PROTOCOL: Nutrition interventions and programs for reducing mortality and morbidity in pregnant and lactating women and women of reproductive age: a systematic review

Maternal fetal and infant mortality and morbidity are among the most significant public health problems in developing and resource-poor nations. In most developing countries important contributing factors to perinatal and maternal mortality are the lack of adequate diagnostic and pathology facilities inadequate or absent postmortem examination poor diagnostic pathology and microbiology capabilities and deficiency in surveillance systems statistical reporting and diagnostic accuracy of adverse maternal and perinatal health events. Most resource-poor nations have no pathologist trained in perinatal pathology who is available to address the clinical diagnostic public health and research aspects of these mortality and morbidity issues which are so prevalent in the developing world. The following article highlights some of the most important global perinatal health problems - including malaria low birth weight HIV/AIDS maternal malnutrition maternal death unsafe abortion and political turmoil - which would benefit by increased contributions from collaborations with physicians trained in perinatal pathology.

Periconception care of the infertile patient: Are we doing enough?

In areas where vitamin A deficiency (VAD) is a public health concern, the maternal dietary intake of vitamin A may be not sufficient to meet either the maternal nutritional requirements, or those of the breastfed infant, due the low retinol concentrations in breast milk. To evaluate the effects of vitamin A supplementation for postpartum women on maternal and infant health. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 February 2016), LILACS (1982 to December 2015), Web of Science (1945 to December 2015), and the reference lists of retrieved studies. Randomised controlled trials (RCTs) or cluster-randomised trials that assessed the effects of vitamin A supplementation for postpartum women on maternal and infant health (morbidity, mortality and vitamin A nutritional status). Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias and checked for accuracy. We assessed the quality of the evidence using the GRADE approach. Fourteen trials of mainly low or unclear risk of bias, enrolling 25,758 women and infant pairs were included. The supplementation schemes included high, single or double doses of vitamin A (200,000 to 400,000 internation units (IU)), or 7.8 mg daily beta-carotene compared with placebo, no treatment, other (iron); or higher (400,000 IU) versus lower dose (200,000 IU). In all trials, a considerable proportion of infants were at least partially breastfed until six months. Supplement (vitamin A as retinyl, water-miscible or beta-carotene) 200,000 to 400,000 IU versus control (placebo or no treatment) Maternal: We did not find evidence that vitamin A supplementation reduced maternal mortality at 12 months (hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.44 to 2.21; 8577 participants; 1 RCT, moderate-quality evidence). Effects were less certain at six months (risk ratio (RR) 0.50, 95% CI 0.09 to 2.71; 564 participants; 1 RCT; low-quality evidence). The effect on maternal morbidity (diarrhoea, respiratory infections, fever) was uncertain because the quality of evidence was very low (50 participants, 1 RCT). We found insufficient evidence that vitamin A increases abdominal pain (RR 1.28, 95% CI 0.95 to 1.73; 786 participants; 1 RCT; low-quality evidence). We found low-quality evidence that vitamin A supplementation increased breast milk retinol concentrations by 0.20 µmol/L at three to three and a half months (mean difference (MD) 0.20 µmol/L, 95% CI 0.08 to 0.31; 837 participants; 6 RCTs). Infant: We did not find evidence that vitamin A supplementation reduced infant mortality at two to 12 months (RR 1.08, 95% CI 0.77 to 1.52; 6090 participants; 5 RCTs; low-quality evidence). Effects on morbidity (gastroenteritis at three months) was uncertain (RR 6.03, 95% CI 0.30 to 121.82; 84 participants; 1 RCT; very low-quality evidence). There was low-quality evidence for the effect on infant adverse outcomes (bulging fontanelle at 24 to 48 hours) (RR 2.00, 95% CI 0.61 to 6.55; 444 participants; 1 RCT). Supplement (vitamin A as retinyl) 400,000 IU versus 200,000 IUThree studies (1312 participants) were included in this comparison. None of the studies assessed maternal mortality, maternal morbidity or infant mortality. Findings from one study showed that there may be little or no difference in infant morbidity between the doses (diarrhoea, respiratory illnesses, and febrile illnesses) (312 participants, data not pooled). No firm conclusion could be drawn on the impact on maternal and infant adverse outcomes (limited data available).The effect on breast milk retinol was also uncertain due to the small amount of information available. There was no evidence of benefit from different doses of vitamin A supplementation for postpartum women on maternal and infant mortality and morbidity, compared with other doses or placebo. Although maternal breast milk retinol concentrations improved with supplementation, this did not translate to health benefits for either women or infants. Few studies reported on maternal and infant mortality and morbidity. Future studies should include these important outcomes.

