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Round Up: Maternal health and maternal mortality
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© 2010 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2010;18(36):197–205 0968-8080/10 $ – see front matter PII: S 0 9 6 8 - 8 0 8 0 ( 1 0 ) 3 6 5 4 2 - 6
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ROUND UP
Maternal health and maternal mortality Trends in maternal mortality, UN inter-agency estimates, 1990 to 2008 The number of women dying due to complications of pregnancy, childbirth and unsafe abortion has decreased by 34% from an estimated 546,000 in 1990 to 358,000 in 2008, according to this inter-agency report by WHO, UNICEF, UNFPA, and the World Bank.1 The analysis was led by an academic team at the University of Berkeley and supported by the maternal mortality estimation inter-agency group. The WHO Department of Reproductive Health and Research/ Special Programme on Human Reproduction (RHR/HRP) was instrumental in coordinating the analysis, including its review by external technical experts, country consultation and preparation of the report. Although progress is notable, the annual rate of decline is less than half of what is needed to achieve the MDG 5 target of reducing the maternal mortality ratio by 75% between 1990 and 2015. This would require an annual decline of 5.5%. The 34% decline since 1990 translates into an average annual decline of just 2.3%. Pregnant women still die from four major causes: postpartum haemorrhage, infections, hypertensive disorders, and unsafe abortion. Every day, about 1,000 women died due to these complications in 2008. Out of those 1,000 women, 570 lived in sub-Saharan Africa, 300 in South Asia and 5 in high-income countries. The risk of a woman in a developing country dying from a pregnancyrelated cause during her lifetime is about 36 times higher compared with a woman living in a developed country. This report covers the period from 1990 to 2008 and highlights the following:
• 10 out of 87 countries with maternal mortality ratios equal to or over 100 in 1990 are on track, with an annual decline of 5.5% between 1990 and 2008. At the other extreme, 30 countries have made insufficient or no progress since 1990.
• In sub-Saharan Africa, maternal mortality decreased by 26%. • In Asia, the number of maternal deaths is estimated to have dropped from 315,000 to 139,000 between 1990 and 2008, a 52% decrease. • 99% of all maternal deaths in 2008 occurred in developing regions, with sub-Saharan Africa and South Asia accounting for 57% and 30% of all deaths, respectively. These new estimates show that it is possible to prevent many more women from dying if countries invest more in their health systems and in the quality of maternity and abortion care. The UN maternal mortality estimates (Table 1) use all available country data on maternal mortality, as well as improved methods of estimation. The methods for maternal mortality estimates were peer reviewed by an external technical advisory group. The intensive country consultation carried out as part of the development of these estimates has been instrumental in identifying increased data collection efforts in recent years, including the special systems to capture data on maternal deaths. There are, however, major gaps in the availability and quality of data for many countries where maternal mortality levels are high, and only through statistical modelling is it possible to obtain an understanding of the trend.2 The full report, which includes a detailed description of the methodology and the underlying data used to develop the estimates, is available on the web.1 1. Trends in Maternal Mortality, 1990 to 2008. Estimates developed by WHO, UNICEF, UNFPA and the World Bank, 2010. Geneva: World Health Organization, 2010. At:. 2. HRP/RHR News. UN MDG Summit Special Issue. No. 13. World Health Organization, September 2010.
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Round Up: Maternal health and maternal mortality / Reproductive Health Matters 2010;18(36):197–205
Community-based interventions improve newborn outcomes but not maternal mortality A systematic review was done of the effectiveness of community-based intervention packages for preventing maternal morbidity and mortality and improving neonatal outcomes during pregnancy, delivery and the post-partum period. The review included 27 experimental and nonexperimental studies which employed rigorous impact evaluation techniques, covering a wide range of interventions. Studies were from Asia 198
(22), Africa (3), European Union (1) and South America (1). The review did not find a significant reduction in maternal mortality across all studies, but it did find a significant reduction across studies with low risk of bias. Significant reductions were observed in neonatal mortality, stillbirths and perinatal mortality. The interventions also led to reductions in maternal morbidity, increased referrals to a health facility for pregnancy-related complications, improved rates of early breastfeeding, and improved newborn care-related outcomes. The review offers evidence of the value,
Round Up: Maternal health and maternal mortality / Reproductive Health Matters 2010;18(36):197–205
particularly for infants, of integrating maternal and newborn care in community settings through a range of strategies, many of which can be delivered by community health workers. The most successful packages were those which emphasised clean practices by involving family members, provision of care through trained community health workers, and strengthened referrals for mothers and newborns.1 However, the importance of skilled delivery and facility-based emergency obstetric care still needs greater attention. 1. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for preventing maternal morbidity and mortality and improving neonatal outcomes. The International Initiative for Impact Evaluation, March 2010.
Free resources for training in maternal and neonatal care
FREDERIC COURBET/PANOS PICTURES
Training all health professionals attending births will contribute to reducing maternal deaths. This
article presents three training courses for which the training content can be freely downloaded from the internet. Midwifery Education Modules, developed by the WHO, are aimed at the main causes of maternal death, eclampsia, abortion, prolonged and obstructed labour, post-partum haemorrhage and sepsis. Student participation is encouraged, and each module takes two weeks of teaching. Emergency Obstetric Care for Doctors and Midwives consists of a pre-course knowledge questionnaire, participant's notebook, a trainer guide, and an extensive set of presentation Powerpoint graphics. A site assessment tool is included to identify possible barriers to implementing change, and a follow-up tool for continuous support of students and faculty after the course and to assess the effect of the training. The Perinatal Education Program encourages groups of health care workers to come together and study in their own time. Modular manuals cover normal labour and delivery and its complications and neonatal care. Each manual takes
Merlin provides emergency health services, Dissikou, Nana-Grebizi, Central African Republic, 2008 199
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about a year to study. Six additional manuals have been introduced covering perinatal HIV/ AIDS, primary newborn care, mother- and babyfriendly care, saving mothers and babies, birth defects, and primary maternal care.1
of births are attended by a health professional – up from 32% in 2000 – Cambodia is unlikely to meet its Millennium Development Goal of reducing maternal mortality to 140 deaths per 100,000 live births by 2015.1
1. van Lonkhuijzen LRCW, van Roosmalen J, Zeeman G. Implementing safe motherhood: free resources for training in maternal and neonatal care. International Journal of Gynecology and Obstetrics 2010; 109(3):189.
