Routine Maternity Care Research Articles

Effect of a short message service intervention on infant feeding practices in Shanghai, China: a prospective, community-based, controlled study

BackgroundInfant feeding practices can have long-term health effects for children. Short message service (SMS) through mobile telephones has been increasingly used for health promotion and health services. We assessed the effectiveness of an SMS intervention for improvement of infant feeding practices.MethodsWe recruited participants from four community health centres (CHCs) in Shanghai, China. Two CHCs were designated the intervention group and two other CHCs were designated the control group. We recruited participants at the beginning of the third trimester. Mothers were eligible to participate if they: owned a mobile phone, were first-time mothers, were aged older than 20 years, were at less than 13 weeks gestation, had completed at least compulsory junior high school education (up to age 15 years), were carrying a singleton fetus, and had no illness that restricted breastfeeding after childbirth. All participants received routine maternal and child health care. Mothers in the intervention group also received weekly SMS messages for infant feeding from the third trimester to 12 months post-partum. Participants were followed up at 4, 6, and 12 months post-partum. The primary outcome was duration of exclusive breastfeeding (EBF). We compared the duration of EBF between groups by survival analysis.FindingsWe enrolled 582 participants (281 in the intervention group and 301 in the control group). At 6 months after birth, 265 mothers in the intervention and 284 in the control groups were followed up. Participants in the intervention group had a significantly longer median duration of EBF at 6 months compared with those in the control group (11·4 weeks, 95% CI 10·3–12·6 vs 8·9 weeks, 95% CI 7·8–9·9; p<0·0002).InterpretationAn SMS intervention might help to promote EBF for new mothers. Large randomised controlled trials are needed to further explore this approach.FundingNestlé Foundation, Shanghai Municipal Health Bureau.

Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth

Each year approximately 350,000 women in the United Kingdom and millions more worldwide, experience perineal suturing following childbirth. The postpartum management of perineal trauma is a core component of routine maternity care. However, for those women whose perineal wound dehisces (breaks down), the management varies depending on individual practitioners preferences as there is limited scientific evidence and no clear guidelines to inform best practice. For most women the wound will be managed expectantly whereas, others may be offered secondary suturing. To evaluate the therapeutic effectiveness of secondary suturing of dehisced perineal wounds compared to non-suturing (healing by secondary intention, expectancy). We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013) and reference lists of retrieved studies. Randomised controlled trials of secondary suturing of dehisced perineal wounds (second-, third- or fourth-degree tear or episiotomy), following wound debridement and the removal of any remaining suture material within the first six weeks following childbirth compared with non-suturing. Three review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy. Two small studies of poor methodological quality including 52 women with a dehisced and/or infected episiotomy wound at point of entry have been included.Only one small study presented data in relation to wound healing at less than four weeks, (the primary outcome measure for this review), although no reference was made to demonstrate how healing was measured. There was a trend to favour this outcome in the resuturing group, however, this difference was not statistically significant (risk ratio (RR) 1.69, 95% confidence interval (CI) 0.73 to 3.88, one study, 17 women).Similarly, only one trial reported on rates of dyspareunia (a secondary outcome measure for this review) at two months and six months with no statistically significant difference between both groups; two months, (RR 0.44, 95% CI 0.18 to 1.11, one study, 26 women) and six months, (RR 0.39, 95% CI 0.04 to 3.87, one study 32 women). This trial also included data on the numbers of women who resumed sexual intercourse by two months and six months. Significantly more women in the secondary suturing group had resumed intercourse by two months (RR 1.78, 95% CI 1.10 to 2.89, one study, 35 women), although by six months there was no significant difference between the two groups (RR 1.08, 95% CI, 0.91 to 1.28).Neither of the trials included data in relation to the following prespecified secondary outcome measures: pain at any time interval; the woman's satisfaction with the aesthetic results of the perineal wound; exclusive breastfeeding; maternal anxiety or depression. Based on this review, there is currently insufficient evidence available to either support or refute secondary suturing for the management of broken down perineal wounds following childbirth. There is an urgent need for a robust randomised controlled trial to evaluate fully the comparative effects of both treatment options.

