Reducing maternal, newborn, and infant mortality globally : an integrated action agenda

International Journal of Gynecology & Obstetrics, Improving maternal health, 2012

Abstract

There has been increasing awareness over recent years of the persisting burden of worldwide maternal, newborn, and child mortality. The majority of maternal deaths occur during labor, delivery, and the immediate postpartum period, with obstetric hemorrhage as the primary medical cause of death. Other causes of maternal mortality include hypertensive diseases, sepsis/infections, obstructed labor, and abortion-related complications. Recent estimates indicate that in 2009 an estimated 3.3 million babies died in the first month of life and that overall, 7.3 million children under 5 die each year. Recent data also suggest that sufficient evidence- and consensus-based interventions exist to address reproductive, maternal, newborn, and child health globally, and if implemented at scale, these have the potential to reduce morbidity and mortality. There is an urgent need to put elements in place to promote integrated interventions among healthcare professionals and their associations. What is needed is the political will and partnerships to implement evidence-based interventions at scale.

  1. Why do maternal and newborn deaths matter?
  2. Addressing determinants
  3. Defining evidence-based interventions for maternal, newborn, and child survival
  4. Delivering integrated MNCH interventions in primary care settings

Read Reducing maternal, newborn, and infant mortality globally: An integrated action agenda, International Journal of Gynecology & Obstetrics, Improving maternal health, DOI: 10.1016/j.ijgo.2012.04.001, 2012. Featured image : sti. Source: Modified from Kerber et al.

Rapid resolution and redress scheme for severe birth injury

Seeks views on the proposed investigations into severe avoidable birth injury and the support and compensation scheme

 

England is a safe place to give birth, and every year thousands of babies are safely delivered to delighted parents by experienced and dedicated NHS staff. This is the outcome that all families expect and the vast majority of families experience. However, tragedies can sometimes occur, and babies can suffer serious harm during delivery. Thankfully these incidents are rare, but it is clear that there is still more that the UK Department of Health can do to achieve its vision to make NHS maternity services among the safest in the world.   

The rapid resolution and redress scheme (RRR) aims to introduce a system of consistent and independent investigations for all instances where there may be severe avoidable birth injury, along with access to ongoing support and compensation for eligible babies through an administrative scheme.

The main aims are:

  • reducing the number of severe avoidable birth injuries by encouraging a learning culture
  • improving the experience of families and clinicians when harm has occurred
  • making more effective use of NHS resources

This consultation – opened since 2 March 2017 and closing at
11:45pm on 26 May 2017 – seeks views about the proposed scheme, including:

  • how the scheme is administered
  • the eligibility threshold for compensation
  • how learning would best be shared and acted on to reduce future harm

This consultation is accompanied by a consultation-stage impact assessment and 2 independent research reports that were commissioned by the department to inform the early stages of policy development in preparing for the consultation.

2017 Documents

  • A rapid resolution and redress scheme for severe avoidable birth injury: a consultation, PDF, 871KB, 42 pages.
  • A rapid resolution and redress scheme for severe avoidable birth injury: impact assessment, PDF, 3.34MB, 81 pages.
  • DH birth injury compensation policy research
    PDF, 1.61MB, 74 pages.
  • No-Fault Compensation Schemes: review, PDF, 1.68MB, 87 pages.

Stillbirth: the overall trend masks big variations in rates across the UK

Fifteen babies a day in UK are stillborn or die within month of birth

Fifteen babies are dying every day in the UK from stillbirth, during labour or within four weeks of being born, according to a new report.

Perinatal Mortality Surveillance Reports for UK Births, MBRRACE-UK.

There has been slight fall in the rates of stillbirths and neonatal deaths in the UK compared with rates in 2013 which continues the downward trend in rates from 2003 onwards. However, the overall trend masks big variations in death rates across the UK from 4.1 to 7.1 per 1,000 births. Women from the poorest backgrounds and black and Asian mothers run a higher risk than others that their baby will die in the womb or soon after birth.

Fifteen babies a day in UK are stillborn or die within month of birth, the Guardian, 17 May 2016.