1. In brief: Cambodia needs more midwives to reduce maternal deaths. IRIN News, 9 August 2010.
Rebirth of the midwife, Laos
In public birthing centres in Iran, 5–7 women in labour will share a room, and continuous or one-to-one support during labour by a midwife or nurse is not routine. Consequently, most women have negative recollections of their birth experience and prefer caesarean delivery in subsequent pregnancies. This study evaluated the effect of continuous support provided by midwives during labour on the duration of the different stages of labour and the rate of caesarean delivery. 100 eligible nulliparous women at the Iran University of Medical Sciences, Tehran, who had not received education classes on childbirth, were randomised in 2003. In the intervention group (n=50), continuous support was provided during labour by an experienced midwife, in a private room with the option to move around and eat or drink. The control group (n=50) were admitted to the labour ward; they did not receive continuous support or have a private room, were not permitted food and did not receive education or any explanation about labour. The two groups did not differ by age, employment, educational level, gestational age, economic status or neonatal weight. Mean duration of the active phase of labour (167.9 vs. 247.7 minutes, p<0.001), second stage of labour (34.9 vs. 55.3 min, p=0.003), and the number of caesarean deliveries (4 vs. 12, p=0.026) were significantly lower in the intervention group compared with the control group. The rates of oxytocin use and Apgar scores of less than seven at five minutes were similar between the groups. Continuous support provided during labour may reduce the duration of labour and the number of caesarean deliveries, as well as reduce both the negative impact of birth on women and the likelihood of a woman subsequently choosing an elective caesarean delivery. This model of support should be available to all women.1
Laos has one of the region's highest maternal mortality ratios – 405 deaths per 100,000 live births – partly due to deliveries by untrained birth attendants. After not conducting midwifery training for 23 years, due to lack of funding and interest from students, there are less than 100 midwives nationwide for a population of 6.2 million – many lacking even basic training. Only 20% of women delivered in a health centre in 2005 and older women, who gave birth in their villages, encourage their daughters to do the same. The government resumed courses in eight training centres in October 2009 with US$1 million of UNFPA support. Persuading people of the importance of midwives is not easy, and it is hoped that more people will come to health centres if they trust midwives. In contrast, Sri Lanka reduced maternal deaths by training community midwives in the 1980s. The maternal death rate dropped by 70% from 1995 to 2005 and skilled birth attendants were present at 96% of deliveries. Laos plans to establish a national licensing system for midwives. For now, the goal is to get midwives into communities.1 1. Laos: rebirth of a midwife. IRIN News, 25 August 2010.
Cambodia needs more midwives to reduce maternal deaths Cambodia must increase the number of trained health professionals to reduce its high maternal mortality ratio of 540 per 100,000 live births – the second highest in the region after Laos. There is one doctor or midwife for every 1,000 people in Cambodia, compared with two per 1,000 in Thailand, and 12 per 1,000 in Japan. While 56% 200
Effect of continuous support during labour, Iran
Round Up: Maternal health and maternal mortality / Reproductive Health Matters 2010;18(36):197–205
1. Kahanian M, Javadi F, Haghighi MM. Effect of continuous support during labour on duration of labour and rate of caesarean delivery. International Journal of Gynecology and Obstetrics 2010;109(3):198–200.
Domestic violence, perinatal and neonatal mortality, India Between 10 and 64% of women experience lifetime physical or sexual violence from their male partners. This study investigated the relationship between domestic violence and perinatal, neonatal and infant mortality, about which evidence is much more limited. A prospective follow-up study was carried out in 2002–03 in four Indian states, among a cohort of rural women selected from the 1998–99 National Family and Health Survey-2. Data for 3,909 birth outcomes in this four-year period were analysed. After controlling for potentially confounding factors, births to mothers who experienced two or more episodes of recent domestic violence experienced higher perinatal (HR 1.85, 95% confidence interval, CI 1.12–2.79) and neonatal (HR 1.62, 95% CI, 1.11–2.53) mortality, compared to births to women who reported no violence. Births to women who experienced violence had 68% higher risk of infant mortality compared with the no violence group. A single episode of violence did not lead to a higher risk of mortality. Possible reasons for the link between domestic violence and poor birth outcomes include the role of blunt trauma to the fetus, elevated levels of maternal stress, poor physical health of the mother from violence and the deterrent effect of violence on maternal health care-seeking behaviour. There should be greater focus on violence prevention within child survival programmes.1 1. Koenig MA, Stephenson R, Acharya R, et al. Domestic violence and early childhood mortality in rural India: evidence from prospective data. International Journal of Epidemiology 2010;39(3):825–33.
Care-seeking for post-partum morbidity, rural India Despite high morbidity and the danger of maternal death, women in low-resource settings frequently fail to seek post-partum care from formal providers. 2,114 mothers were interviewed through a household survey in February
2008 in the rural Murshidabad district of India, in order to elucidate factors influencing careseeking behaviour for post-partum health problems. 929 (43.9%) women had post-partum morbidity in the six weeks after delivery, of whom 5.8% did not seek any care, 49.2% sought care from informal providers, and 45.0% sought care from formal providers. Factors associated with seeking care from a formal rather than informal provider included being from a more educated household (p<0.05), delivering at a health facility (p<0.001), having a severe postpartum complication (p<0.05), and being Muslim rather than Hindu (p<0.01). Women who did not seek any attention appeared to be most influenced by distance to a health care facility and whether they had had an institutional delivery, which underscores the importance of trying to increase rates of institutional delivery in order to improve post-partum care as well as delivery and birth outcomes. The finding that Hindu women were less likely to seek care than Muslim women should be investigated further.1 1. Tuddenham SA, Hafizur Rahman M, Singh S, et al. Care seeking for postpartum morbidities in Murshidabad, rural India. International Journal of Gynecology and Obstetrics 2010;109(3):245–46.
Improvements in maternal health care in Angola? Angola's civil war, which ended in 2002, established a routine of shunning clinics in favour of home births. Reversing this trend is crucial to reducing the maternal mortality rate, which is one of the highest in the world. Since 1998, the number of women delivering babies at municipal clinics in Matala district of Huila province has increased from 500 to 3,000 annually, out of 10,000 annual births in the district. The rehabilitation of road infrastructure by Chinese, Brazilian and Portuguese companies is improving public transport and access to health care. A 77-bed Chinese-built hospital is yet to be opened, and is an example of health infrastructure developing without adequate medical skills and personnel. Eight Cuban doctors will work at the hospital – boosting to nine the number of doctors serving a population of 230,000. The hospital requires 248 personnel, including theatre nurses and laboratory technicians, but there are only 201
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44 medical staff available in the district. A new strategy, led by the government and supported by UNICEF, WHO and UNFPA, has been launched to improve basic health care at existing health facilities in 16 municipalities, covering 23% of the population. The initiative provides routine immunisation, antenatal and child care, access to safe water, and the distribution of free, insecticideimpregnated mosquito nets. The government hopes to extend the project to another 54 municipalities to cover 70% of the population.1 1. Angola: putting a dent in maternal death rate. IRIN News. 14 May 2010.