The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: A systematic review

Psychological interventions delivered by non-specialist health workers are effective for the treatment of perinatal depression in low- and middle-income countries. In this systematic review, we describe the content and delivery of such interventions. Nine studies were identified. The interventions shared a number of key features, such as delivery provided within the context of routine maternal and child health care beginning in the antenatal period and extending postnatally; focus of the intervention beyond the mother to include the child and involving other family members; and attention to social problems and a focus on empowerment of women. All the interventions were adapted for contextual and cultural relevance; for example, in domains of language, metaphors and content. Although the competence and quality of non-specialist health workers delivered interventions was expected to be achieved through structured training and ongoing supervision, empirical evaluations of these were scarce. Scalability of these interventions also remains a challenge and needs further attention.

Availability and components of maternity services according to providers and users perspectives in North Gondar, northwest Ethiopia

BackgroundThe goal of reducing maternal mortality can be achieved when women receive important service components at the time of their maternity care. This study attempted to assess the availability and the components of maternity services according to the perspectives of service users and providers.MethodA linked facility and population-based survey was conducted over three months (January to March 2012) in North Gondar Zone. Twelve kebeles (clusters) were selected randomly from six districts to identify maternity clients cared for by skilled providers. Then 12 health centers and 3 hospitals utilized by the corresponding cluster population were selected for facility survey. Interview with facility managers/heads, providers and clients and observations were used for data collection. Data were entered using Epi Info and were exported to SPSS software for analysis.ResultsAntenatal and delivery care were available in most of the visited facilities. However, the majority of them were not fully functioning for EmOC according to their level. Signal functions including administration of anticonvulsants and assisted vaginal delivery were missing in seven and five of the 12 health centers, respectively. Only one hospital met the criteria for comprehensive emergency obstetric care (performed cesarean section). Only 24% of the providers used partograph consistently. About 538 (32.3%) and 231 (13.8%) of the women received antenatal and delivery care from skilled providers, respectively. Most of the services were at health centers by nurses/midwives. At the time of the antenatal care, women received the important components of the services (percentage of users in bracket) like blood pressure checkup (79%), urine testing (35%), tetanus immunization (45%), iron supplementation (64%), birth preparedness counseling (51%) and HIV testing (71%). During delivery, 80% had their blood pressure measured, 78% were informed on labor progress, 89% had auscultation of fetal heartbeat, 80% took drugs to prevent bleeding and 78% had counseling on early & exclusive breast-feeding.ConclusionAntenatal and delivery care were available in most of the visited facilities. However, important components of both the routine and emergency maternity care services were incomplete. Improving the functional capacity of health facilities for the delivery of routine maternity and EmOC services are needed.

Identification of pregnancies at increased risk of brachial plexus birth palsy – the construction of a weighted risk score

Objective: Since it is difficult to identify women at increased risk of fetal brachial plexus birth palsy (BPBP) during labor and delivery, we aimed to construct and validate a risk score.Methods: A retrospective case-control study was undertaken in 2001 and 2006 in an urban context in Malmö, Sweden. A risk score was constructed for all women who had received routine municipal maternal health care at Skåne University Hospital (n = 10 459). The model was validated among all pregnant women with BPBP and controls in Sweden between 2006 and 2007.Results: The likelihood of BPBP increased as the risk score rose: 3.1% of the women studied had a risk score ≥5, including 32.1% of the BPBP cases, where the risk showed a 38-fold increase, as compared to those with a risk score ≤1 (2/3 of the population).Conclusion: Our findings indicate that it is possible to identify women at increased risk of having a child with BPBP by using variables observable in advance of delivery.

Supporting the adolescent mother–infant relationship: preliminary trial of a brief perinatal attachment intervention

The purpose of this study is to test a brief, attachment intervention added to routine maternity care that aims to improve the adolescent mother-infant relationship during transition to motherhood. A pre-test, post-test, peer-control-group trial was set in a large tertiary maternity hospital in Melbourne, Australia. Participants were multi-cultural, pregnant adolescents (n = 97). The two-session 'AMPLE' intervention was provided in late pregnancy and neonatally. The main outcome measure was mother-infant interaction quality at age 4months, blind-coded using the Emotional Availability Scales (EAS) (fourth edition). Study acceptability was high: participation rate 82.9 % and completion rate 75.3 %. Thirty-five participants received the intervention plus usual care (intervention group) and 38 received usual care (control group). There were no pre-test between-group differences across demographic, psychosocial or obstetric domains. At post-test, mother-infant interaction was significantly better in the intervention group. MANOVA analyses showed an overall intervention effect on emotional availability in 20min of free play (n = 73), F (6,65) = 5.05, p < .01, partial η (2) = .32, and in 25min of play plus brief separation-reunion (n = 55), F (6,48) = 2.72, p = .02, partial η (2) = .25. T tests showed significant between-group differences in specific EAS subscales. All effect sizes were medium-large. This promising intervention appears to exert a clinically meaningful effect on the adolescent mother-infant relationship. Further research is warranted to replicate the findings and confirm causality. The study suggests a brief attachment focus, incorporated into routine maternity care, could influence the developmental trajectory of infants of young mothers from birth.

