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1.  Dose of early intervention treatment during children’s first 36 months of life is associated with developmental outcomes: an observational cohort study in three low/low-middle income countries 
BMC Pediatrics  2014;14(1):281.
Background
The positive effects of early developmental intervention (EDI) on early child development have been reported in numerous controlled trials in a variety of countries. An important aspect to determining the efficacy of EDI is the degree to which dosage is linked to outcomes. However, few studies of EDI have conducted such analyses. This observational cohort study examined the association between treatment dose and children’s development when EDI was implemented in three low and low-middle income countries as well as demographic and child health factors associated with treatment dose.
Methods
Infants (78 males, 67 females) born in rural communities in India, Pakistan, and Zambia received a parent-implemented EDI delivered through biweekly home visits by trainers during the first 36 months of life. Outcome was measured at age 36 months with the Mental (MDI) and Psychomotor (PDI) Development Indices of the Bayley Scales of Infant Development-II. Treatment dose was measured by number of home visits completed and parent-reported implementation of assigned developmental stimulation activities between visits. Sociodemographic, prenatal, perinatal, and child health variables were measures as correlates.
Results
Average home visits dose exceeded 91% and mothers engaged the children in activities on average 62.5% of days. Higher home visits dose was significantly associated with higher MDI (mean for dose quintiles 1–2 combined = 97.8, quintiles 3–5 combined = 103.4, p = 0.0017). Higher treatment dose was also generally associated with greater mean PDI, but the relationships were non-linear. Location, sociodemographic, and child health variables were associated with treatment dose.
Conclusions
Receiving a higher dose of EDI during the first 36 months of life is generally associated with better developmental outcomes. The higher benefit appears when receiving ≥91% of biweekly home visits and program activities on ≥67% of days over 3 years. It is important to ensure that EDI is implemented with a sufficiently high dose to achieve desired effect. To this end groups at risk for receiving lower dose can be identified and may require special attention to ensure adequate effect.
doi:10.1186/1471-2431-14-281
PMCID: PMC4288653  PMID: 25344731
Treatment dose; Early developmental intervention; Neurodevelopmental disability; Birth asphyxia; Developing countries
2.  A multi-country study of the “intrapartum stillbirth and early neonatal death indicator” in hospitals in low-resource settings 
Objective
To determine the feasibility of introducing a simple indicator of quality of obstetric and neonatal care and to determine the proportion of potentially avoidable perinatal deaths in hospitals in low-income countries.
Methods
Between September 1, 2011, and February 29, 2012, data were collected from women who had a term pregnancy and were admitted to the labor ward of 1 of 6 hospitals in 4 low-income countries. Fetal heart tones on admission were monitored, and demographic and birth data were recorded.
Results
Data were obtained for 3555 women and 3593 neonates (including twins). The doptone was used on 97% of women admitted. The overall perinatal mortality rate was 34 deaths per 1000 deliveries. Of the perinatal deaths, 40%–45% occurred in the hospital and were potentially preventable by better hospital care.
Conclusion
The results demonstrated that it is possible to accurately determine fetal viability on admission via a doptone. Implementation of doptone use, coupled with a concise data record, might form the basis of a low-cost and sustainable program to monitor and evaluate efforts to improve quality of care and ultimately might to help to reduce the in-hospital component of perinatal mortality in low-income countries.
doi:10.1016/j.ijgo.2013.04.008
PMCID: PMC3893914  PMID: 23796259
Doptone; Fetal heart tones; Hospital-based perinatal mortality; Neonatal mortality; Perinatal mortality; Stillbirth
3.  A review of studies with chlorhexidine applied directly to the umbilical cord 
American journal of perinatology  2013;30(8):10.1055/s-0032-1329695.
Infection-related neonatal mortality due to omphalitis in developing country home births is an important public health problem. Three cluster randomized trials of 4% chlorhexidine applied to the umbilical cord stump from 1 to multiple times in the days following a home birth have evaluated this intervention compared to other types of cord care on the development of omphalitis and neonatal mortality. Each of the 3 studies showed significant reductions in either omphalitis, neonatal mortality, or both with the 4% chlorhexidine. However, the optimal dosing schedule remains uncertain. While further studies are needed to clarify this issue, from the 3 studies it is now clear that with a minimum of one application of 4% chlorhexidine to the umbilical cord stump following delivery, the incidence of omphalitis and neonatal mortality can be reduced, especially in preterm newborns. This intervention, which is safe, inexpensive and requires minimal training and skill, should strongly be considered for adoption wherever home births occur.
doi:10.1055/s-0032-1329695
PMCID: PMC3875170  PMID: 23254380
5.  Stillbirth and early neonatal mortality in rural Central Africa 
Objective
To develop a prospective perinatal registry that characterizes all deliveries, differentiates between stillbirths and early neonatal deaths (ENDs), and determines the ratio of fresh to macerated stillbirths in the northwest Democratic Republic of Congo.
