD, and SMO, as well as the risk of stillbirths and perinatal mortalities. CONCLUSIONS: Advanced maternal age predisposes women to adverse pregnancy outcomes. The findings of this study would facilitate antenatal counselling and management of women in this age category.

Maternal and institutional characteristics associated with the administration of prophylactic antibiotics for caesarean section: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: To illustrate the variability in the use of antibiotic prophylaxis for caesarean section, and its effect on the prevention of postoperative infections. DESIGN: Secondary analysis of a cross-sectional study. SETTING: Twenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health. POPULATION: Three hundred and fifty-nine health facilities with the capacity to perform caesarean section. METHODS: Descriptive analysis and effect estimates using multilevel logistic regression. MAIN OUTCOME MEASURES: Coverage of antibiotic prophylaxis for caesarean section. RESULTS: A total of 89 121 caesarean sections were performed in 332 of the 359 facilities included in the survey; 87% under prophylactic antibiotic coverage. Thirty five facilities provided 0-49% coverage and 77 facilities provided 50-89% coverage. Institutional coverage of prophylactic antibiotics varied greatly within most countries, and was related to guideline use and the practice of clinical audits, but not to the size, location of the institution or development index of the country. Mothers with complications, such as HIV infection, anaemia, or pre-eclampsia/eclampsia, were more likely to receive antibiotic prophylaxis. At the same time, mothers undergoing caesarean birth prior to labour and those with indication for scheduled deliveries were also more likely to receive antibiotic prophylaxis, despite their lower risk of infection, compared with mothers undergoing emergency caesarean section. CONCLUSIONS: Coverage of antibiotic prophylaxis for caesarean birth may be related to the perception of the importance of guidelines and clinical audits in the facility. There may also be a tendency to use antibiotics when caesarean section has been scheduled and antibiotic prophylaxis is already included in the routine clinical protocol. This study may act as a signal to re-evaluate institutional practices as a way to identify areas where improvement is possible.

Mode and timing of twin delivery and perinatal outcomes in low- and middle-income countries: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: To describe the mode and timing of delivery of twin pregnancies at ≥34 weeks of gestation and their association with perinatal outcomes. DESIGN: Secondary analysis of a cross-sectional study. POPULATION: Twin deliveries at ≥34 weeks of gestation from 21 low- and middle-income countries participating in the WHO Multicountry Survey on Maternal and Newborn Health. METHODS: Descriptive analysis and effect estimates using multilevel logistic regression. MAIN OUTCOME MEASURES: Stillbirth, perinatal mortality, and neonatal near miss (use of selected life saving interventions at birth). RESULTS: The average length of gestation at delivery was 37.6 weeks. Of all twin deliveries, 16.8 and 17.6% were delivered by caesarean section before and after the onset of labour, respectively. Prelabour caesarean delivery was associated with older maternal age, higher institutional capacity and wealth of the country. Compared with spontaneous vaginal delivery, lower risks of neonatal near miss (adjusted odds ratio, aOR, 0.63; 95% confidence interval, 95% CI, 0.44-0.94) were found among prelabour caesarean deliveries. A lower risk of early neonatal mortality (aOR 0.12; 95% CI 0.02-0.56) was also observed among prelabour caesarean deliveries with nonvertex presentation of the first twin. The week of gestation with the lowest rate of prospective fetal death varied by fetal presentation: 37 weeks for vertex-vertex; 39 weeks for vertex-nonvertex; and 38 weeks for a nonvertex first twin. CONCLUSIONS: The prelabour caesarean delivery rate among twins varied largely between countries, probably as a result of overuse of caesarean delivery in wealthier countries and limited access to caesarean delivery in low-income countries. Prelabour delivery may be beneficial when the first twin is nonvertex. International guidelines for optimal twin delivery methods are needed.

Maternal and perinatal outcomes among nulliparous adolescents in low- and middle-income countries: a multi-country study.

OBJECTIVE: To investigate the risk of adverse pregnancy outcomes and caesarean section among adolescents in low- and middle-income countries. DESIGN: Secondary analysis using facility-based cross-sectional data from the World Health Organization (WHO) Global Survey on Maternal and Perinatal Health. SETTING: Twenty-three countries in Africa, Latin America, and Asia. POPULATION: Women admitted for delivery in 363 health facilities during 2-3 months between 2004 and 2008. METHODS: We constructed multilevel logistic regression models to estimate the effect of young maternal age on risks of adverse pregnancy outcomes. MAIN OUTCOME MEASURES: Risk of adverse pregnancy outcomes among young mothers. RESULTS: A total of 78 646 nulliparous mothers aged ≤24 years and their singleton infants were included in the analysis. Compared with mothers aged 20-24 years, adolescents aged 16-19 years had a significantly lower risk of caesarean section (adjusted OR 0.75, 95% CI 0.71-0.79). When the analysis was restricted to caesarean section indicated for presumed cephalopelvic disproportion, the risk of caesarean section was significantly higher among mothers aged ≤15 years (aOR 1.27, 95% CI 1.07-1.49) than among those aged 20-24 years. Higher risks of low birthweight and preterm birth were found among adolescents aged 16-19 years (aOR 1.10, 95% CI 1.03-1.17; aOR 1.16, 95% CI 1.09-1.23, respectively) and ≤15 years (aOR 1.33, 95% CI 1.14-1.54; aOR 1.56, 95% CI 1.35-1.80, respectively). CONCLUSIONS: Adolescent girls experiencing pregnancy at a very young age (i.e. <16 years) have an increased risk of adverse pregnancy outcomes.

Knowledge and attitude of women on cervical cancer risk factors, prevention and screening / Монголын Анагаах Ухаан

Introduction Cervical cancer is one of the most common types of cancer in women worldwide. It can be prevented by identifying pre-cancer lesions at early stages using Pap smear screening and treating these lesions. Knowledge and attitude on cervical cancer and Pap smear tests are associated with actual participation in cervical cancer screening. Therefore, our study aimed to investigate cervical cancer and Pap smear knowledge and attitudes among Mongolian women. Materials and Methods A total of 671 women aged 30 to 60 years from urban and rural areas participated in the study. The multiple clusters sampling method was used. We examined the relations of socio-demographic characteristics with lack of knowledge and negative attitude towards Pap smear tests by using a multilogistic regression analysis. Result The response rate was 89% (671/750). 62% of the participants correctly answered less than 4 out of 8 questions about cervical cancer risk factors. Also 47,2% and 79,3% of the total number of the women had never heard of Pap Smear and HPV. Only 16,4% of the respondents have some knowledge about them. Almost all (93%) participants agreed that there is a defficiency of information about cancer and its screening.58% and 28% of respondents said that they would participate in Pap smear tests voluntarily and agree to vaccinate their daughters. Positive attitude on Pap smear tests was higher among women living in rural areas and those who have had a Pap smear test. Conclusions Cervical cancer and Pap smear knowledge and attitude among the women in Mongolia are low. Having higher education and higher income level did not ensure positive attitude to cervical cancer screening. Strategies for communicating accurate information about cervical cancer, prevention, and detection as well as risk and treatment of cervical cancer are needed.