Malawian president lifts ban on traditional birth attendants A ban on traditional birth attendants (TBAs), in place since 2007, was effectively lifted by Malawi's president on return from the UN Summit on the Millennium Development Goals in New York. The lifting of the ban still requires Ministry of Health approval, the issuing of guidelines, and consultation with stakeholders, but according to health practitioners, the announcement will allow them to operate openly again. The president said: “We need to train TBAs in safer delivery methods. We should not completely stop them because their work is very important.” The rationale for the ban was that low-skilled TBAs were unable to identify obstetric emergencies early enough. Combined with delays due to poor transport infrastructure and the paucity of medical facilities this contributed to the high maternal mortality ratio, estimated at 510 per 100,000 live births. It was hoped that by preventing TBAs from practising, mothers would use medical facilities, but nearly half of all deliveries still occur outside medical facilities. TBAs continued to exist but went underground for fear of fines. TBAs have two weeks training, and many believe this is not long enough for them to recognise birth complications at an early stage. Linkages between TBAs and health services must be strengthened, and communications improved with clinics to respond to emergencies, e.g. by using motorcycle ambulances.1 1. Malawi: President lifts ban on traditional birth assistants. IRIN News, 11 October 2010.
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Should men and women be encouraged to start childbearing at a younger age? In many developed countries, the average age of women at first childbirth is now 28–30. Fertility awareness programmes have discovered that many men and women overestimate women's fecundity according to age, the probability of conception during a monthly cycle, and the chances of conceiving after in-vitro fertilisation treatment. The postponement of childbearing until the mid-30s or later increases the proportion of couples with fertility problems, increases the risk of becoming a fertility patient, and increases the risk of childlessness or having fewer children than desired. Advising couples to conceive at a younger age is fraught with problems; many couples face economic and practical concerns regarding childbearing, and individuals have the right to choose for themselves an appropriate family planning arrangement. Possible strategies for action include increasing individuals’ knowledge about the impact of increased age and other risk factors; including young men, in the agenda of fertility awareness and decisionmaking about parenthood; and ensuring that societies develop in such a way that young couples can combine family and working life during their most fertile years.1 1. Schmidt L. Should men and women be encouraged to start childbearing at a younger age? Expert Review of Obstetrics and Gynecology 2010;52(2):145–47.
WHO position on misoprostol for post-partum haemorrhage prevention and treatment WHO has clarified its position on misoprostol use in the community for post-partum haemorrhage (PPH) prevention and management, to reduce maternal death, following a request in July 2009 from Member States for clear guidance.1 WHO currently includes misoprostol in its Model List of Essential Medicines for early pregnancy termination, medical management of miscarriage and labour induction. An application to include misoprostol for PPH prevention has been deferred until the publication of a large trial in Pakistan and review of the doserelated safety. For PPH prevention, WHO recommends that:
Round Up: Maternal health and maternal mortality / Reproductive Health Matters 2010;18(36):197–205
“in the absence of active management of the third stage of labour, an uterotonic drug (oxytocin or misoprostol) should be offered by a health worker trained in its use for prevention of PPH… For misoprostol, this recommendation places a high value on the potential benefits of avoiding PPH and ease of administration of an oral drug in settings where other care is not available, but notes there is only one study… There is still uncertainty about the lowest effective dose and optimal route of administration.” 1 This recommendation – for administration after birth – has been misinterpreted as a recommendation for community distribution during pregnancy for use after birth. While they do not condemn community distribution during pregnancy, WHO does not recommend it because potential benefits and harms have not been determined. From among 52 facility-based, randomised, controlled trials with more than 40,000 participants, 15 maternal deaths were reported in seven trials with 24,609 participants. 11 deaths occurred among women receiving misoprostol compared with four women receiving other uterotonics or placebo. It is plausible that misoprostol at high doses could have adverse effects that may overshadow benefits. Furthermore, advance provision may lead to inappropriate use for labour induction at very high doses with catastrophic results. Studies cited2 as evidence of safe and effective misoprostol use are all non-randomised and conducted by groups who firmly believe that misoprostol works. WHO will continue to review the evidence critically and update its guidance.1 1. Clarifying WHO position on misoprostol use in the community to reduce maternal death. Geneva: WHO Department of Reproductive Health and Research, 2010.
tiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognised if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths using data from different countries. In Ghana, an evaluation conducted between 2003 and 2006 found that a delivery fee exemption policy significantly reduced the maternal mortality ratio (MMR). However, the evidence was even stronger when the ratios for direct and indirect maternal deaths were separated. There was a substantial effect on direct maternal deaths but no impact on indirect maternal deaths, as would be expected from an intervention targeting the delivery period. In 1918, the MMR for all-cause maternal deaths in England and Wales increased substantially compared to the previous year; nearly all the change was due to a peak in indirect deaths due to the influenza epidemic. This pattern is likely to be found in modern-day outbreaks of infectious diseases such as cholera or yellow fever. Data from South Africa for 1998–2004 demonstrate that using only the MMR for all-cause maternal deaths masked a greater increase in the indirect causes of maternal death from AIDS, which was growing and often undiagnosed. Data from Rwanda from 1998 showed that malaria was causing a large proportion of maternal deaths and responses dealing with malaria during pregnancy needed strengthening.1 1. Cross S, Bell JS, Graham WJ. What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries. Bulletin of WHO 2010;88(2):147–53.
The implications of maternal death classification for tracking progress towards MDG5
Guidance on management of hypertension in pregnancy, UK
The first target of the 5th Millennium Development Goal – to reduce maternal mortality by 75% between 1990 and 2015 – is critically off track. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effec-
Hypertensive disorders of pregnancy cover a spectrum of conditions, including chronic (preexisting) hypertension, pre-eclampsia, and gestational hypertension. They cause one in 50 stillbirths in normal babies and 10% of all preterm births and contribute to a third of cases of severe maternal morbidity. Pre-eclampsia is one of the 203
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most common causes of maternal death in the UK. This article summarises the most recent recommendations from the UK's National Institute for Health and Clinical Excellence (NICE) on how to manage hypertensive disorders during pregnancy. It covers how to reduce the risk of such disorders occurring; what to advise women with chronic hypertension about managing it during the preconception and antenatal periods, including the risks of antihypertensive medications; how to manage women with new onset hypertension during pregnancy, including assessment of proteinuria, management of gestational hypertension and management of pre-eclampsia; fetal monitoring guidelines; guidelines on intrapartum care; medical management of severe hypertension or severe pre-eclampsia in critical care; and postnatal care and follow up. The recommendations should give health professionals confidence to reduce unnecessary tests and emphasise an approach centred on individual women. The guidance may reduce interventions that result in morbidity, such as inducing preterm birth, and emphasises interventions that will benefit both woman and baby.1 1. Visintin C, Mugglestone MA, Almerie MQ, et al. Management of hypertensive disorders during pregnancy: summary of NICE guidance. BMJ 2010;340:c2207.