Method
Birth outcomes were obtained from 4 rural health districts.
Results
A total of 8230 women consented, END rate was 32 deaths per 1000 live births, and stillbirth rate was 33 deaths per 1000 deliveries. The majority (75%) of ENDs and stillbirths occurred in neonates weighing 1500 g or more. Odds of stillbirth and END increased in mothers who were single or who did not receive prenatal care, and among premature, low birth weight, or male infants. The ratio of fresh to macerated stillbirths was 4:1.
Conclusion
Neonates weighing 1500 g or more at birth represent a group with a high likelihood of survival in remote areas, making them potentially amenable to targeted intervention packages. The ratio of fresh to macerated stillbirths was approximately 10-fold higher than expected, suggesting a more prominent role for improved intrapartum obstetric interventions.
doi:10.1016/j.ijgo.2008.12.012
PMCID: PMC3972762  PMID: 19201402
Africa; Early neonatal death; Fresh and macerated stillbirth; Low-income country
6.  Randomized Trial of Early Developmental Intervention on Outcomes in Children after Birth Asphyxia in Developing Countries 
The Journal of pediatrics  2012;162(4):705-712.e3.
Objective
To determine if early developmental intervention (EDI) improves developmental abilities in resuscitated children.
Study design
This was a parallel group, randomized controlled trial of infants unresponsive to stimulation who received bag and mask ventilation as part of their resuscitation at birth and infants who did not require any resuscitation born in rural communities in India, Pakistan, and Zambia. Intervention infants received a parent-implemented EDI delivered with home visits by parent trainers every other week for 3 years started the first month after birth. Parents in both intervention and control groups received health and safety counseling during home visits on the same schedule. The main outcome measure was the Mental Development Index (MDI) of the Bayley Scales of Infant Development, 2nd edition, assessed at 36 months by evaluators unaware of treatment group and resuscitation history.
Results
MDI was higher in the EDI (102.6±9.8) compared with the control resuscitated children (98.0±14.6, one-sided p=0.0202) but there was no difference between groups in the non-resuscitated children (100.1±10.7 vs. 97.7±10.4, p=0.1392). The Psychomotor Development Index (PDI) was higher in the EDI group for both the resuscitated (p=0.0430) and non-resuscitated children (p=0.0164).
Conclusions
This trial of home-based, parent provided EDI in children resuscitated at birth provides evidence of treatment benefits on cognitive and psychomotor outcomes. MDI and PDI scores of both non-resuscitated and resuscitated infants were within normal range, independent of early intervention.
doi:10.1016/j.jpeds.2012.09.052
PMCID: PMC3582821  PMID: 23164311
Early intervention; resuscitation; intellectual disability; low and middle income countries; neonatal mortality; infant mortality; developmental outcome
7.  The MANDATE model for evaluating interventions to reduce postpartum hemorrhage 
Objective
To create a comprehensive model of the comparative impact of various interventions on maternal, fetal, and neonatal (MFN) mortality.
Methods
The major conditions and sub-conditions contributing to MFN mortality in low-resource areas were identified, and the prevalence and case fatality rates documented. Available interventions were mapped to these conditions, and intervention coverage and efficacy were identified. Finally, a computer model developed by the Maternal and Neonatal Directed Assessment of Technology (MANDATE) initiative estimated the potential of current and new interventions to reduce mortality.
Results
For PPH, the sub-causes, prevalence, and MFN case fatality rates were calculated. Available interventions were mapped to these sub-causes. Most available interventions did not prevent or treat the overall condition of PPH, but rather sub-conditions associated with hemorrhage and thus prevented only a fraction of the associated deaths.
