- Email: [email protected]
International News - June 2017
Midwifery 49 (2017) A1–A5
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
International News
International news – June 2017 Elizabeth Duff (International News Editor)
Midwives, mothers and families: partners for life! The theme for the International Day of the Midwife (IDM) 2017 was ‘Midwives, Mothers and Families: Partners for Life!’. The International Confederation of Midwives (ICM), promoting the importance of the day, said: ‘Midwives everywhere understand that by working in partnership with women and their families they can support them to make better decisions about what they need to have a safe and fulfilling birth. Midwives were invited and encouraged to share views, photos, stories using the phrase ‘I believe in partnership’ on all ICM information platforms as a celebration of the wonderful work that midwives do around the globe. An example of action was Ugandan midwives who organised a symposium, saying: ‘We want to celebrate and promote the good work that Ugandan Midwives do every day. IDM … is an ideal opportunity to showcase the work of midwives in Uganda’. The IDM celebrations took place in Fort Portal, Kabarole District, Uganda. Midwives presented talks or posters on a study undertaken, a systematic review of a particular subject or a midwifery practice innovation on one of the selected themes: midwifery leadership: opening doors for the family voice in their health care system; innovative teaching strategies to strengthen family partnerships; using evidence-based practice in midwifery. http://unmc.ug/download/IDM-2017.pdf.
Draft statement on skilled attendant at birth The critical progress indicator explicitly adopted by the Sustainable Development Goals (SDG) and the Global Strategy for Women's, Children's and Adolescents' Health, 2016–2030 agendas is the ‘percentage of births delivered by a skilled attendant at birth (SAB)’. In 2004, WHO/FIGO/ICM issued a joint statement that clearly defined SAB and its core functions. Actual practice at country level, however, is challenged by a lack of clear guidelines, standardization of names and functions, and task shifting. In addition, many countries have found that there is a large gap between the defined standards and the skill set/competence of existing birth attendants who are able to correctly manage common obstetric and neonatal complications. Improved, simple and operational definitions and a meta-data E-mail address: [email protected] http://dx.doi.org/10.1016/j.midw.2017.05.002 0266-6138/
analysis of various cadres of birth attendants (skilled and not so skilled) in each low- and middle-income country are urgently needed to support improved measurement of coverage of SAB. WHO, UNFPA and UNICEF have set up a taskforce to harmonize the definition and measurement of maternal health indicators, with special focus on SAB and in consultation with FIGO, ICM, ICN, and IPA. The draft definition of the competent health care provider in maternal and newborn health reads: Quality maternal and newborn health care (QMNHC) is the provision of quality care for women of reproductive age, their newborns and families, before and during pregnancy, birth, and the postnatal period and beyond. This care is provided by competent qualified maternal and newborn health care professionals (QMNHCP) who are educated and regulated as per international and national standards and who work as a team within an enabling and supportive environment. The statement will be finalised by the taskforce after taking account of comments received during the consultation. A background paper explains more about the terms and definitions used and makes clear, for example, that: The term ‘competencies’ is used as the knowledge, skills and behaviours which value respect, communication, community knowledge and understanding required of the health care professional for safe practice in any setting along the continuum of care. This continuum ranges from pre-pregnancy, to pregnancy, intrapartum, post-natal and beyond. They are tailored to women's, newborns and family's circumstances and needs. ‘Competent attendance in maternal and newborn health: the definition of the competent health care provider in maternal and newborn health’ the draft statement and background document to the joint statement can be downloaded at http://www.who. int/reproductivehealth/skilled-birth-attendant/en/.