Maternal alcohol consumption during pregnancy and semen quality of male offspring, Denmark Almost half of pregnant women in Denmark continue to drink small amounts of alcohol throughout pregnancy. This study investigated the association between alcohol consumption during pregnancy and semen quality and levels of reproductive hormones in young, adult sons. From a Danish pregnancy cohort of 11,980 women, established in 1984–87, 347 sons were selected for a follow-up study in 2005–06. Semen and blood samples were analysed and results were related to prospectively, self-reported information on maternal alcohol consumption during pregnancy. Sperm concentration decreased with increasing prenatal alcohol exposure. The adjusted mean sperm concentration among sons of mothers drinking ≥4.5 drinks per week during pregnancy 204
was 40 million/ml (95% CI, 25–60) and was 32% lower than in men exposed to <1.0 drink per week (p=0.04), who had a sperm concentration of 59 million/ml (95% CI, 44–77). The semen volume (p=0.001) and the total sperm count (p=0.005) were also associated with prenatal alcohol exposure; sons prenatally exposed to 1.0–1.5 drinks per week had the highest values. No associations were found for sperm motility, sperm morphology or any of the reproductive hormones, including testosterone. Prenatal exposure to alcohol may have a persisting adverse effect on Sertoli cells, and thereby sperm concentration. If these associations are causal they could explain some of the changes in semen quality over time and between populations.1 1. Ramlau-Hansen CH, Toft G, Jensen MS, et al. Maternal alcohol consumption during pregnancy and semen quality in the male offspring: two decades of follow-up. Human Reproduction 2010;25(9):2340–45.
Enrolling pregnant women in research Although pregnant women need safe and effective medical treatment, they are a marginalised research study population. 64% of pregnant women in the US are given prescriptions during pregnancy, and although there are physiological changes associated with pregnancy, pharmacokinetic studies have not routinely been conducted. Pregnant women must be included in research so that prescribing decisions are evidence-based. Since the US Pediatric Research Equity Act, the results of studies on children have challenged many previously-made assumptions about extrapolating conclusions regarding dosing, safety and efficacy. Similar legislation for pregnant women may be appropriate. The failure to properly treat a pregnant woman can affect both herself and her fetus, and protecting fetuses from research-related risk may ironically put them at greater risk from unstudied clinical interventions. There is debate about the timing of pregnant women's inclusion in studies and the appropriateness of retaining women in clinical trials after they become pregnant. Participation of women in phase 3 clinical trials requires caseby-case justification and would be acceptable, e.g. for conditions with no other available therapies and cases where a drug is being developed specifically for a pregnancy-related condition. If
Round Up: Maternal health and maternal mortality / Reproductive Health Matters 2010;18(36):197–205
randomised, controlled trials are ethically unacceptable, information can be obtained from women already taking the drug. The complexity of studying the effects of medication in pregnant women should not stifle efforts to obtain rigorous data. Physicians, patients, advocacy groups and professional organisations can raise awareness and press for needed research.1 1. Goldkind SF, Sahin L, Gallauresi B. Enrolling pregnant women in research – lessons from the H1N1 influenza pandemic. New England Journal of Medicine 2010; 362(24):2241–43.
Influence of body mass index on miscarriage rate after assisted reproduction, UK Although evidence suggests that women who conceive spontaneously have a greater chance of miscarrying if their body mass index (BMI) is greater than 25kg/m2, the picture is less clear for pregnancies occurring after in-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). This study used data on all 318 pregnancies occurring at a London Assisted Conception Unit between 2006 and 2009 after the implantation of one embryo in IVF or ICSI cycles, in order to assess the effect of BMI on miscarriage rates. Confounding variables studied included female age, duration of infertility, cause of infertility, smoking status, ovarian reserve, history of previous miscarriage, method of oocyte fertilisation and grade of blastocyst transferred. Overall, 26% of women miscarried before 20 weeks gestation. The miscarriage rate was significantly lower in the group with lower weight vs. higher weight (22% vs. 33%, p=0.03). After adjusting for confounding variables, having a BMI of 25 or above more than doubled the risk of miscarriage (adjusted odds ratio 2.3, p=0.01). Increased BMI is independently associated with higher miscarriage rates after IVF and ICSI treatment. Women undertaking assisted reproduction should be strongly encouraged to lose weight.1
1. Sample I. Obese risk miscarriage after IVF. Guardian (UK), 29 June 2010. 2. Rittenberg V, Sobaleva S, Al-Hadi A, et al. Influence of BMI on miscarriage rate after elective single blastocyst transfer. In: Abstracts, 26th Annual Meeting of ESHRE, Rome, 27–30 June 2010. Human Reproduction 2010; 25(Suppl. 1):i28–i30.
Vitamin A supplementation does not improve maternal survival A previous trial in Nepal showed that supplementation with vitamin A or its precursor (betacarotene) in women of reproductive age reduced pregnancy-related mortality by 44%. A large, cluster-randomised, double-blind, placebocontrolled trial undertaken in seven districts in Brong Ahafo Region in Ghana assessed the effect of vitamin A supplementation on 104,484 women aged 15–45 years. Capsules were distributed during home visits every four weeks, and data were gathered on pregnancies, births, and deaths. The main reason for participant drop-out was migration. In the intention to treat analysis, there were 39,601 pregnancies and 138 pregnancy-related deaths in the vitamin A supplementation group (348 deaths per 100,000 pregnancies) compared with 39,234 pregnancies and 148 pregnancyrelated deaths in the placebo group (377 per 100,000 pregnancies), (adjusted odds ratio 0·92, p=0·51). The number of deaths did not differ in significance between the two groups. The evidence, although limited, does not support inclusion of vitamin A supplementation for women in either safe motherhood or child survival strategies.1
1. Kirkwood BR, Hurt L, Amenga-Etego S, et al. Effect of vitamin A supplementation in women of reproductive age on maternal survival in Ghana (ObaapaVitA): a cluster-randomised, placebo-controlled trial. Lancet 2010;375(9726): 1640–49.