Conclusion
The majority of current interventions address sub-conditions that cause death, rather than the overall condition; thus, the potential number of lives saved is likely to be overestimated. Additionally, the location at which mother and infant receive care affects intervention effectiveness and, therefore, the potential to save lives. A comprehensive view of MFN conditions is needed to understand the impact of any potential intervention.
doi:10.1016/j.ijgo.2012.10.030
PMCID: PMC3628756  PMID: 23313144
Low-income countries; Maternal mortality; Model; Postpartum hemorrhage; Stillbirth
8.  Implementation and evaluation of the Helping Babies Breathe curriculum in three resource limited settings: does Helping Babies Breathe save lives? A study protocol 
Background
Neonatal deaths account for over 40% of all under-5 year deaths; their reduction is increasingly critical for achieving Millennium Development Goal 4. An estimated 3 million newborns die annually during their first month of life; half of these deaths occur during delivery or within 24 hours. Every year, 6 million babies require help to breathe immediately after birth. Resuscitation training to help babies breathe and prevent/manage birth asphyxia is not routine in low-middle income facility settings. Helping Babies Breathe (HBB), a simulation-training program for babies wherever they are born, was developed for use in low-middle income countries. We evaluated whether HBB training of facility birth attendants reduces perinatal mortality in the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Global Network research sites.
Methods/design
We hypothesize that a two-year prospective pre-post study to evaluate the impact of a facility-based training package, including HBB and essential newborn care, will reduce all perinatal mortality (fresh stillbirth or neonatal death prior to 7 days) among the Global Network’s Maternal Neonatal Health Registry births ≥1500 grams in the study clusters served by the facilities. We will also evaluate the effectiveness of the HBB training program changing on facility-based perinatal mortality and resuscitation practices. Seventy-one health facilities serving 52 geographically-defined study clusters in Belgaum and Nagpur, India, and Eldoret, Kenya, and 30,000 women will be included. Primary outcome data will be collected by staff not involved in the HBB intervention. Additional data on resuscitations, resuscitation debriefings, death audits, quality monitoring and improvement will be collected. HBB training will include training of MTs, facility level birth attendants, and quality monitoring and improvement activities.
Discussion
Our study will evaluate the effect of a HBB/ENC training and quality monitoring and improvement package on perinatal mortality using a large multicenter design and approach in 71 resource-limited health facilities, leveraging an existing birth registry to provide neonatal outcomes through day 7. The study will provide the evidence base, lessons learned, and best practices that will be essential to guiding future policy and investment in neonatal resuscitation.
Trial registration
Trial registration ClinicalTrials.gov Identifier: NCT01681017
doi:10.1186/1471-2393-14-116
PMCID: PMC4021423  PMID: 24670013
Neonatal mortality; Perinatal mortality; Asphyxia; Stillbirth; Helping Babies Breathe; Resuscitation; Bag and mask ventilation; ≥1500 grams
9.  Infection and stillbirth 
Summary
Infection may cause stillbirth by several mechanisms, including direct infection, placental damage, and severe maternal illness. Various organisms have been associated with stillbirth, including many bacteria, viruses, and protozoa. In developed countries, between 10% and 25% of stillbirths may be caused by an infection, whereas in developing countries, which have much higher stillbirth rates, the contribution of infection is much greater. In developed countries, ascending bacterial infection, both before and after membrane rupture, with organisms such as Escherichia coli, group B streptococci, and Ureaplasma urealyticum is usually the most common infectious cause of stillbirth. However, in areas where syphilis is prevalent, up to half of all stillbirths may be caused by this infection alone. Malaria may be an important cause of stillbirth in women infected for the first time in pregnancy. The two most important viral causes of stillbirth are parvovirus and Coxsackie virus, although a number of other viral infections appear to be causal. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, and the organisms that cause leptospirosis, Q fever, and Lyme disease have all been implicated as etiologic for stillbirth. In certain developing countries, the stillbirth rate is high and the infection-related component so great that achieving a substantial reduction in stillbirth should be possible by reducing maternal infections. However, because infection-related stillbirth is uncommon in developed countries, and because those that do occur are caused by a wide variety of organisms, reducing this etiologic component of stillbirth much further will be difficult.
doi:10.1016/j.siny.2009.02.003
PMCID: PMC3962114  PMID: 19285457
Chorioamnionitis; Infection; Stillbirth
10.  Preconception maternal nutrition: a multi-site randomized controlled trial 
Background
Research directed to optimizing maternal nutrition commencing prior to conception remains very limited, despite suggestive evidence of its importance in addition to ensuring an optimal nutrition environment in the periconceptional period and throughout the first trimester of pregnancy.
Methods/Study design
This is an individually randomized controlled trial of the impact on birth length (primary outcome) of the time at which a maternal nutrition intervention is commenced: Arm 1: ≥ 3 mo preconception vs. Arm 2: 12-14 wk gestation vs. Arm 3: none.