Maternity Care Practices That Support Breastfeeding: CDC Efforts to Encourage Quality Improvement

Breastfeeding has important consequences for women's health, including lower risk of breast and ovarian cancers as well as type 2 diabetes. Although most pregnant women want to breastfeed, a majority encounter difficulties and are not able to breastfeed as long as they want. Routine maternity care practices can pose significant barriers to successful breastfeeding. To address these practices, CDC has taken on a number of initiatives to promote hospital quality improvements in how new mothers are supported to start breastfeeding. The CDC survey on Maternity Practices in Infant Nutrition and Care is a tool to educate hospitals on how their current practices compare to recommended standards. The Best Fed Beginnings program is working with 90 hospitals across the United States to achieve optimal care and create tools for future hospital changes. CDC-funded programs in numerous state health departments have created programs to instigate improvements across the state. These efforts have begun to show success, with significant hospital quality score increases seen between 2009 and 2011. In 2011, more hospitals were designated as Baby-Friendly than in any previous year.

Maternal depression in low- and middle-income countries

Maternal depression is an enormous, neglected public health problem in low- and middle-income countries (LAMICs). Evidence is accumulating to guide intervention, focused on integrating mental health care into routine maternal and child health care through a task sharing approach. Key questions around the 'who, what, when, where and how?' of intervention will be discussed in relation to the existing evidence base. A great deal of attention is now being paid to maternal health in LAMICs. By seizing this opportunity to also attend to maternal mental health care, important public health gains can be made for both the mother and her children.

Alcohol Consumption Among Pregnant Women in a Swedish Sample and Its Effects on the Newborn Outcomes

Little is known about the effects of low levels of maternal alcohol intake on the neuropsychological development of the child. This study is part of an ongoing investigation on maternal drinking and presents data on demographic variables, maternal alcohol use, and birth outcomes from that study. The sample comprised 2,264 women from a Swedish antenatal clinic. Retrospective self-report data were collected on alcohol consumption before and during pregnancy, using the Alcohol Use Disorders Identification Test (AUDIT), and on nicotine use. Specific alcohol biomarkers for excessive drinking, carbohydrate-deficient transferrin (CDT) in serum and phosphatidylethanol (PEth) in whole blood, were determined during mid-pregnancy in a subsample of the women. Data on labor and early characteristics of the child were also assessed. Before pregnancy, 89% of the women regularly consumed alcohol and 49% reported occasional or frequent binge drinking. Nicotine was used by 15% before and by 5% during pregnancy. During pregnancy, 12% continued using alcohol and 5% also admitted binge drinking. However, all alcohol biomarker values were below the reporting limits (CDT≤1.7% disialotransferrin; total PEth<0.1μmol/L). Self-reported drinking during pregnancy was associated with a higher AUDIT score before pregnancy, nicotine use at the time of the first prenatal visit, older age, and previous legal abortions. The AUDIT questionnaire and 2 specific alcohol biomarkers were used in routine maternity care to collect information about drinking during pregnancy and thereby to identify children at risk for alcohol-related complications. While the AUDIT results suggested that a significant number of women continued using alcohol during pregnancy, implying a risk for fetal disorders, the biomarkers showed negative test values thus indicating only modest drinking levels.