PROTOCOL: Effects of interventions for infant and young child feeding (IYCF) promotion on optimal IYCF practices, nutrition, growth and health in low- and middle-income countries: a systematic review.

Significant progress has been made in maternal, newborn, and child health (MNCH) in recent decades. Between 1990 and 2015, the global mortality rate for children under age five years dropped by 53 percent, from 90.6 deaths per 1,000 live births in 1990 to 42.5 in 2015 (Liu and others 2016). Maternal mortality is also on the decline globally.Despite progress, maternal, neonatal, and under-five mortality remain high in many low- and middle-income countries (LMICs). In 2015, approximately 303,000 women died as a result of complications from pregnancy and childbirth (WHO 2015). Globally, an estimated 5.9 million children under age five years die each year, including 2.7 million within the first month of life (Liu and others 2016).Health indicators differ across countries, regions, and socioeconomic levels (Lozano and others 2011). Approximately 99 percent of all newborn deaths occur in LMICs (Bayer 2001). Maternal mortality is concentrated in Sub-Saharan Africa (Hogan and others 2010), where mortality rates for the poor are double those for the nonpoor, and they are higher among rural populations and women with low levels of education (PLoS Medicine Editors 2010). Children living in low-income countries are three times more likely to die before age five years than children living in high-income countries (HICs) (Black and others 2013).Pneumonia, diarrhea, malaria, and inadequate nutrition drive early childhood deaths around the world. In 2015, an estimated 526,000 episodes of diarrhea and 922,000 cases of pneumonia in children under age five years led to death (Liu and others 2016). Undernutrition is a primary underlying cause of 3.5 million maternal and child deaths each year (Black and others 2013); stunting, wasting, and micronutrient deficiencies are responsible for approximately 35 percent of the disease burden in children under age five years and 11 percent of the total global disease burden (Lozano and others 2011). Although maternal mortality is caused chiefly by postpartum hemorrhage, preeclampsia and eclampsia, and sepsis, a large proportion of maternal deaths can be attributed to limited access to skilled care during childbirth and the postnatal period (Lozano and others 2011) as well as to limited access to family planning services and safe abortions (UNFPA and Guttmacher Institute 2010).An appropriate mix of interventions can significantly reduce the burden of maternal and child mortality and morbidity. However, these interventions often do not reach those who need them most (Bayer 2001; Sines, Tinker, and Ruben 2006). An integrated approach that includes community-based care as an essential component has the potential to substantially improve maternal, newborn, and child health outcomes.This chapter provides a summary of community-based programs for improving MNCH. The chapter discusses strategies to improve the supply of services, including through community-based interventions and home visitations implemented by community health workers (CHWs), and strategies to increase demand for services, including through community mobilization efforts. The chapter summarizes the evidence about the impact of such interventions, describes contextual factors that affect implementation, and considers issues of cost-effectiveness. It concludes by highlighting research gaps, the challenges of scaling up, and the way forward.

Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas.