192 (derived from 480) randomized mothers and living offspring in each arm in each of four research sites (Guatemala, India, Pakistan, Democratic Republic of the Congo). The intervention is a daily 20 g lipid-based (118 kcal) multi-micronutient (MMN) supplement. Women randomized to receive this intervention with body mass index (BMI) <20 or whose gestational weight gain is low will receive an additional 300 kcal/d as a balanced energy-protein supplement. Researchers will visit homes biweekly to deliver intervention and monitor compliance, pregnancy status and morbidity; ensure prenatal and delivery care; and promote breast feeding. The primary outcome is birth length. Secondary outcomes include: fetal length at 12 and 34 wk; incidence of low birth weight (LBW); neonatal/infant anthropometry 0-6 mo of age; infectious disease morbidity; maternal, fetal, newborn, and infant epigenetics; maternal and infant nutritional status; maternal and infant microbiome; gut inflammatory biomarkers and bioactive and nutritive compounds in breast milk. The primary analysis will compare birth Length-for-Age Z-score (LAZ) among trial arms (independently for each site, estimated effect size: 0.35). Additional statistical analyses will examine the secondary outcomes and a pooled analysis of data from all sites.
Discussion
Positive results of this trial will support a paradigm shift in attention to nutrition of all females of child-bearing age.
Trial registration
ClinicalTrials.gov NCT01883193.
doi:10.1186/1471-2393-14-111
PMCID: PMC4000057  PMID: 24650219
Preconception; Maternal; Nutrition; Birth length; Epigenetics; Microbiome
11.  Disparities in interventions for child and maternal mortality 
Lancet  2012;379(9822):1178-1180.
doi:10.1016/S0140-6736(12)60474-7
PMCID: PMC3957338  PMID: 22464372
12.  The Association of Parasitic Infections in Pregnancy and Maternal and Fetal Anemia: A Cohort Study in Coastal Kenya 
Background
Relative contribution of these infections on anemia in pregnancy is not certain. While measures to protect pregnant women against malaria have been scaling up, interventions against helminthes have received much less attention. In this study, we determine the relative impact of helminthes and malaria on maternal anemia.
Methods
A prospective observational study was conducted in coastal Kenya among a cohort of pregnant women who were recruited at their first antenatal care (ANC) visit and tested for malaria, hookworm, and other parasitic infections and anemia at enrollment. All women enrolled in the study received presumptive treatment with sulfadoxine-pyrimethamine, iron and multi-vitamins and women diagnosed with helminthic infections were treated with albendazole. Women delivering a live, term birth, were also tested for maternal anemia, fetal anemia and presence of infection at delivery.
Principal Findings
Of the 706 women studied, at the first ANC visit, 27% had moderate/severe anemia and 71% of women were anemic overall. The infections with highest prevalence were hookworm (24%), urogenital schistosomiasis (17%), trichuria (10%), and malaria (9%). In adjusted and unadjusted analyses, moderate/severe anemia at first ANC visit was associated with the higher intensities of hookworm and P. falciparum microscopy-malaria infections. At delivery, 34% of women had moderate/severe anemia and 18% of infants' cord hemoglobin was consistent with fetal anemia. While none of the maternal infections were significantly associated with fetal anemia, moderate/severe maternal anemia was associated with fetal anemia.
Conclusions
More than one quarter of women receiving standard ANC with IPTp for malaria had moderate/severe anemia in pregnancy and high rates of parasitic infection. Thus, addressing the role of co-infections, such as hookworm, as well as under-nutrition, and their contribution to anemia is needed.
Author Summary
International guidelines recommend routine prevention and treatments which are safe and effective during pregnancy to reduce hookworm, malaria and other infections among pregnant women living in geographic areas where these infections are prevalent. Despite their effectiveness, programs to address common infections such as hookworm, schistosomiasis and malaria during pregnancy have not been widely adopted. Hookworm, malaria and other infections have been associated with anemia in children, but the studies on the impact of these infections on anemia in pregnancy have not been as clear. This study was undertaken to evaluate the prevalence of parasitic infections among women attending antenatal care which provided the nationally recommended malaria preventive treatment program in coastal Kenya. At the first ANC visit, more than 70% of women were anemic, nearly one-fourth had hookworm and about 10% had malaria. Women with high levels of hookworm or malaria infections were at risk of anemia.
doi:10.1371/journal.pntd.0002724
PMCID: PMC3937317  PMID: 24587473
13.  Exposure of Pregnant Women to Indoor Air Pollution: A Study from nine low and middle income countries 
Objective
We studied exposure to solid fuel smoke and second-hand tobacco smoke among pregnant women in south Asia, Africa and Latin America.
Design
Prospective cross-sectional survey.