New multinational fetal growth charts from WHO A study, published by PLOS Medicine, shows that there is significant variation in fetal growth between countries. Fetal growth was also shown to some extent influenced by maternal age, height, weight, parity and by fetal sex. The article (which is open access) also provides new WHO charts for estimating fetal growth and should be particularly useful for countries who may not have resources to develop their own charts. The research, including 1387 healthy women with low-risk pregnancies, was a collaboration between WHO's Department of
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Reproductive Health and Research and the Special Programme of Research (HRP) together with investigators from 10 countries (Argentina, Brazil, Democratic Republic of Congo, Denmark, Egypt, France, Germany, India, Norway and Thailand). Using repeated ultrasound measurements the researchers were able to establish fetal growth charts for head and abdominal circumference, length of thigh bone and fetal weight. Estimating fetal weight is important as small size at birth is associated with perinatal mortality and child morbidity as well as longer-term health risks as an adult. Ultrasound estimation of fetal weight is a key tool in identifying high-risk pregnancies. Many countries, however, use fetal growth charts based on a single population from high-income countries. The differences observed between countries in the WHO study, with regard to maternal factors and fetal sex, indicate that local diagnosis may be improved when these factors are taken into account. Using the new WHO internationally-adjusted fetal growth charts is therefore recommended. The study includes an example of fetal growth charts that have been adjusted for sex. The authors suggest that these WHO charts for growth in estimated fetal weight are more suitable for international use than those commonly applied today. However, the differences between countries, with maternal factors and fetal sex also having an effect, mean that these growth charts may need to be adjusted for local clinical use to increase their diagnostic and predictive performance. The considerable variation in fetal growth and birthweight which occurs even under optimal conditions, and which is not explicable in terms of maternal and population factors, may suggest, first, that such natural variation in offspring size is a collective adaptive strategy that has proved extremely successful from an evolutionary point of view and, second, that major determinants of variation in human development before birth are still to be determined. Although the present study encompasses 10 countries, it still represents only a small selection of population groups when the substantial anthropometric variations existing even within continents are taken into account. Building on the results of this study, WHO is currently developing guidance that will allow countries to develop fetal growth charts specific to their own country. Kiserud T et al. (2017) The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight. PLoS Med 14(1), e1002220.
Women at the centre in new WHO guidance on health and rights of women living with HIV The World Health Organization (WHO) has launched the Consolidated guideline on sexual and reproductive health and rights of women living with HIV, which takes a woman-centred approach throughout to effectively address and represent the needs of girls and women, as well as those of their families and communities. A woman-centred approach to healthcare is one that consciously adopts the perspectives of women, their families and communities. This means that health services see women as active participants in, as well as beneficiaries of, trusted health systems that respond to women's needs, rights and preferences in humane and holistic ways. Such an approach to healthcare is crucial when working to safeguard the sexual and reproductive health and rights of women living with HIV. In 2015, there were an estimated 17.8 million
women aged 15 and older living with HIV in 2015, constituting 51 percent of all adults living with HIV. HIV is not only driven by gender inequality, but also further entrenches inequalities, leaving girls and women more vulnerable to its impact. Girls and women often do not have equal access to health services and information and can also face additional negative health impacts as a result of living with HIV – including stigma, shame, violence and abuse. Manjulaa Narasimhan, Scientist at WHO, commented ‘Supporting evidence-based recommendations and building an enabling environment will help advance the health and well-being of women living with HIV in all their diversity.’ Taking this approach, the process adopted for the development of the guidelines was unique in its meaningful engagement of communities of women living with HIV. In taking a woman-centred approach, the new WHO guidelines are founded upon the principles of human rights and gender equality: ‘When human rights are safeguarded, and gender inequalities are addressed, interventions to improve the sexual and reproductive health of women living with HIV can then, and only then, effectively meet their needs,’ said Ian Askew, Director of WHO Department of Reproductive Health and Research. An integrated approach to health and human rights lies at the heart of ensuring the dignity and well-being of women living with HIV. This includes, but is not limited to, the right to the highest attainable standard of health; the right to life and physical integrity, including freedom from violence; the right to equality and nondiscrimination on the basis of sex; and the right to freedom from torture or cruel, inhuman or degrading treatment. The right to SRH is an integral part of the right to health, enshrined in article 12 of the International Covenant on Economic, Social and Cultural Rights. The promotion of gender equality is central to the achievement of SRHR of all women, including women living with HIV in all their diversity. This means recognizing and taking into account how unequal power in women's intimate relationships, harmful gender norms and women's lack of access to and control over resources affect their access to and experiences with health services. http://www.who.int/reproductivehealth/topics/gender_ rights/women-living-with-hiv/en/.
Is birth weight a good proxy for population health? Despite dramatic improvements in human health, babies' average birth-weights have not increased over the last 150 years. Research from the London School of Economics and Political Science (LSE) reveals that average birth weights, as well as the proportions of babies born at different birth weights, are very similar today to the numbers recorded in the nineteenth century in Europe and North America. In contrast, average adult height and life expectancy has increased dramatically. Dr Eric Schneider, Assistant Professor of Economic History at LSE and author of the paper, said: ‘Birth weights are used by health care professionals as a proxy for the health of babies in the womb, so there is an implicit assumption that they have increased historically as our overall health has improved. This is why my findings are so surprising and begs the question - are we looking at the right things when trying to measure fetal health, at both the individual and population level, in this way?’. Understanding the conditions for the unborn baby in the womb is a significant endeavour because recent research has found that they can affect children's health across their entire life, even into old age. These findings raise questions about the international birth weight standards that determine the 'ideal' weight that a baby should be.