These variations remain despite the fact that a novel method of analysis introduced by MBRRACE-UK has been used to take into account aspects of case-mix to allow ‘fairer’ comparisons of mortality rates between services provided for high risk and low risk pregnancies. The new analytical method which divides the figures for Trusts and Health Boards into five groups based on the services they deliver, also takes into account the random variation in rates which can occur because of the small number of births which occur in some areas.

Weight gain between pregnancies increases risk of stillbirth and infant death

Weight gain between pregnancies linked to stillbirths and infant deaths

obese while pregnant image
Swedish research shows women who put on weight after first pregnancy increase risk of stillbirth by 30-50% and likelihood of infant death by up to 60%.

2015 Study Abstract

Background
Maternal overweight and obesity are risk factors for stillbirth and infant mortality. Whether temporal changes in maternal weight affect these risks is not clear. We aimed to assess whether change of BMI between first and second pregnancies affects risks of stillbirth and infant mortality in the second-born offspring.

Methods
In a Swedish population-based cohort of women who gave birth to their first and second child between Jan 1, 1992, and Dec 31, 2012, we investigated associations between change in maternal body-mass index (BMI) during early pregnancy from first to second pregnancies and risks of stillbirth and neonatal, postneonatal, and infant mortality after the second pregnancy. Relative risks (RRs) for each outcome according to BMI change categories were calculated with binomial regression.

Findings
Complete information was available for 456 711 (77·7%) of 587 710 women who had their first and second single births in the study period. Compared with women with a stable BMI (change between −1 kg/m2 and

Interpretation
Our findings emphasise the need to prevent weight gain before pregnancy in healthy and overweight women and that weight loss should be promoted in overweight women.

Sources and more information
  • Weight change between successive pregnancies and risks of stillbirth and infant mortality: a nationwide cohort study,
    theLancet, PIIS0140-6736(15)00990-3, 02 December 2015.
  • Weight gain between pregnancies linked to stillbirths and infant deaths,
    theGuardian, 2 December 2015.
  • Weight gain between pregnancies ‘linked to stillbirth’,
    NHS Choices, December 3 2015.

UK Dept of Health plan to halve stillbirth, neonatal and maternal deaths

New ambition to halve rate of stillbirths and infant deaths

This post content is published by Gov UK Department of Health

image of parent_holding_baby_hand
Government announces new commitment to ensure England is one of the safest places in the world to have a baby.

New ambition to halve rate of stillbirths and infant deaths

The Health Secretary, Jeremy Hunt, has announced a new ambition to reduce the rate of stillbirths, neonatal and maternal deaths in England by 50% by 2030.

The number of brain injuries occurring during or soon after birth will also be targeted as part of a new commitment by the government, in partnership with consultants, midwives and other experts across the country to make England one of the safest places to have a baby.

The government will work with national and international experts to ensure that best practice is applied consistently across the NHS and that staff can review and learn from every stillbirth and neonatal death.

Maternity services will be asked to come up with initiatives that can be more widely adopted across the country as part of a national approach – such as appointing maternity safety champions to report to the board and ensuring all staff have the right training to enable them to identify the risks and symptoms of perinatal mental health.

Trusts will receive a share of over £4 million of government investment to buy high-tech digital equipment and to provide training for staff already working to improve outcomes for mums and babies. This includes a £2.24 million fund to help trusts to buy monitoring or training equipment to improve safety, such as cardiotocography (CTG) equipment to monitor babies’ heartbeat and quickly detect problems, or training mannequins that staff can practise emergency procedures on.

A further £500,000 will be invested in developing a new system for staff to review and learn from every stillbirth and neonatal death. The new safety investigation unit will also be asked, once established, to consider a particular focus on maternity cases for its first year.

Over £1 million will be invested in rolling out training packages developed in agreement with the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, to make sure staff have the skills and confidence they need to deliver world-leading safe care.

This builds on previous government commitments to invest £75 million in improving perinatal mental health services and ensuring all maternity care is considered as part of ‘Ofsted style’ ratings for commissioners.

Over time this initiative will allow the money spent on caring for injured children or paid as compensation to be re-invested in improved front line services.

Health Secretary Jeremy Hunt said:

The NHS is already a safe place to give birth, but the death or injury of even one new baby or mum is a devastating tragedy which we must do all we can to prevent.