Setting
Antenatal clinics in Argentina, Brazil, Ecuador, Guatemala, Uruguay, Democratic Republic of Congo, Zambia, India and Pakistan.
Sample
A total of 7961 pregnant women in ten sites in nine countries were interviewed between October 2004 and September 2005.
Methods
A standardized questionnaire on exposure to indoor air pollution (IAP) and to secondhand smoke was administered to pregnant women during antenatal care.
Main Outcome Measures
Exposure to IAP and second-hand tobacco smoke.
Results
South Asian pregnant women commonly reported use of wood (49.1%–89.7%), crop residue and animal dung for cooking and heating fuel. African pregnant women reported higher use of charcoal (85.4%–93.5%). Latin American pregnant women had greater use of petroleum gas. Among south Asian women, solid fuel use and cooking on an open flame inside the home were common. There was a significant association between solid fuel use and allowing smoking within the home at the Asian sites and in Zambia (p<0.05).
Conclusions
Pregnant women from low/middle income countries were commonly exposed to IAP secondary to use of solid fuels. Among these populations, exposure to second-hand tobacco smoke was also common. This combination of exposures likely increases the risk of poor pregnancy outcomes among the most vulnerable women. Our study highlights the importance of further research on the combined impact of IAP and second-hand tobacco smoke exposures on adverse maternal and perinatal outcomes.
doi:10.3109/00016340903473566
PMCID: PMC3928066  PMID: 19961275
Pregnancy; indoor air pollution; second-hand tobacco smoke exposure; smoking
14.  First look: a cluster-randomized trial of ultrasound to improve pregnancy outcomes in low income country settings 
Background
In high-resource settings, obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve obstetric care. Whether or not ultrasound use will improve care and ultimately pregnancy outcomes in low-resource settings is unknown.
Methods/Design
This multi-country cluster randomized trial will assess the impact of antenatal ultrasound screening performed by health care staff on a composite outcome consisting of maternal mortality and maternal near-miss, stillbirth and neonatal mortality in low-resource community settings. The trial will utilize an existing research infrastructure, the Global Network for Women’s and Children’s Health Research with sites in Pakistan, Kenya, Zambia, Democratic Republic of Congo and Guatemala. A maternal and newborn health registry in defined geographic areas which documents all pregnancies and their outcomes to 6 weeks post-delivery will provide population-based rates of maternal mortality and morbidity, stillbirth, neonatal mortality and morbidity, and health care utilization for study clusters. A total of 58 study clusters each with a health center and about 500 births per year will be randomized (29 intervention and 29 control). The intervention includes training of health workers (e.g., nurses, midwives, clinical officers) to perform ultrasound examinations during antenatal care, generally at 18–22 and at 32–36 weeks for each subject. Women who are identified as having a complication of pregnancy will be referred to a hospital for appropriate care. Finally, the intervention includes community sensitization activities to inform women and their families of the availability of ultrasound at the antenatal care clinic and training in emergency obstetric and neonatal care at referral facilities.
Discussion
In summary, our trial will evaluate whether introduction of ultrasound during antenatal care improves pregnancy outcomes in rural, low-resource settings. The intervention includes training for ultrasound-naïve providers in basic obstetric ultrasonography and then enabling these trainees to use ultrasound to screen for pregnancy complications in primary antenatal care clinics and to refer appropriately.
Trial registration
Clinicaltrials.gov (NCT # 01990625)
doi:10.1186/1471-2393-14-73
PMCID: PMC3996090  PMID: 24533878
Maternal mortality; Maternal near miss; Perinatal mortality; Obstetric ultrasound; Low-income countries
15.  Intrapartum Perinatal Mortality 
Indian pediatrics  2012;49(3):187-188.
PMCID: PMC3918931  PMID: 22484737
16.  Prevalence of Suicidal Thoughts and Attempts Among Pregnant Pakistani Women 
Objective
To determine the prevalence of suicidal thoughts and attempts and to identify demographic variables and mental health correlates such as anxiety/depression and domestic violence among pregnant women in an urban community in Pakistan.
Design
Cross sectional data from a prospective cohort study are presented.
Setting
Women enrolled in an antenatal care clinic and followed to delivery in an urban area of Pakistan
Population
Cohort of pregnant women in Pakistan.
Methods
1,369 pregnant women were enrolled and interviewed regarding various maternal characteristics and pregnancy outcomes, and were asked specific questions about suicidal thoughts and attempts and administered the Aga Khan University Anxiety Depression Scale at 20–26 weeks of gestation.
Main outcome measures
Suicidal thoughts and attempts, verbal, sexual or physical abuse.