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© 2010 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2010;18(36):197–205 0968-8080/10 $ – see front matter PII: S 0 9 6 8 - 8 0 8 0 ( 1 0 ) 3 6 5 4 2 - 6
www.rhmjournal.org.uk
ROUND UP
Maternal health and maternal mortality Trends in maternal mortality, UN inter-agency estimates, 1990 to 2008 The number of women dying due to complications of pregnancy, childbirth and unsafe abortion has decreased by 34% from an estimated 546,000 in 1990 to 358,000 in 2008, according to this inter-agency report by WHO, UNICEF, UNFPA, and the World Bank.1 The analysis was led by an academic team at the University of Berkeley and supported by the maternal mortality estimation inter-agency group. The WHO Department of Reproductive Health and Research/ Special Programme on Human Reproduction (RHR/HRP) was instrumental in coordinating the analysis, including its review by external technical experts, country consultation and preparation of the report. Although progress is notable, the annual rate of decline is less than half of what is needed to achieve the MDG 5 target of reducing the maternal mortality ratio by 75% between 1990 and 2015. This would require an annual decline of 5.5%. The 34% decline since 1990 translates into an average annual decline of just 2.3%. Pregnant women still die from four major causes: postpartum haemorrhage, infections, hypertensive disorders, and unsafe abortion. Every day, about 1,000 women died due to these complications in 2008. Out of those 1,000 women, 570 lived in sub-Saharan Africa, 300 in South Asia and 5 in high-income countries. The risk of a woman in a developing country dying from a pregnancyrelated cause during her lifetime is about 36 times higher compared with a woman living in a developed country. This report covers the period from 1990 to 2008 and highlights the following:
• 10 out of 87 countries with maternal mortality ratios equal to or over 100 in 1990 are on track, with an annual decline of 5.5% between 1990 and 2008. At the other extreme, 30 countries have made insufficient or no progress since 1990.
• In sub-Saharan Africa, maternal mortality decreased by 26%. • In Asia, the number of maternal deaths is estimated to have dropped from 315,000 to 139,000 between 1990 and 2008, a 52% decrease. • 99% of all maternal deaths in 2008 occurred in developing regions, with sub-Saharan Africa and South Asia accounting for 57% and 30% of all deaths, respectively. These new estimates show that it is possible to prevent many more women from dying if countries invest more in their health systems and in the quality of maternity and abortion care. The UN maternal mortality estimates (Table 1) use all available country data on maternal mortality, as well as improved methods of estimation. The methods for maternal mortality estimates were peer reviewed by an external technical advisory group. The intensive country consultation carried out as part of the development of these estimates has been instrumental in identifying increased data collection efforts in recent years, including the special systems to capture data on maternal deaths. There are, however, major gaps in the availability and quality of data for many countries where maternal mortality levels are high, and only through statistical modelling is it possible to obtain an understanding of the trend.2 The full report, which includes a detailed description of the methodology and the underlying data used to develop the estimates, is available on the web.1 1. Trends in Maternal Mortality, 1990 to 2008. Estimates developed by WHO, UNICEF, UNFPA and the World Bank, 2010. Geneva: World Health Organization, 2010. At:
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Round Up: Maternal health and maternal mortality / Reproductive Health Matters 2010;18(36):197–205
Community-based interventions improve newborn outcomes but not maternal mortality A systematic review was done of the effectiveness of community-based intervention packages for preventing maternal morbidity and mortality and improving neonatal outcomes during pregnancy, delivery and the post-partum period. The review included 27 experimental and nonexperimental studies which employed rigorous impact evaluation techniques, covering a wide range of interventions. Studies were from Asia 198
(22), Africa (3), European Union (1) and South America (1). The review did not find a significant reduction in maternal mortality across all studies, but it did find a significant reduction across studies with low risk of bias. Significant reductions were observed in neonatal mortality, stillbirths and perinatal mortality. The interventions also led to reductions in maternal morbidity, increased referrals to a health facility for pregnancy-related complications, improved rates of early breastfeeding, and improved newborn care-related outcomes. The review offers evidence of the value,
Round Up: Maternal health and maternal mortality / Reproductive Health Matters 2010;18(36):197–205
particularly for infants, of integrating maternal and newborn care in community settings through a range of strategies, many of which can be delivered by community health workers. The most successful packages were those which emphasised clean practices by involving family members, provision of care through trained community health workers, and strengthened referrals for mothers and newborns.1 However, the importance of skilled delivery and facility-based emergency obstetric care still needs greater attention. 1. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for preventing maternal morbidity and mortality and improving neonatal outcomes. The International Initiative for Impact Evaluation, March 2010.
Free resources for training in maternal and neonatal care
FREDERIC COURBET/PANOS PICTURES
Training all health professionals attending births will contribute to reducing maternal deaths. This
article presents three training courses for which the training content can be freely downloaded from the internet. Midwifery Education Modules, developed by the WHO, are aimed at the main causes of maternal death, eclampsia, abortion, prolonged and obstructed labour, post-partum haemorrhage and sepsis. Student participation is encouraged, and each module takes two weeks of teaching. Emergency Obstetric Care for Doctors and Midwives consists of a pre-course knowledge questionnaire, participant's notebook, a trainer guide, and an extensive set of presentation Powerpoint graphics. A site assessment tool is included to identify possible barriers to implementing change, and a follow-up tool for continuous support of students and faculty after the course and to assess the effect of the training. The Perinatal Education Program encourages groups of health care workers to come together and study in their own time. Modular manuals cover normal labour and delivery and its complications and neonatal care. Each manual takes
Merlin provides emergency health services, Dissikou, Nana-Grebizi, Central African Republic, 2008 199
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about a year to study. Six additional manuals have been introduced covering perinatal HIV/ AIDS, primary newborn care, mother- and babyfriendly care, saving mothers and babies, birth defects, and primary maternal care.1
of births are attended by a health professional – up from 32% in 2000 – Cambodia is unlikely to meet its Millennium Development Goal of reducing maternal mortality to 140 deaths per 100,000 live births by 2015.1
1. van Lonkhuijzen LRCW, van Roosmalen J, Zeeman G. Implementing safe motherhood: free resources for training in maternal and neonatal care. International Journal of Gynecology and Obstetrics 2010; 109(3):189.