BackgroundDespite efforts at curbing maternal morbidity and mortality, developing countries are still burdened with high rates of maternal morbidity and mortality. Ethiopia is not an exception and has one of the world’s highest rates of maternal deaths. Reducing the huge burden of maternal mortality remains the single most serious challenge in Ethiopia. There is a paucity of information with regards to the local level magnitude and causes of maternal mortality. We assessed the magnitude, trends and causes of maternal mortality using surveillance data from the Kersa Health and Demographic Surveillance System (HDSS), in Eastern Ethiopia.MethodThe analysis used surveillance data extracted from the Kersa HDSS database for the duration of 2008 to 2014. Data on maternal deaths and live births during the seven year period were used to determine the maternal mortality ratio in the study. The data were mainly extracted from a verbal autopsy database. The sample was comprised of all reproductive aged women who died during pregnancy, childbirth or 42 days after delivery. Chi-squared test for linear trend was used to examine the significance of change in rates over time.ResultsOut of the total 311 deaths of reproductive aged women during the study period, 72 (23.2%) died during pregnancy or within 42 days of delivery. The overall estimated maternal mortality ratio was 324 per 100,000 live births (95% CI: 256, 384). The observed maternal mortality ratio has shown a declining trend over the seven years period though there is no statistical significance for the reduction (χ2 = 0.56, P = 0.57). The estimated pregnancy related mortality ratio was 543 per 100,000 live births (95% CI: 437, 663). Out of those who died due to pregnancy and related causes, only 26% attended at least one antenatal care service. The most common cause of maternal death was postpartum haemorrhage (46.5%) followed by hypertensive disorders of pregnancy (16.3%).ConclusionThe magnitude of maternal mortality is considerably high but has shown a decreasing trend. Community-based initiatives that aim to improve maternal health should be strengthened further to reduce the prevailing maternal mortality. Targeted information education and communication should be provided.

Color lines: Disparities in pharmacy treatment, education, and practice

The United States has experienced a steady rise in pregnancy-related deaths over the last 3 decades. The rate of severe maternal morbidity has also increased. It is estimated that approximately 50% of maternal deaths are preventable. National, multidisciplinary, collaborative efforts are required to effectively address this problem. The complex nature of certain conditions and the concomitant risk of significant maternal morbidity and mortality have yielded a subset of women who require obstetric critical care. Institutions and clinicians face challenges as they identify a framework within which to provide this specialized level of care. Systematic, multidisciplinary review of maternal morbidity and mortality events continues to generate meaningful data and recommendations for improvement. The purpose of this article was to describe important concepts related to maternal mortality including the classification and leading causes of maternal death in the United States. The preventability of maternal mortality is also explored including evidence-based best practices and strategies.

Background: Maternal and child health (MCH) services are critical interventions that improve maternal and child health outcomes globally. Purpose: To review maternal and child health services: prevention of complications, reduction of maternal, neonatal, and child morbidity and mortality rates: Narrative review Method: A narrative review method was used to synthesize current evidence on effective MCH interventions. Results: Evidence from global and regional literature highlights effective interventions including antenatal care, skilled birth attendance, emergency obstetric care, postnatal care, immunization, and nutrition programs. Conclusion: The need for strengthened health systems, community participation, and policy support is emphasized to achieve Sustainable Development Goals (SDGs) 3.1 and 3.2. Suggestion: Implementing frequent CHW home visits is vital in the Prevention of Complications, Reduction of Maternal, Neonatal and Child Morbidity and Mortality Rate. Aim for multiple visits during both antenatal and postnatal periods, as the strongest neonatal mortality reduction (24%) occurred in studies with ≥ 3 visits and integrated antenatal plus postnatal care, Package interventions into comprehensive home-based care

Uterine rupture is the leading cause of maternal and perinatal morbidity and it accounts for 36% of the maternal mortality in Ethiopia. The maternal and perinatal outcomes of uterine rupture were inconclusive for the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used for this systematic review and meta-analysis. We systematically used PubMed, Cochrane Library, and African Journals online databases for searching. The Newcastle- Ottawa quality assessment scale was used for critical appraisal. Egger's test and I2 statistic used to assess the check for publication bias and heterogeneity. The random-effect model was used to estimate the pooled prevalence and odds ratios with 95% confidence interval (CI). The pooled maternal mortality and morbidity due to uterine rupture in Ethiopia was 7.75% (95% CI: 4.14, 11.36) and 37.1% (95% CI: 8.44, 65.8), respectively. The highest maternal mortality occurred in Southern region (8.91%) and shock was the commonest maternal morbidity (24.43%) due to uterine rupture. The pooled perinatal death associated with uterine rupture was 86.1% (95% CI: 83.4, 89.9). The highest prevalence of perinatal death was observed in Amhara region (91.36%) and the lowest occurred in Tigray region (78.25%). Prolonged duration of operation was a significant predictor of maternal morbidity (OR = 1.39; 95% CI: 1.06, 1.81). The percentage of maternal and perinatal deaths due to uterine rupture was high in Ethiopia. Uterine rupture was associated with maternal morbidity and prolonged duration of the operation was found to be associated with maternal morbidities. Therefore, birth preparedness and complication readiness plan, early referral and improving the duration of operation are recommended to improve maternal and perinatal outcomes of uterine rupture.