Results
Overall, 148 of the 1369 (11%) women studied had considered suicide. Of these, 148 women, 67 (45%) had attempted suicide. Eighteen percent of the women were classified as having depression/anxiety, almost half (48%) reported experiencing verbal abuse and 20% reported physical/sexual abuse. Women who had anxiety/depression or had experienced verbal or physical/sexual abuse were significantly more likely to have had suicidal thoughts and attempts.
Conclusions
Women at greatest risk for having suicidal thoughts or a suicide attempt were those who were depressed/anxious and had experienced some form of domestic abuse. With the high prevalence of these conditions, attention should be given to the establishment of effective mental health treatment programs for pregnant women.
doi:10.3109/00016349.2010.526185
PMCID: PMC3918941  PMID: 21050149
Suicidal thoughts; suicide attempts; pregnancy; abuse; anxiety/depression
17.  High Mortality Rates for Very Low Birth Weight Infants in Developing Countries Despite Training 
Pediatrics  2010;126(5):e1072-e1080.
OBJECTIVE
The goal was to determine the effect of training in newborn care and resuscitation on 7-day (early) neonatal mortality rates for very low birth weight (VLBW) infants. The study was designed to test the hypothesis that these training programs would reduce neonatal mortality rates for VLBW infants.
METHODS
Local instructors trained birth attendants from 96 rural communities in 6 developing countries in protocol and data collection, the World Health Organization Essential Newborn Care (ENC) course, and a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP), by using a train-the-trainer model. To test the impact of ENC training, data on infants of 500 to 1499 g were collected by using a before/after, active baseline, controlled study design. A cluster-randomized, controlled trial design was used to test the impact of the NRP.
RESULTS
A total of 1096 VLBW (500–1499 g) infants were enrolled, and 98.5% of live-born infants were monitored to 7 days. All-cause, 7-day neonatal mortality, stillbirth, and perinatal mortality rates were not affected by ENC or NRP training.
CONCLUSIONS
Neither ENC nor NRP training of birth attendants decreased 7-day neonatal, stillbirth, or perinatal mortality rates for VLBW infants born at home or at first-level facilities. Encouragement of delivery in a facility where a higher level of care is available may be preferable when delivery of a VLBW infant is expected.
doi:10.1542/peds.2010-1183
PMCID: PMC3918943  PMID: 20937655
neonatal mortality; perinatal mortality; stillbirth; developing countries; health care systems; very low birth weight; prematurity
18.  Anemia prevalence and risk factors in pregnant women in an urban area of Pakistan 
Food and nutrition bulletin  2008;29(2):132-139.
Background.
Anemia affects almost two-thirds of pregnant women in developing countries and contributes to maternal morbidity and mortality and to low birthweight.
Objective.
To determine the prevalence of anemia and the dietary and socioeconomic factors associated with anemia in pregnant women living in an urban community setting in Hyderabad, Pakistan.
Methods.
This was a prospective, observational study of 1,369 pregnant women enrolled at 20 to 26 weeks of gestation and followed to 6 weeks postpartum. A blood sample was obtained at enrollment to determine hemoglobin levels. Information on nutritional knowledge, attitudes, and practice and dietary history regarding usual food intake before and during pregnancy were obtained by trained interviewers within 1 week of enrollment.
Results.
The prevalence of anemia (defined by the World Health Organization as hemoglobin < 11.0 g/dL) in these subjects was 90.5%; of these, 75.0% had mild anemia (hemoglobin from 9.0 to 10.9 g/dL) and 14.8% had moderate anemia (hemoglobin from 7.0 to 8.9 g/dL). Only 0.7% were severely anemic (hemoglobin < 7.0 g/dL). Nonanemic women were significantly taller, weighed more, and had a higher body mass index. Multivariate analysis after adjustment for education, pregnancy history, iron supplementation, and height showed that drinking more than three cups of tea per day before pregnancy (adjusted prevalence odds ratio [aPOR], 3.2; 95% confidence interval [CI], 1.3 to 8.0), consumption of clay or dirt during pregnancy (aPOR, 3.7; 95% CI, 1.1 to 12.3), and never consuming eggs or consuming eggs less than twice a week during pregnancy (aPOR, 1.7; 95% CI, 1.1 to 2.5) were significantly associated with anemia. Consumption of red meat less than twice a week prior to pregnancy was marginally associated with anemia (aPOR, 1.2; 95% CI, 0.8 to 1.8) but was significantly associated with lower mean hemoglobin concentrations (9.9 vs. 10.0 g/dL, p = .05) during the study period. A subanalysis excluding women with mild anemia found similar associations to those of the main model, albeit even stronger.