Use of Routine Interventions in Labour and Birth in Canadian Hospitals: Comparing Results of the 1993 and 2007 Canadian Hospital Maternity Policies and Practices Surveys

ObjectivesTo compare policies and practices of routine interventions in labour and birth in Canadian hospitals in 1993 and 2007 and to describe trends regarding adherence to evidencebased guidelines. MethodsWe used data from surveys of Canadian hospitals in 1993 and 2007 on routine maternity care practices and policies, including interventions in labour and birth. ResultsThe response rate of hospitals in 1993 was 91% (523/572), and in 2007 it was 92% (323/353). In 1993, 65% of hospitals (335/516) had a policy that all women should have initial electronic fetal heart rate monitoring, and in 2007, 74% (235/319) had such a policy. In 1993, 55% of hospitals (284/516) used epidural anaesthesia as one of the methods for pain control, and in 2007, 87% of hospitals (278/318) did so. In 1993, 37% of hospitals (193/521) had a “no enema/suppository” policy on admission, and in 2007, 88% (282/322) did. In 1993, 87% of hospitals (450/516) had a policy encouraging the presence of both the woman’s partner and other labour support people in the room during the course of labour; in 2007, 80% (259/323) did. In 1993, hospitals estimated that 62% of primiparous women and 44% of multiparous women had an episiotomy in their units. In 2007, the episiotomy rate, irrespective of parity, was 17%. In 1993, 20% of hospitals (98/498) had a policy specifying the length of the second stage of labour, and in 2007, 33% (101/307) had such a policy. ConclusionPositive and negative trends in adherence to best practices were seen in policies and practices of routine interventions during labour and birth in Canadian hospitals between 1993 and 2007.

Implementing brief interventions in health care: lessons learned from the Swedish Risk Drinking Project.

The Risk Drinking Project was a national implementation endeavour in Sweden, carried out from 2004 to 2010, based on a government initiative to give alcohol issues a more prominent place in routine primary, child, maternity and occupational health care. The article describes and analyses the project. Critical factors that were important for the results are identified. The magnitude of the project contributed to its reach and impact in terms of providers’ awareness of the project goals and key messages. The timing of the project was appropriate. The increase in alcohol consumption in Sweden and diminished opportunities for primary prevention strategies since entry to the European Union in 1995 have led to increased expectations for health care providers to become more actively involved in alcohol prevention. This awareness provided favourable conditions for this project. A multifaceted approach was used in the project. Most educational courses were held in workshops and seminars to encourage learning-by-doing. Motivational interviewing was an integral aspect. The concept of risk drinking was promoted in all the activities. Subprojects were tailored to the specific conditions of each respective setting, building on the skills the providers already had to modify existing work practices. Nurses were afforded a key role in the project.

Breastfeeding Policies and Practices in Canadian Hospitals: Comparing 1993 with 2007

The Baby-Friendly Hospital Initiative (BFHI) promotes the World Health Organization International Code of Marketing of Breast-milk Substitutes (WHO Code) and the WHO/UNICEF's Ten Steps to Successful Breastfeeding (Ten Steps). The purpose of this study is to describe and compare maternity hospitals' adherence to the BFHI in 1993 and 2007 for Canada and for each province and territory. A survey of all Canadian maternity hospitals was conducted in 1993 and 2007 on routine maternity care practices and policies including infant feeding. The overall response rate was 91 percent (n = 523/572 hospitals) in 1993 and 92 percent (n = 323/353 hospitals) in 2007. Eighty-two percent (415/507) of hospitals in 1993 and 68 percent (198/292) in 2007 had exclusive contracts with formula companies. Fifty-eight percent (302/517) of hospitals in 1993 and 90 percent (289/322) in 2007 never gave breastfeeding mothers sample packs containing formula. Fifty-eight percent (296/507) in 1993 and 85 percent (273/321) in 2007 had written breastfeeding policies (Step 1); 97 percent (503/518) in 1993 and 99 percent (320/322) in 2007 allowed mothers to breastfeed, on cue, whenever the babies indicated an interest 24 hours a day (Step 8); 24 percent (126/519) in 1993 and 64 percent (206/321) in 2007 reported that they did not provide soothers (Step 9); 58 percent (297/513) in 1993 and 68 percent (215/316) in 2007 always offered information on breastfeeding support groups and/or advice at time of discharge (Step 10). In the 14 years separating the two surveys, Canadian maternity hospitals substantially improved their implementation of the WHO Code and their adherence to the WHO/UNICEF Ten Steps.

A systematic review of structured versus non-structured breastfeeding programmes to support the initiation and duration of exclusive breastfeeding in acute and primary healthcare settings.