1. In brief: Cambodia needs more midwives to reduce maternal deaths. IRIN News, 9 August 2010.
Rebirth of the midwife, Laos
In public birthing centres in Iran, 5–7 women in labour will share a room, and continuous or one-to-one support during labour by a midwife or nurse is not routine. Consequently, most women have negative recollections of their birth experience and prefer caesarean delivery in subsequent pregnancies. This study evaluated the effect of continuous support provided by midwives during labour on the duration of the different stages of labour and the rate of caesarean delivery. 100 eligible nulliparous women at the Iran University of Medical Sciences, Tehran, who had not received education classes on childbirth, were randomised in 2003. In the intervention group (n=50), continuous support was provided during labour by an experienced midwife, in a private room with the option to move around and eat or drink. The control group (n=50) were admitted to the labour ward; they did not receive continuous support or have a private room, were not permitted food and did not receive education or any explanation about labour. The two groups did not differ by age, employment, educational level, gestational age, economic status or neonatal weight. Mean duration of the active phase of labour (167.9 vs. 247.7 minutes, p<0.001), second stage of labour (34.9 vs. 55.3 min, p=0.003), and the number of caesarean deliveries (4 vs. 12, p=0.026) were significantly lower in the intervention group compared with the control group. The rates of oxytocin use and Apgar scores of less than seven at five minutes were similar between the groups. Continuous support provided during labour may reduce the duration of labour and the number of caesarean deliveries, as well as reduce both the negative impact of birth on women and the likelihood of a woman subsequently choosing an elective caesarean delivery. This model of support should be available to all women.1
Laos has one of the region's highest maternal mortality ratios – 405 deaths per 100,000 live births – partly due to deliveries by untrained birth attendants. After not conducting midwifery training for 23 years, due to lack of funding and interest from students, there are less than 100 midwives nationwide for a population of 6.2 million – many lacking even basic training. Only 20% of women delivered in a health centre in 2005 and older women, who gave birth in their villages, encourage their daughters to do the same. The government resumed courses in eight training centres in October 2009 with US$1 million of UNFPA support. Persuading people of the importance of midwives is not easy, and it is hoped that more people will come to health centres if they trust midwives. In contrast, Sri Lanka reduced maternal deaths by training community midwives in the 1980s. The maternal death rate dropped by 70% from 1995 to 2005 and skilled birth attendants were present at 96% of deliveries. Laos plans to establish a national licensing system for midwives. For now, the goal is to get midwives into communities.1 1. Laos: rebirth of a midwife. IRIN News, 25 August 2010.
Cambodia needs more midwives to reduce maternal deaths Cambodia must increase the number of trained health professionals to reduce its high maternal mortality ratio of 540 per 100,000 live births – the second highest in the region after Laos. There is one doctor or midwife for every 1,000 people in Cambodia, compared with two per 1,000 in Thailand, and 12 per 1,000 in Japan. While 56% 200
Effect of continuous support during labour, Iran
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1. Kahanian M, Javadi F, Haghighi MM. Effect of continuous support during labour on duration of labour and rate of caesarean delivery. International Journal of Gynecology and Obstetrics 2010;109(3):198–200.
Domestic violence, perinatal and neonatal mortality, India Between 10 and 64% of women experience lifetime physical or sexual violence from their male partners. This study investigated the relationship between domestic violence and perinatal, neonatal and infant mortality, about which evidence is much more limited. A prospective follow-up study was carried out in 2002–03 in four Indian states, among a cohort of rural women selected from the 1998–99 National Family and Health Survey-2. Data for 3,909 birth outcomes in this four-year period were analysed. After controlling for potentially confounding factors, births to mothers who experienced two or more episodes of recent domestic violence experienced higher perinatal (HR 1.85, 95% confidence interval, CI 1.12–2.79) and neonatal (HR 1.62, 95% CI, 1.11–2.53) mortality, compared to births to women who reported no violence. Births to women who experienced violence had 68% higher risk of infant mortality compared with the no violence group. A single episode of violence did not lead to a higher risk of mortality. Possible reasons for the link between domestic violence and poor birth outcomes include the role of blunt trauma to the fetus, elevated levels of maternal stress, poor physical health of the mother from violence and the deterrent effect of violence on maternal health care-seeking behaviour. There should be greater focus on violence prevention within child survival programmes.1 1. Koenig MA, Stephenson R, Acharya R, et al. Domestic violence and early childhood mortality in rural India: evidence from prospective data. International Journal of Epidemiology 2010;39(3):825–33.
Care-seeking for post-partum morbidity, rural India Despite high morbidity and the danger of maternal death, women in low-resource settings frequently fail to seek post-partum care from formal providers. 2,114 mothers were interviewed through a household survey in February
2008 in the rural Murshidabad district of India, in order to elucidate factors influencing careseeking behaviour for post-partum health problems. 929 (43.9%) women had post-partum morbidity in the six weeks after delivery, of whom 5.8% did not seek any care, 49.2% sought care from informal providers, and 45.0% sought care from formal providers. Factors associated with seeking care from a formal rather than informal provider included being from a more educated household (p<0.05), delivering at a health facility (p<0.001), having a severe postpartum complication (p<0.05), and being Muslim rather than Hindu (p<0.01). Women who did not seek any attention appeared to be most influenced by distance to a health care facility and whether they had had an institutional delivery, which underscores the importance of trying to increase rates of institutional delivery in order to improve post-partum care as well as delivery and birth outcomes. The finding that Hindu women were less likely to seek care than Muslim women should be investigated further.1 1. Tuddenham SA, Hafizur Rahman M, Singh S, et al. Care seeking for postpartum morbidities in Murshidabad, rural India. International Journal of Gynecology and Obstetrics 2010;109(3):245–46.
Improvements in maternal health care in Angola? Angola's civil war, which ended in 2002, established a routine of shunning clinics in favour of home births. Reversing this trend is crucial to reducing the maternal mortality rate, which is one of the highest in the world. Since 1998, the number of women delivering babies at municipal clinics in Matala district of Huila province has increased from 500 to 3,000 annually, out of 10,000 annual births in the district. The rehabilitation of road infrastructure by Chinese, Brazilian and Portuguese companies is improving public transport and access to health care. A 77-bed Chinese-built hospital is yet to be opened, and is an example of health infrastructure developing without adequate medical skills and personnel. Eight Cuban doctors will work at the hospital – boosting to nine the number of doctors serving a population of 230,000. The hospital requires 248 personnel, including theatre nurses and laboratory technicians, but there are only 201
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44 medical staff available in the district. A new strategy, led by the government and supported by UNICEF, WHO and UNFPA, has been launched to improve basic health care at existing health facilities in 16 municipalities, covering 23% of the population. The initiative provides routine immunisation, antenatal and child care, access to safe water, and the distribution of free, insecticideimpregnated mosquito nets. The government hopes to extend the project to another 54 municipalities to cover 70% of the population.1 1. Angola: putting a dent in maternal death rate. IRIN News. 14 May 2010.