With more support and greater transparency in maternity services across England we will ensure every mother and baby receives the best and safest care, 24 hours a day, 7 days a week – this is at the heart of the NHS values we are backing with funding from a strong economy.

Countries like Sweden are proof that focusing on these issues can really improve safety – with the help of staff on the frontline, we can improve standards here at home.

The ambition is part of a wider government aim to reduce all avoidable harm by 50% and save 6,000 lives by 2017, and it will form a key part of the work of the patient safety campaign Sign up to Safety. The government will align next steps with the Independent Review of Maternity Services’ recommendations, which is already looking at ways to improve quality and safety.

Dr David Richmond, President of the Royal College of Obstetricians and Gynaecologists (RCOG), said:

We support this initiative and our important role in it as leaders of the profession. Good progress has been made but the fact is many of these incidents could be avoided with improvements to the care women and their babies receive.

The RCOG will continue to work closely with our clinical colleagues and the Royal College of Midwives to provide better multi-disciplinary training packages and promote more effective team working, so that this aspect of care can be improved. The challenges of reducing health problems and deaths in mothers and babies due to contributory factors such as smoking, obesity and alcohol also require similar commitment.

Women who experienced a stillbirth almost five times more likely to suffer same tragedy again

Risk of recurrent stillbirth: systematic review and meta-analysis

Women who experience a stillbirth in their initial pregnancy have a higher risk of stillbirth in a subsequent pregnancy. Even after adjusting for potential confounding factors, the increased risk remains. Risk of recurrent unexplained stillbirth is largely unstudied,  evidence about this remains controversial. Roman Soto image.

2015 Study Abstract

Objective
To determine the risk of recurrent stillbirth.

Design
Systematic review and meta-analysis of cohort and case-control studies.

Data sources
Embase, Medline, Cochrane Library, PubMed, CINAHL, and Scopus searched systematically with no restrictions on date, publication, or language to identify relevant studies. Supplementary efforts included searching relevant internet resources as well as hand searching the reference lists of included studies. Where published information was unclear or inadequate, corresponding authors were contacted for more information.

Study selection
Cohort and case-control studies from high income countries were potentially eligible if they investigated the association between stillbirth in an initial pregnancy and risk of stillbirth in a subsequent pregnancy. Stillbirth was defined as fetal death occurring at more than 20 weeks’ gestation or a birth weight of at least 400 g. Two reviewers independently screened titles to identify eligible studies based on inclusion and exclusion criteria agreed a priori, extracted data, and assessed the methodological quality using scoring criteria from the critical appraisal skills programme. Random effects meta-analyses were used to combine the results of the included studies. Subgroup analysis was performed on studies that examined unexplained stillbirth.

Results
13 cohort studies and three case-control studies met the inclusion criteria and were included in the meta-analysis. Data were available on 3 412 079 women with pregnancies beyond 20 weeks duration, of who 3 387 538 (99.3%) had had a previous live birth and 24 541 (0.7%) a stillbirth. A total of 14 283 stillbirths occurred in subsequent pregnancies, 606/24 541 (2.5%) in women with a history of stillbirth and 13 677/3 387 538 (0.4%) among women with no such history (pooled odds ratio 4.83, 95% confidence interval 3.77 to 6.18). 12 studies specifically assessed the risk of stillbirth in second pregnancies. Compared with women who had a live birth in their first pregnancy, those who experienced a stillbirth were almost five times more likely to experience a stillbirth in their second pregnancy (odds ratio 4.77, 95% confidence interval 3.70 to 6.15). The pooled odds ratio using the adjusted effect measures from the primary studies was 3.38 (95% confidence interval 2.61 to 4.38). Four studies examined the risk of recurrent unexplained stillbirth. Methodological differences between these studies precluded pooling the results.

Conclusions
The risk of stillbirth in subsequent pregnancies is higher in women who experience a stillbirth in their first pregnancy. This increased risk remained after adjusted analysis. Evidence surrounding the recurrence risk of unexplained stillbirth remains controversial.

Sources and more information
  • Risk of recurrent stillbirth: systematic review and meta-analysis, thebmj, 2015;350:h3080, 24 June 2015.
  • Women with history of stillbirth at ‘high risk of another’, NHS News, June 26 2015.