Background Breastfeeding has many important health benefits for the woman and her baby. Despite evidence of benefit from a large number of well conducted studies, breastfeeding uptake and the duration of exclusive breastfeeding remain low in many countries. In order to improve breastfeeding rates, policy and guidelines at global, individual country level and in local healthcare settings have recommended that structured programmes to support breastfeeding should be introduced. The objective of this review was to consider the evidence of outcomes of structured compared with non-structured breastfeeding programmes in acute maternity care settings to support initiation and duration of exclusive breastfeeding. Review methods The definition of structured programme used included a multi-faceted or single intervention approach to support breastfeeding; definition of non-structured included support offered within standard care. The review considered quantitative and qualitative studies which addressed outcomes following the introduction of a structured programme in acute healthcare settings to support breastfeeding compared with no programme. The primary outcomes of interest were uptake of breastfeeding and duration of exclusive breastfeeding (only breast milk, including milk expressed). Studies which only considered community based interventions were not included. Search strategy A search of the literature published between 1992 and 2010 was conducted, which followed a four step process. After a limited search of MEDLINE and CINAHL to identify key words contained in the title or abstract and index terms to describe relevant interventions, a second extensive search was undertaken using identified key words and index terms. The third step included a search of reference lists and bibliographies of relevant articles and the fourth step included a search of grey and unpublished literature and national databases Methodological quality Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction. Results Twenty-six articles were included; one randomised controlled trial, two non randomised trials, one cross-sectional study, five systematic reviews, 15 cohort studies and two descriptive studies. Due to the poor quality of evidence presented and clinical and methodological heterogeneity of study designs, including definitions of breastfeeding and duration of follow-up, it was not possible to combine studies or individual outcomes in meta-analyses, therefore findings are presented in a narrative form. In most studies the structured programme of interest reflected some or all of the Baby Friendly Hospital Initiative ‘Ten Steps’. Most studies found a statistically significant improvement in initiation of breastfeeding following introduction of a structured breastfeeding programme, although effect sizes varied widely. The impact of introducing a structured programme on the duration of exclusive breastfeeding and duration of any breastfeeding was also evident, although not all studies found statistically significant differences. At hospital discharge or within the first week post-birth, implementation of a structured programme appeared to increase duration of exclusive breastfeeding and the duration of any breastfeeding compared with usual care. After hospital discharge and up to six months post-birth, use of structured programmes also appeared to support continued duration of exclusive and any breastfeeding although differences in outcomes were not reported across all included studies. At six months, three of five studies which included data on longer-term outcomes showed women were statistically significantly more likely to be exclusively breastfeeding. Only one of these studies compared outcomes following implementation of BFHI. Conclusions Despite the poor overall quality of studies, structured programmes, regardless of content, compared with standard care appear to influence the uptake and duration of exclusive breastfeeding and any breastfeeding. In healthcare settings with low breastfeeding uptake and duration rates, structured programmes may have a greater benefit. TRUNCATED AT 600 WORDS

A systematic review of structured versus non-structured breastfeeding programmes to support the initiation and duration of exclusive breastfeeding in acute and primary healthcare settings.

A systematic review of structured versus non-structured breastfeeding programmes to support the initiation and duration of exclusive breastfeeding in acute and primary healthcare settings.

Analysis on the intervention services status of prevention of mother to child transmission of HIV/AIDS in China