Malawian president lifts ban on traditional birth attendants A ban on traditional birth attendants (TBAs), in place since 2007, was effectively lifted by Malawi's president on return from the UN Summit on the Millennium Development Goals in New York. The lifting of the ban still requires Ministry of Health approval, the issuing of guidelines, and consultation with stakeholders, but according to health practitioners, the announcement will allow them to operate openly again. The president said: “We need to train TBAs in safer delivery methods. We should not completely stop them because their work is very important.” The rationale for the ban was that low-skilled TBAs were unable to identify obstetric emergencies early enough. Combined with delays due to poor transport infrastructure and the paucity of medical facilities this contributed to the high maternal mortality ratio, estimated at 510 per 100,000 live births. It was hoped that by preventing TBAs from practising, mothers would use medical facilities, but nearly half of all deliveries still occur outside medical facilities. TBAs continued to exist but went underground for fear of fines. TBAs have two weeks training, and many believe this is not long enough for them to recognise birth complications at an early stage. Linkages between TBAs and health services must be strengthened, and communications improved with clinics to respond to emergencies, e.g. by using motorcycle ambulances.1 1. Malawi: President lifts ban on traditional birth assistants. IRIN News, 11 October 2010.
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Should men and women be encouraged to start childbearing at a younger age? In many developed countries, the average age of women at first childbirth is now 28–30. Fertility awareness programmes have discovered that many men and women overestimate women's fecundity according to age, the probability of conception during a monthly cycle, and the chances of conceiving after in-vitro fertilisation treatment. The postponement of childbearing until the mid-30s or later increases the proportion of couples with fertility problems, increases the risk of becoming a fertility patient, and increases the risk of childlessness or having fewer children than desired. Advising couples to conceive at a younger age is fraught with problems; many couples face economic and practical concerns regarding childbearing, and individuals have the right to choose for themselves an appropriate family planning arrangement. Possible strategies for action include increasing individuals’ knowledge about the impact of increased age and other risk factors; including young men, in the agenda of fertility awareness and decisionmaking about parenthood; and ensuring that societies develop in such a way that young couples can combine family and working life during their most fertile years.1 1. Schmidt L. Should men and women be encouraged to start childbearing at a younger age? Expert Review of Obstetrics and Gynecology 2010;52(2):145–47.
WHO position on misoprostol for post-partum haemorrhage prevention and treatment WHO has clarified its position on misoprostol use in the community for post-partum haemorrhage (PPH) prevention and management, to reduce maternal death, following a request in July 2009 from Member States for clear guidance.1 WHO currently includes misoprostol in its Model List of Essential Medicines for early pregnancy termination, medical management of miscarriage and labour induction. An application to include misoprostol for PPH prevention has been deferred until the publication of a large trial in Pakistan and review of the doserelated safety. For PPH prevention, WHO recommends that:
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“in the absence of active management of the third stage of labour, an uterotonic drug (oxytocin or misoprostol) should be offered by a health worker trained in its use for prevention of PPH… For misoprostol, this recommendation places a high value on the potential benefits of avoiding PPH and ease of administration of an oral drug in settings where other care is not available, but notes there is only one study… There is still uncertainty about the lowest effective dose and optimal route of administration.” 1 This recommendation – for administration after birth – has been misinterpreted as a recommendation for community distribution during pregnancy for use after birth. While they do not condemn community distribution during pregnancy, WHO does not recommend it because potential benefits and harms have not been determined. From among 52 facility-based, randomised, controlled trials with more than 40,000 participants, 15 maternal deaths were reported in seven trials with 24,609 participants. 11 deaths occurred among women receiving misoprostol compared with four women receiving other uterotonics or placebo. It is plausible that misoprostol at high doses could have adverse effects that may overshadow benefits. Furthermore, advance provision may lead to inappropriate use for labour induction at very high doses with catastrophic results. Studies cited2 as evidence of safe and effective misoprostol use are all non-randomised and conducted by groups who firmly believe that misoprostol works. WHO will continue to review the evidence critically and update its guidance.1 1. Clarifying WHO position on misoprostol use in the community to reduce maternal death. Geneva: WHO Department of Reproductive Health and Research, 2010.
tiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognised if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths using data from different countries. In Ghana, an evaluation conducted between 2003 and 2006 found that a delivery fee exemption policy significantly reduced the maternal mortality ratio (MMR). However, the evidence was even stronger when the ratios for direct and indirect maternal deaths were separated. There was a substantial effect on direct maternal deaths but no impact on indirect maternal deaths, as would be expected from an intervention targeting the delivery period. In 1918, the MMR for all-cause maternal deaths in England and Wales increased substantially compared to the previous year; nearly all the change was due to a peak in indirect deaths due to the influenza epidemic. This pattern is likely to be found in modern-day outbreaks of infectious diseases such as cholera or yellow fever. Data from South Africa for 1998–2004 demonstrate that using only the MMR for all-cause maternal deaths masked a greater increase in the indirect causes of maternal death from AIDS, which was growing and often undiagnosed. Data from Rwanda from 1998 showed that malaria was causing a large proportion of maternal deaths and responses dealing with malaria during pregnancy needed strengthening.1 1. Cross S, Bell JS, Graham WJ. What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries. Bulletin of WHO 2010;88(2):147–53.
The implications of maternal death classification for tracking progress towards MDG5
Guidance on management of hypertension in pregnancy, UK
The first target of the 5th Millennium Development Goal – to reduce maternal mortality by 75% between 1990 and 2015 – is critically off track. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effec-
Hypertensive disorders of pregnancy cover a spectrum of conditions, including chronic (preexisting) hypertension, pre-eclampsia, and gestational hypertension. They cause one in 50 stillbirths in normal babies and 10% of all preterm births and contribute to a third of cases of severe maternal morbidity. Pre-eclampsia is one of the 203
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most common causes of maternal death in the UK. This article summarises the most recent recommendations from the UK's National Institute for Health and Clinical Excellence (NICE) on how to manage hypertensive disorders during pregnancy. It covers how to reduce the risk of such disorders occurring; what to advise women with chronic hypertension about managing it during the preconception and antenatal periods, including the risks of antihypertensive medications; how to manage women with new onset hypertension during pregnancy, including assessment of proteinuria, management of gestational hypertension and management of pre-eclampsia; fetal monitoring guidelines; guidelines on intrapartum care; medical management of severe hypertension or severe pre-eclampsia in critical care; and postnatal care and follow up. The recommendations should give health professionals confidence to reduce unnecessary tests and emphasise an approach centred on individual women. The guidance may reduce interventions that result in morbidity, such as inducing preterm birth, and emphasises interventions that will benefit both woman and baby.1 1. Visintin C, Mugglestone MA, Almerie MQ, et al. Management of hypertensive disorders during pregnancy: summary of NICE guidance. BMJ 2010;340:c2207.