Conclusions.
A high percentage of women at 20 to 26 weeks of pregnancy had mild to moderate anemia. Pica, tea consumption, and low intake of eggs and red meat were associated with anemia. Women of childbearing age should be provided nutritional education regarding food sources of iron, especially prior to becoming pregnant, and taught how food choices can either enhance or interfere with iron absorption.
PMCID: PMC3917507  PMID: 18693477
Anemia; developing countries; pregnancy
19.  A conference report on prenatal corticosteroid use in low- and middle-income countries 
Objective
To evaluate the evidence for prenatal corticosteroid use in low- and middle-income countries and to make recommendations regarding implementation and further research.
Methods
Studies and meta-analyses on prenatal corticosteroids relevant to low- and middle-income countries were identified and reviewed at the Maternal and Child Health Integrated Project (MCHIP) Antenatal Corticosteroid Conference held in Washington on October 19, 2010.
Results
There is strong evidence regarding the effectiveness of prenatal corticosteroid use in hospitals in high- and middle-income countries, usually in settings with high-level newborn care. For births occurring in hospitals in low-income countries without high-level neonatal care or for births outside hospitals, no studies have been conducted to evaluate prenatal corticosteroid use. The efficacy and safety of prenatal corticosteroid use in these settings must be evaluated.
Conclusions
The conference working group recommended expanding the use of prenatal corticosteroids in hospitals with high-level newborn care in low-income countries. For other low-income country settings, further research regarding efficacy and safety should precede the widespread introduction of prenatal corticosteroids.
doi:10.1016/j.ijgo.2011.07.017
PMCID: PMC3910250  PMID: 21930269
Low-resource countries; Prenatal corticosteroids; Preterm birth
20.  Stillbirth in Developing Countries: A review of causes, risk factors and prevention strategies 
In reviewing the research on stillbirth in developing countries, it becomes clear that because almost half of the deliveries in these settings occur at home, under-reporting of stillbirths is a significant problem, and reliable data about rates and causes are unavailable in some areas of the world. Nevertheless, of the estimated 3 million stillbirths which occur yearly, the vast majority in developing countries, with rates in many developing countries ten-fold higher than elsewhere. Classification systems have been adapted for developing countries; however, there is not a standard international system, nor is there agreement about stillbirth definitions making comparisons of cause of stillbirth over time or between sites problematic. From available data, prolonged and obstructed labor, and various infections all without adequate treatment, appear to account for the majority of stillbirths in developing countries. Strategies that have effectively reduced stillbirth in developed countries have had mixed results in developing countries or have not yet been tested; however, identification and treatment of infections such as syphilis has been shown effective in reducing stillbirth risk, while strategies to improve obstetric care have not been widely evaluated. Despite the large number of stillbirths worldwide, the topic of stillbirths in developing countries has received very little research, programmatic or policy attention. Better access to appropriate obstetric care, especially during labor, should reduce developing country stillbirth rates dramatically.
doi:10.1080/14767050802559129
PMCID: PMC3893926  PMID: 19089779
stillbirth; developing countries; perinatal mortality
21.  Maternal Mortality: Editorial for AJOBGYN 
doi:10.1016/j.ajog.2011.07.045
PMCID: PMC3893928  PMID: 22083050
22.  Infectious Causes of Stillbirth: A Clinical Perspective 
Untreated infection may cause stillbirth by several mechanisms, including direct fetal infection, placental damage, and severe maternal illness. Many bacteria, viruses, and protozoa have been associated with stillbirth. In developed countries, up to 24% of stillbirths have been attributed to infection, although with increased availability of sophisticated diagnostics and rigorous screening, it appears likely that higher numbers may actually be associated with infection. In developed countries, ascending bacterial infection is usually the most common infectious cause of stillbirth, with a number of viral infections also an important factor. Screening, prevention and treatment of maternal infections are important to reduce stillbirth risk.
doi:10.1097/GRF.0b013e3181eb6620
PMCID: PMC3893929  PMID: 20661048
Stillbirth; infection; chorioamnionitis
23.  INFECTION – RELATED STILLBIRTHS 
Lancet  2010;375(9724):1482-1490.