The purpose of this study is to get to know the intervention services implementation status of prevention of mother to child transmission (PMTCT) of HIV/AIDS in China, and the trend of recent five years. We carried out relevant surveys and investigations among the areas where PMTCT work had been implemented during January 2005 to December 2009. Health providers in these fields provided routine maternal health care, HIV counseling and test for 10 360 655 pregnant women and comprehensive intervention measures to 10 123 HIV infected pregnant women which included antiretroviral (ARV) drugs usage, safety delivery, and exclusive breastfeeding, and collected relevant data and materials to analysis the ratio of main interventions and its change trend. The HIV/AIDS counseling rate was increasing year by year (χ(2)(trend) = 3184.5, P < 0.001), during 2005 to 2009 the rate was 69.8% (406 151/581 975), 84.5% (1 346 745/1 594 579), 90.3% (1 582 757/1 753 191), 93.7% (1 926 224/2 055 232), 82.3% (3 599 228/4 375 678) respectively. HIV/AIDS test rate was increasing (χ(2)(trend) = 146 194.7, P < 0.001), the rate from 2005 to 2009 was 57.8% (336 459/581 975), 80.8% (1 287 812/1 594 579), 87.0% (1 524 595/1 753 191), 89.2% (1 833 246/2 055 232), 85.5% (3 741 337/4 375 678)respectively. The total number of HIV/AIDS infected maternities was 10 123 during 2005-2009, 6156 of them delivered, the general usage rate of ARVs was 71.0% (4373/6156), and increasing to 75.3% (1554/2065) by the end of 2009, the rates of 2005 to 2008 were 64.6% (362/560), 66.9% (623/931), 66.7% (857/1284), 74.2% (977/1316) respectively. The difference was significant (χ(2)(trend) = 47.6, P < 0.001). The proportion of using ARVs during pregnant period was 58.5% (2557/4373). The proportion of using ARVs among born infants of HIV infected maternities was 83.4% (4999/5994), and increasing yearly, 77.2% (409/530) of 2005, 80.1% (720/899) of 2006, 83.8% (1053/1257) of 2007, 89.4% (1116/1249) of 2008, 82.6% (1701/2059) of 2009, the difference was significant (χ(2)(trend) = 13.0, P < 0.001). The general rate of exclusive breastfeeding was 92.9% (5276/5681) and the rate of HIV test in 18 months was 74.6% (2482/3324). The rate of HIV/AIDS counseling and test of general maternities is increasing and the proportion of mainly intervention measures have been increased year by year.

The compliance of medical staff for the routine administration of iron in the 1st year to their children

We aimed to study the personal compliance of physicians and nurses with recommendations for the administration of iron supplements for their own children and their compliance with the routine child and maternal health care surveillance recommended during the first year of life. Five hundred physicians and nurses from Haifa and Tel Aviv area working in hospitals and the community were asked to answer a self administered questionnaire. The questionnaire included questions assessing their compliance (using a 100mm analogue visual scale) with iron and vitamin A+D supplementation, immunizations and routine examinations at the child and maternal health care center for their children. One hundred and forty one physicians and 135 nurses (55.2%) cooperated and returned the questionnaire. We found that 41.2% of medical personnel graded their compliance with iron supplementations as 6 or less, in a scale of 0-10. Significant differences were found between the different professions. Nurses were significantly more compliant compared to physicians (54.9% of nurses reported full compliance compared to only 32.4% of physicians, (p=0.001)). The degree of seniority also affected compliance. Specialists were significantly less compliant compared to interns (22% vs. 38.8% respectively). Certified nurses were also less compliant compared to uncertified nurses (52.9% vs. 61.5% respectively). Significant differences between physicians and nurses were also noted in A+D administration and routine health visits. Although nurses demonstrated more compliance with vaccinations these differences were not significant (p=0.076). The compliance of medical staff for iron and A+D administration to their own children is poor especially among physicians.

ICPC-2 defined pattern of illnesses in a practice-based research network in an urban city in West Africa

ABSTRACTBackgroundIn optimising the health of individuals, families and communities, attention should be focused on the clinical processes at medical facilities based in the community. Networks of general and family practices offer this unique opportunity. In establishing the burden of diseases in a community, the traditional classification used is the International Classification of Diseases. This study uses the International Classification of Primary Care. The aim of the study was to document the pattern of illnesses presenting in general/family physician practices in a city in Nigeria.MethodA nine-item interviewer-administered questionnaire containing closed-ended questions was administered to 881 patients presenting at 67 private general/family practice clinics/hospitals in 15 local government areas of urban Lagos by trained general practitioners, using the ICPC-2 pager, which asks for socio-demographic information, reasons for the presentation, and the provisional diagnosis within a 24-hour period.ResultsChildren younger than five years accounted for 20.4% of those presenting, while 25- to 39-year-olds accounted for 44.4%. Geriatric patients (60 years and older) comprised 3.0%. Social classes 1 to 4 accounted for 36.8% of the patients, while social classes 5 to 8 accounted for 43.2%. Of all the patients, 18.7% earned less than 1 US$/day. The seven topmost reasons for visiting the medical practice/clinic/hospital were: General and unspecified 23.1%; pregnancy, child bearing and family planning 13.9%; respiratory problems 10.9%; problems related to the digestive system 9.6%; musculoskeletal 5.6%; Skin 4.4%; and neurological problems 4.2%.ConclusionThe skills of general/family practitioners in West Africa and on the rest of the continent should concentrate on general and unspecified illnesses, routine and emergency maternal and child care, and problems related to the respiratory, digestive, musculoskeletal, skin and neurological systems.