BackgroundUterine rupture is the leading cause of maternal and perinatal morbidity and it accounts for 36% of the maternal mortality in Ethiopia. The maternal and perinatal outcomes of uterine rupture were inconclusive for the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used for this systematic review and meta-analysis. We systematically used PubMed, Cochrane Library, and African Journals online databases for searching. The Newcastle- Ottawa quality assessment scale was used for critical appraisal. Egger’s test and I2 statistic used to assess the check for publication bias and heterogeneity. The random-effect model was used to estimate the pooled prevalence and odds ratios with 95% confidence interval (CI).ResultsThe pooled maternal mortality and morbidity due to uterine rupture in Ethiopia was 7.75% (95% CI: 4.14, 11.36) and 37.1% (95% CI: 8.44, 65.8), respectively. The highest maternal mortality occurred in Southern region (8.91%) and shock was the commonest maternal morbidity (24.43%) due to uterine rupture. The pooled perinatal death associated with uterine rupture was 86.1% (95% CI: 83.4, 89.9). The highest prevalence of perinatal death was observed in Amhara region (91.36%) and the lowest occurred in Tigray region (78.25%). Prolonged duration of operation was a significant predictor of maternal morbidity (OR = 1.39; 95% CI: 1.06, 1.81).ConclusionsThe percentage of maternal and perinatal deaths due to uterine rupture was high in Ethiopia. Uterine rupture was associated with maternal morbidity and prolonged duration of the operation was found to be associated with maternal morbidities. Therefore, birth preparedness and complication readiness plan, early referral and improving the duration of operation are recommended to improve maternal and perinatal outcomes of uterine rupture.