Infection is an important cause of stillbirth world-wide; in low and middle income countries (LMICs), 50% or more are likely caused by infection. In contrast, in high income countries, only10-25% of stillbirths are caused by infection. Syphilis, where prevalent, causes the majority of infectious stillbirths and is the infection most amenable to screening and treatment. Ascending bacterial infection is a common cause of stillbirth, but prevention has proven elusive. Many viral infections are causal for stillbirth but aside from vaccination for common childhood diseases, it is unclear how most viral-caused stillbirths may be prevented. Malaria, because of its high prevalence and extensive placental damage accounts for large numbers of stillbirths. Intermittent malarial prophylaxis and insecticide impregnated bed nets should decrease stillbirths. Many animal and vector-borne infections cause stillbirth. Because this relationship is especially important in LMICs, research that more clearly defines this relationship is crucial to reduce the unacceptably high stillbirth rates in those areas.
doi:10.1016/S0140-6736(09)61712-8
PMCID: PMC3893931  PMID: 20223514
Stillbirth; infection; congenital syphilis; vector-borne infections
24.  Tobacco Use and Secondhand Smoke Exposure During Pregnancy in Two African Countries: Zambia and the Democratic Republic of the Congo 
Acta obstetricia et gynecologica Scandinavica  2010;89(4):10.3109/00016341003605693.
Objective
To study pregnant women’s knowledge, attitudes and behaviors towards tobacco use and secondhand smoke (SHS) exposure, and exposure to advertising for and against tobacco products in Zambia and the Democratic Republic of the Congo (DRC).
Design
Prospective cross-sectional survey between November 2004 and September 2005.
Setting
Antenatal care clinics in Lusaka, Zambia and Kinshasa, DRC.
Population
Pregnant women in Zambia (909) and the DRC (847).
Methods
Research staff administered a structured questionnaire to pregnant women attending antenatal care clinics.
Main Outcome Measures
Pregnant women’s use of tobacco, exposure to SHS, knowledge of the harms of tobacco, and exposure to advertising for and against tobacco products.
Results
Only about 10% of pregnant women reported having ever tried cigarettes (6.6% Zambia; 14.1% DRC). However, in the DRC, 41.8% of pregnant women had ever tried other forms of tobacco, primarily snuff. About 10% of pregnant women and young children were frequently or always exposed to SHS. Pregnant women’s knowledge of the hazards of smoking and SHS exposure was extremely limited. About 13% of pregnant women had seen or heard advertising for tobacco products in the last 30 days.
Conclusions
Tobacco use and SHS exposure pose serious threats to the health of women, infants, and children. In many African countries, maternal and infant health outcomes are often poor and will likely worsen if maternal tobacco use increases. Our findings suggest that a “window of opportunity” exists to prevent increased tobacco use and SHS exposure of pregnant women in Zambia and the DRC.
doi:10.3109/00016341003605693
PMCID: PMC3875167  PMID: 20230310
25.  Prevalence of Anxiety, Depression and Associated Factors among Pregnant Women of Hyderabad, Pakistan 
The International journal of social psychiatry  2009;55(5):10.1177/0020764008094645.
Background
Few studies have examined the relationship between antenatal depression, anxiety and domestic violence in pregnant women in developing countries, despite the World Health Organization's estimates that depressive disorders will be the second leading cause of the global disease burden by 2020. There is a paucity of research on mood disorders, their predictors and sequelae among pregnant women in Pakistan.
Aims
To determine the prevalence of anxiety and depression and evaluate associated factors, including domestic violence, among pregnant women in an urban community in Pakistan.
Methods
All pregnant women living in identified areas of Hyderabad, Pakistan were screened by government health workers for an observational study on maternal characteristics and pregnancy outcomes. Of these, 1368 (76%) of eligible women were administered the validated Aga Khan University Anxiety Depression Scale at 20–26 weeks of gestation.
Results
18 percent of the women were anxious and/or depressed. Psychological distress was associated with husband unemployment (p=0.032), lower household wealth (p=0.027), having 10 or more years of formal education (p=0.002), a first (p=0.002) and an unwanted pregnancy (p<0.001). The strongest factors associated with depression/anxiety were physical/sexual and verbal abuse; 42% of women who were physically and/or sexually abused and 23% of those with verbal abuse had depression/anxiety compared to 8% of those who were not abused.
Conclusions
Anxiety and depression commonly occur during pregnancy in Pakistani women; rates are highest in women experiencing sexual/physical as well as verbal abuse, but they also are increased among women with unemployed spouses and those with lower household wealth. These results suggest that developing a screening and treatment program for domestic violence and depression/anxiety during pregnancy may improve the mental health status of pregnant Pakistani women.
doi:10.1177/0020764008094645
PMCID: PMC3875176  PMID: 19592433
Pregnancy; depression; anxiety; Pakistan; measurement

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