Single egg transferred IVF babies less likely to be born prematurely, underweight or stillborn

While there has been a considerable increase in assisted reproduction cycles over the past 20 years, this has been accompanied by a significant improvement in health outcomes for these babies

newborn image
While there has been a considerable increase in assisted reproduction cycles over the past 20 years, this has been accompanied by a significant improvement in health outcomes for these babies, particularly for singleton babies.

The health of artificially conceived children has steadily improved in the last 20 years with fewer babies being born prematurely or affected by low birth weight, research has shown. Researchers who analysed data from Nordic countries described the decline in premature and stillbirths as “remarkable“.

This was the main finding of a large cohort study comparing the health of babies born using assisted reproduction technology (ART), such as in vitro fertilisation (IVF), with those conceived naturally over the last 20 years.

Researchers found big improvements over time in a number of areas, including reductions in the number of miscarriages and babies born prematurely or with a low birth weight. All of these can be complications of multiple births (twins, triplets, or sometimes more).

The study looked at ART in Norway, Sweden, Denmark and Finland, and it is unclear whether we could expect to see similar improvements in the UK.

While it is likely we share similar advances in technology and improved protocols with Nordic countries, there may be other important differences as a result of eligibility for treatment.

In some Nordic countries, eligibility for reproductive treatment has been extended to include couples with less severe fertility problems. This may have accounted for some of the improvements seen over the years.

The most recent UK data from 2013 reports the ART multiple birth rate has fallen from 25% in 2008 to 16% in 2013. This would suggest a potentially similar improvement in UK outcomes for ART.

The study carried out at the University Hospital of Copenhagen found implanting one fertilised egg back into the womb reduces the chance of twins or triplets, which increase risks for the unborn babies. Where one egg was transferred babies were less likely to be born prematurely, underweight or stillborn.

Sources and more information

  • Trends in perinatal health after assisted reproduction: a Nordic study from the CoNARTaS group, Oxford Journals, Hum. Reprod. (2015) doi: 10.1093/humrep/deu345, January 20, 2015. Full study PDF.
  • Largest study of babies born after infertility treatment shows significant improvements in health over past 20 years,
    Oxford University Press (OUP), 19 January 2015.
  • IVF babies see health improvement with fewer underweight or stillborn,
    theguardian, 21 January 2015.
  • IVF babies are less likely to be born prematurely or die in infancy than 20 years ago, study reveals, DailyMail, 21 January 2015.
  • Nordic IVF outcomes improving – is the same true for the UK?,
    nhs.uk/news, 21 January 2015.

Exposure to diethylstilbestrol during sensitive life stages: a legacy of heritable health effects

DES usage review buttress the need for adequate and rigorous research into the use of drugs in pregnancy and ensure that they do more good than harm before being introduced for consumption

DES legacy of heritable health effects ianalysis image
DiEthylStilbestrol usage review buttress the need for adequate and rigorous research into the use of drugs in pregnancy and ensure that they do more good than harm before being introduced for consumption.

Abstract

Diethylstilbestrol (DES) is a potent estrogen mimic that was predominantly used from the 1940s to 1970s in hopes of preventing miscarriage in pregnant women. Decades later, DES is known to enhance breast cancer risk in exposed women, and cause a variety of birth related adverse outcomes in their daughters such as spontaneous abortion, second trimester pregnancy loss, preterm delivery, stillbirth, and neonatal death. Additionally, children exposed to DES in utero suffer from sub/infertility and cancer of reproductive tissues. DES is a pinnacle compound which demonstrates the fetal basis of adult disease. The mechanisms of cancer and endocrine disruption induced by DES are not fully understood. Future studies should focus on common target tissue pathways affected and the health of the DES grandchildren.