In September 2000, 189 world leaders signed a declaration on eight Millennium Development Goals (MDGs) to improve the lives of women, men, and children in their respective countries (United Nations General Assembly 2000). Goal 5a calls for the reduction of maternal mortality by 75 percent between 1990 and 2015. Goal 5a was supplemented by MDG 5b on universal access to contraception. MDGs 5a and 5b have been important catalysts for the reductions in maternal mortality levels that have been achieved in many settings.Despite substantial progress, challenges remain. The majority of low-income countries (LICs), particularly in Sub-Saharan Africa and postconflict settings, have not made sufficient progress to meet MDG 5a. The post-2015 agenda on sustainable development is broader than the MDG agenda, with a greater number of nonhealth goals and a strong focus on inequity reduction; the new agenda includes an absolute reduction in maternal mortality as a marker of progress. This new indicator is expected to be framed as targets for preventable maternal deaths (Bustreo and others 2013; Gilmore and Camhe Gebreyesus 2012).The International Classification of Diseases (ICD-10) defines maternal death as “[The] death of a woman while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” (WHO 2010, 156). Subsequent guidance on the classification of causes includes nine groups of underlying causes (box 3.1) (WHO 2012).Despite the increased global focus on maternal mortality as a public health issue, little detailed knowledge is available on the levels of maternal mortality and morbidity and the causes of their occurrence. A large proportion of maternal deaths occur in settings in which vital registration is deficient and many sick women do not access services. To obtain data on population levels of maternal mortality in these settings, special surveys are needed, including the following (Abouzahr 1999):Maternal death studies require large sample sizes; recent national-level data are often nonexistent, and maternal mortality tracking relies principally on mathematical models. This lack of data has led to a repeated call for countries to improve their vital registration systems and to strengthen other mechanisms for informing intervention strategies, such as the maternal death surveillance and response system proposed within the new accountability framework (WHO 2013). Accountability remains a central part of United Nations Secretary General Ban Ki-Moon’s updated global strategy to accelerate progress for women’s, children’s, and adolescent’s health ( http://www.everywomaneverychild.org/global-strategy-2 ). The accountability framework, developed under the 2010 global strategy to accelerate women’s and children’s health, included recommendations for improvements in resource tracking; international and national oversight; and data monitoring, including maternal mortality (Commission on Information and Accountability for Women’s and Children’s Health 2011).Information on maternal morbidity is frequently collected in hospital studies, which are only representative of patients who seek care. Community-based studies are rare in LICs and suffer from methodological limitations, particularly when they rely on self-reporting of obstetric complications. Self-reporting is known not to agree sufficiently with medical diagnoses to estimate prevalence. In particular, studies validating retrospective interview surveys find that women without medical diagnoses of complications during labor frequently reported symptoms of morbidity during surveys, a phenomenon that can lead to an overestimation of prevalence (Ronsmans and others 1997; Souza and others 2008). In addition, community-based studies have focused on direct obstetric complications; little is known about the nature and incidence of many indirect complications that are aggravated by pregnancy. For example, reliable population-based estimates of the occurrence of asthma during pregnancy do not exist in LICs.This chapter addresses the extent and nature of maternal mortality and morbidity and serves as a backdrop to subsequent chapters on obstetric interventions in LICs. It introduces the determinants of maternal mortality and morbidity and their strategic implications. The next section uses the most recent estimates from the World Health Organization (WHO) to show that women face a higher risk of maternal death in Sub-Saharan Africa. It discusses the recent findings of a WHO meta-analysis that show that the most important direct causes are hemorrhage, hypertension, abortion, and sepsis; however, the proportion of deaths due to indirect causes is increasing in most parts of the world. The chapter then focuses on pregnancy-related complications, including nonfatal illnesses such as antenatal and postpartum depression, using the findings from systematic reviews conducted by the Child Health Epidemiology Reference Group. The most common contributors to maternal morbidity are probably anemia and depression at the community level, but prolonged and obstructed labor results in the highest burden of disease because of fistulas (IHME 2013). The chapter discusses the broader determinants of maternal morbidity and mortality, and then concludes by making the links with the interventions highlighted in chapter 7 in this volume (Gulmezoglu and others 2016).

Malnutrition contributes to direct and indirect causes of maternal mortality, which is particularly high in Afghanistan. Women's nutritional status before, during, and after pregnancy affects their own well‐being and mortality risk and their children's health outcomes. Though maternal nutrition interventions have documented positive impact on select child health outcomes, there are limited data regarding the effects of maternal nutrition interventions on maternal health outcomes globally. This scoping review maps policies, data, and interventions aiming to address poor maternal nutrition outcomes in Afghanistan. We used broad search categories and approaches including database and website searches, hand searches of reference lists from relevant articles, policy and programme document requests, and key informant interviews. Inclusion and exclusion criteria were developed by type of source document, such as studies with measures related to maternal nutrition, relevant policies and strategies, and programmatic research or evaluation by a third party with explicit interventions targeting maternal nutrition. We abstracted documents systematically, summarized content, and synthesized data. We included 20 policies and strategies, 29 data reports, and nine intervention evaluations. The availability of maternal nutrition intervention data and the inclusion of nutrition indicators, such as minimum dietary diversity, have increased substantially since 2013, yet few nutrition evaluations and population surveys include maternal outcomes as primary or even secondary outcomes. There is little evidence on the effectiveness of interventions that target maternal nutrition in Afghanistan. Policies and strategies more recently have shifted towards multisectoral efforts and specifically target nutrition needs of adolescent girls and women of reproductive age. This scoping review presents evidence from more than 10 years of efforts to improve the maternal nutrition status of Afghan women. We recommend a combination of investments in measuring maternal nutrition indicators and improving maternal nutrition knowledge and behaviours.

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