Maternal alcohol consumption during pregnancy and semen quality of male offspring, Denmark Almost half of pregnant women in Denmark continue to drink small amounts of alcohol throughout pregnancy. This study investigated the association between alcohol consumption during pregnancy and semen quality and levels of reproductive hormones in young, adult sons. From a Danish pregnancy cohort of 11,980 women, established in 1984–87, 347 sons were selected for a follow-up study in 2005–06. Semen and blood samples were analysed and results were related to prospectively, self-reported information on maternal alcohol consumption during pregnancy. Sperm concentration decreased with increasing prenatal alcohol exposure. The adjusted mean sperm concentration among sons of mothers drinking ≥4.5 drinks per week during pregnancy 204
was 40 million/ml (95% CI, 25–60) and was 32% lower than in men exposed to <1.0 drink per week (p=0.04), who had a sperm concentration of 59 million/ml (95% CI, 44–77). The semen volume (p=0.001) and the total sperm count (p=0.005) were also associated with prenatal alcohol exposure; sons prenatally exposed to 1.0–1.5 drinks per week had the highest values. No associations were found for sperm motility, sperm morphology or any of the reproductive hormones, including testosterone. Prenatal exposure to alcohol may have a persisting adverse effect on Sertoli cells, and thereby sperm concentration. If these associations are causal they could explain some of the changes in semen quality over time and between populations.1 1. Ramlau-Hansen CH, Toft G, Jensen MS, et al. Maternal alcohol consumption during pregnancy and semen quality in the male offspring: two decades of follow-up. Human Reproduction 2010;25(9):2340–45.
Enrolling pregnant women in research Although pregnant women need safe and effective medical treatment, they are a marginalised research study population. 64% of pregnant women in the US are given prescriptions during pregnancy, and although there are physiological changes associated with pregnancy, pharmacokinetic studies have not routinely been conducted. Pregnant women must be included in research so that prescribing decisions are evidence-based. Since the US Pediatric Research Equity Act, the results of studies on children have challenged many previously-made assumptions about extrapolating conclusions regarding dosing, safety and efficacy. Similar legislation for pregnant women may be appropriate. The failure to properly treat a pregnant woman can affect both herself and her fetus, and protecting fetuses from research-related risk may ironically put them at greater risk from unstudied clinical interventions. There is debate about the timing of pregnant women's inclusion in studies and the appropriateness of retaining women in clinical trials after they become pregnant. Participation of women in phase 3 clinical trials requires caseby-case justification and would be acceptable, e.g. for conditions with no other available therapies and cases where a drug is being developed specifically for a pregnancy-related condition. If
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randomised, controlled trials are ethically unacceptable, information can be obtained from women already taking the drug. The complexity of studying the effects of medication in pregnant women should not stifle efforts to obtain rigorous data. Physicians, patients, advocacy groups and professional organisations can raise awareness and press for needed research.1 1. Goldkind SF, Sahin L, Gallauresi B. Enrolling pregnant women in research – lessons from the H1N1 influenza pandemic. New England Journal of Medicine 2010; 362(24):2241–43.
Influence of body mass index on miscarriage rate after assisted reproduction, UK Although evidence suggests that women who conceive spontaneously have a greater chance of miscarrying if their body mass index (BMI) is greater than 25kg/m2, the picture is less clear for pregnancies occurring after in-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). This study used data on all 318 pregnancies occurring at a London Assisted Conception Unit between 2006 and 2009 after the implantation of one embryo in IVF or ICSI cycles, in order to assess the effect of BMI on miscarriage rates. Confounding variables studied included female age, duration of infertility, cause of infertility, smoking status, ovarian reserve, history of previous miscarriage, method of oocyte fertilisation and grade of blastocyst transferred. Overall, 26% of women miscarried before 20 weeks gestation. The miscarriage rate was significantly lower in the group with lower weight vs. higher weight (22% vs. 33%, p=0.03). After adjusting for confounding variables, having a BMI of 25 or above more than doubled the risk of miscarriage (adjusted odds ratio 2.3, p=0.01). Increased BMI is independently associated with higher miscarriage rates after IVF and ICSI treatment. Women undertaking assisted reproduction should be strongly encouraged to lose weight.1
1. Sample I. Obese risk miscarriage after IVF. Guardian (UK), 29 June 2010. 2. Rittenberg V, Sobaleva S, Al-Hadi A, et al. Influence of BMI on miscarriage rate after elective single blastocyst transfer. In: Abstracts, 26th Annual Meeting of ESHRE, Rome, 27–30 June 2010. Human Reproduction 2010; 25(Suppl. 1):i28–i30.
Vitamin A supplementation does not improve maternal survival A previous trial in Nepal showed that supplementation with vitamin A or its precursor (betacarotene) in women of reproductive age reduced pregnancy-related mortality by 44%. A large, cluster-randomised, double-blind, placebocontrolled trial undertaken in seven districts in Brong Ahafo Region in Ghana assessed the effect of vitamin A supplementation on 104,484 women aged 15–45 years. Capsules were distributed during home visits every four weeks, and data were gathered on pregnancies, births, and deaths. The main reason for participant drop-out was migration. In the intention to treat analysis, there were 39,601 pregnancies and 138 pregnancy-related deaths in the vitamin A supplementation group (348 deaths per 100,000 pregnancies) compared with 39,234 pregnancies and 148 pregnancyrelated deaths in the placebo group (377 per 100,000 pregnancies), (adjusted odds ratio 0·92, p=0·51). The number of deaths did not differ in significance between the two groups. The evidence, although limited, does not support inclusion of vitamin A supplementation for women in either safe motherhood or child survival strategies.1
1. Kirkwood BR, Hurt L, Amenga-Etego S, et al. Effect of vitamin A supplementation in women of reproductive age on maternal survival in Ghana (ObaapaVitA): a cluster-randomised, placebo-controlled trial. Lancet 2010;375(9726): 1640–49.
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