Summary

The legacy of the adverse effects that stem from DES administration to pregnant women in the 1950s to 1970s has not completely formed. The male and female offspring of those women have reported significant fertility, cancer, and birth-related outcomes, but the cancer outcomes are not completely understood, with few exceptions (CCA and breast cancer in women over 40 yr old). Information on DES mothers and daughters, in addition to substantial animal data, earned DES a place in the First Annual Report on Carcinogens, a critical review of carcinogenic compounds produced by the National Toxicology Program, in 1980 and was noted by the International Agency for Research on Cancer in their Monographs (IARC 1974). As the male and female offspring of those women age, the overall effect of DES on reproductive cancers will be better understood. Even more important to understand is the potential effect of this endocrine disruptor and carcinogen on the 3rd generation offspring who were not directly exposed, but may be affected in a heritable way through estrogen reprogramming and DNA modification. Further research is needed to indicate the mechanisms of action on the target tissues, so that future pharmaceuticals/environmental estrogen mimics will avoid these pathways, leading to healthier future generations.

Sources and full study
  • Exposure to diethylstilbestrol during sensitive life stages: a legacy of heritable health effects, NCBI PMID: 23897597, Birth Defects Res C Embryo Today.;99(2):134-46. doi: 10.1002/bdrc.21035, 2013 Jun.
  • Full text: PMCID: PMC3817964, NIHMSID: NIHMS520381, doi: 10.1002/bdrc.21035, Nov 5, 2013.
      • INTRODUCTION
      • DES EXPOSURE MAGNITUDE
      • HEALTH EFFECTS
      • Effects in DES Mothers
      • Effects in DES Daughters
      • Effects in DES Sons
      • EFFECTS OF DES IN A 3rd GENERATION
      • GENE CHANGES AND PROPOSED MECHANISMS OF ACTION
More DES DiEthylStilbestrol Resources

Born Asleep

UK Stillborn Baby Scandal Full Documentary, BBC Panorama 2014

More than half of stillbirths in the UK could be prevented if the NHS implemented additional scans, a leading obstetrician has told Panorama.



Every year in the UK, four thousand babies are stillborn. It’s one of the worst rates in the developed world. Panorama’s Paul Kenyon meets the clinicians who say they could save hundreds of babies’ lives a year, with cheap and simple interventions that the medical establishment appears slow to accept

Sources and more information
  • Video available for 11 months in HD on BBC iPlayer.
  • Read Half of UK stillbirths could be prevented with scans, BBC News Health, 30 September 2014.
  • Read Pledge to end UK ‘scandal’ of 17 stillborn babies a day, Express, 28 September 2014.
  • Read One in five child deaths ‘preventable’, BBC News Health, 5 September 2014.

A Comparison of Pregnancy Experience in DES-exposed and DES-unexposed Daughters

In this 1980 study, the difference in pregnancy outcomes between the DES daughters and the unexposed is highly significant

A comparison of pregnancy experience in DES-exposed and DES-unexposed daughters
Pregnancy outcomes in DES Daugters are worse than those in unexposed women

Reproductive histories were compared for 226 diethylstilbestrol-exposed daughters and 203 DES-unexposed daughters whose mothers participated in a double-blind evaluation 27 years before. Irregular menstruation was slightly more common among the exposed (10%) than among the unexposed (4%). Nineteen of the exposed and only four of the unexposed had primary infertility. Among those at risk, 86% of the unexposed and 67% of the exposed had become pregnant. The reasons for these differences are not known. Comparison of evaluable first pregnancy outcome revealed full-term live birth to be more common among the unexposed (85%) than the exposed (47%). Premature live birth was experienced by 22% of the exposed but only 7% of the unexposed. Nonviable outcomes of stillbirth, neonatal death, miscarriage and ectopic pregnancy occurred in 31% of the exposed and 8% of the unexposed. The difference in pregnancy outcomes between the groups is highly significant. The DES-exposed with transverse cervicovaginal ridges were more likely to experience a nonviable outcome. Overall 82% of the exposed and 93% of the unexposed had at least one live offspring.

Sources: A comparison of pregnancy experience in DES-exposed and DES-unexposed daughters, NCBI, Dr Herbst A, Feb 1980

Related post: Continued follow-up of #Pregnancy Outcomes in #DiEthylStilbestrol-exposed Offspring, by Dr Herbst A, Oct 2000

Sadly for many DES daughters having their own children is not possible! Many of us who have experienced miscarriages, want to have kids but are struggling or unable to…
More about DES pregnancy risks – our posts tagged pregnancy

More DES DiEthylStilbestrol Resources