Two‐stage ultrasonography in screening for fetal anomalies at 13–14 and 18–22 weeks of gestation

The aim of this study was to assess the value of two-stage screening by ultrasonography in detecting selected major fetal anomalies in a low-risk obstetric population. In a defined geographic area, 4789 consecutive low-risk pregnant women participated in screening by two-stage ultrasonography as part of routine maternal care. The examinations were usually performed by specially trained midwives at 13-14 and 18-22 weeks of gestation. Of the women, 4073 had both scans, 440 had the early one only, and 276 the late scan only. Pregnancy outcomes were ascertained from obstetric and pediatric records, and the data were supplemented with information from the national birth and malformation registries. Of the 4855 fetuses, 33 (0.7%) had major structural defects considered detectable by ultrasonography. Of these, six (18%) were identified at the early scan, and an additional 10 (30%) at the late scan, yielding a total sensitivity of 48% for the two-stage screening. Twenty offspring had chromosomal abnormalities; 10 were identified by increased nuchal translucency at the early scan, one additional one (by hydronephrosis) at the late scan, and the remaining nine at birth. In a low-risk population, first-trimester scanning is useful in finding fetuses with chromosomal anomalies, but a second-trimester scan is needed for other types of defects. The sensitivity of routine screening by midwives for fetal structural defects in a general obstetric population remains lower than that reported by specialized centers.

Two-stage ultrasonography in screening for fetal anomalies at 13-14 and 18-22 weeks of gestation

Background. The aim of this study was to assess the value of two-stage screening by ultrasonography in detecting selected major fetal anomalies in a low-risk obstetric population. Methods. In a defined geographic area, 4789 consecutive low-risk pregnant women participated in screening by two-stage ultrasonography as part of routine maternal care. The examinations were usually performed by specially trained midwives at 13–14 and 18–22 weeks of gestation. Of the women, 4073 had both scans, 440 had the early one only, and 276 the late scan only. Pregnancy outcomes were ascertained from obstetric and pediatric records, and the data were supplemented with information from the national birth and malformation registries. Results. Of the 4855 fetuses, 33 (0.7%) had major structural defects considered detectable by ultrasonography. Of these, six (18%) were identified at the early scan, and an additional 10 (30%) at the late scan, yielding a total sensitivity of 48% for the two-stage screening. Twenty offspring had chromosomal abnormalities; 10 were identified by increased nuchal translucency at the early scan, one additional one (by hydronephrosis) at the late scan, and the remaining nine at birth. Conclusions. In a low-risk population, first-trimester scanning is useful in finding fetuses with chromosomal anomalies, but a second-trimester scan is needed for other types of defects. The sensitivity of routine screening by midwives for fetal structural defects in a general obstetric population remains lower than that reported by specialized centers.

Learning curve in ultrasonographic screening for selected fetal structural anomalies in early pregnancy

Objective To assess the value of first trimester screening by ultrasonography in detecting structural anomalies of the fetus in a general obstetric population. Methods During 1993–1998, 20,465 consecutive pregnant women who resided in a defined geographic area participated in ultrasonographic screening for major malformations. These included anomalies of the central nervous system, urinary tract, abdominal wall, and long bones. Heart anomalies were not expected to be detected. The examinations were offered at 13–14 weeks’ gestation as part of routine maternal care and were done by specially trained midwives. The pregnancy outcomes were ascertained from obstetric and pediatric records, and the data were completed by information from the national birth and malformation registries. Results A total of 307 fetuses (1.5%) with a major malformation were found; 67 fetuses (0.3%) had noncardiac major structural defects expected to be detectable by ultrasonography in early pregnancy. Thirty-five of 67 (52%) were identified at the early scan. Sensitivity for these defects increased from 22% to 79% from the first to the last (sixth) study year ( P = .009). Conclusion In a low-risk population, adequate sensitivity in screening for major malformations by early ultrasonography can be achieved after a learning curve of 3–4 years.