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Dr Schneider said: ‘In Pakistan 32 per cent of babies are born at a low birth weight, meaning that they weigh in at less than 2500 g, and it is assumed that if health conditions improve, average birth weights will rise. However, given that this did not happen in Western Europe and the United States, despite significant historical improvements to maternal health care, it's possible that birth weights in Pakistan will not increase to the level set by the standards.’. Dr Schneider added: ‘My results do not in any way downplay the very real health risks low birth weight babies face or the fact that children developing in the womb are extremely sensitive to poor conditions, such as a lack of key nutrients or infection. I look at statistics at a population level to analyse what they can tell us on the general rather than the individual level.’. Schneider analysed birth weights recorded in historical maternity records that have survived for a number of European and North American maternity hospitals. Schneider EB. Fetal health stagnation: Have health conditions in utero improved in the United States and Western and Northern Europe over the past 150 years? Social Science and Medicine, doi: http://dx.doi.org/10.1016/j.socscimed.2017.02.018, published online 17 February 2017.
Mistreatment of women during childbirth: a sad reality worldwide Women worldwide face diverse forms of mistreatment during childbirth by health-care providers. Recent evidence, which has been generated through the HRP Alliance research capacity strengthening programme, suggests that this unacceptable mistreatment can include physical and verbal abuse, violations of privacy, stigma and discrimination, and neglect and abandonment. Health-care providers should ensure high quality, evidencebased and respectful care to women and their infants during childbirth and labour, but evidence shows that some providers have misconceptions about what constitutes acceptable behaviour. In the first known qualitative studies of their kind to be conducted in Guinea, it became clear that the mistreatment of women during childbirth in the country is a reality. This research, which was led by scientists from the Cellule de recherche en santé de la reproduction en Guinée (CERREGUI), University National Hospital-Donka and WHO, was published in the journal BMC Reproductive Health. The authors of one article note that this can include, ‘physical abuse such as slapping, pinching and excessive fundal pressure. Women also experience verbal abuse, neglect and abandonment during childbirth’. The research highlighted how some health-care providers considered different forms of abuse as acceptable. What is more, some women also accepted some forms of mistreatment. In one article, the authors note, ‘Midwives and doctors may use abusive techniques to get women to cooperate, and paradoxically some women accept such mistreatment if they believe it will benefit their health or their baby's health.’. Mistreatment of women during childbirth occurs in countries across the world and puts the lives and well-being of women at risk. It also constitutes a violation of the right to the highest attainable standard of health, which includes the right to dignified, respectful healthcare throughout pregnancy and childbirth, as well as the right to be free from violence and discrimination. These research articles were co-authored by researchers from Guinea and staff working at the WHO Department of Reproductive Health and Research including HRP.
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CERREGUI, the research institution based in Guinea, received support from the HRP Alliance research capacity strengthening programme for this research. The articles form part of a multi-country study on mistreatment of women during childbirth in four countries: Guinea, Ghana, Nigeria and Myanmar. They come from the first qualitative stage of the study, which aims to better understand contributing factors to mistreatment during childbirth, and to pinpoint areas for action. High quality and respectful healthcare is crucial to prevent maternal death and to make progress towards achieving the sustainable development goals, as well as the aims of the aligned Global Strategy for Women's, Children's and Adolescents’ Health. The mistreatment of women during childbirth is therefore a significant barrier to reducing maternal mortality in countries worldwide. http://www.who.int/reproductivehealth/topics/maternal_ perinatal/mistreatment-during-childbirth/en/.
Dietary kit reduces baby blues shown to be a precursor to postnatal depression A dietary supplement kit, created to counter mood-altering brain changes linked to depression, virtually eliminated the ‘baby blues’ among women in a new study at Toronto's Centre for Addiction and Mental Health (CAMH). Postpartum or ‘baby’ blues are common among women after giving birth. However, when severe, they substantially increase the risk of clinically diagnosed postpartum depression, which affects 13 per cent of new mothers and is the most common complication of child-bearing. The study, published in the Proceedings of the National Academy of Sciences (PNAS), was led by Dr. Jeffrey Meyer, who heads the Neuroimaging Program in Mood & Anxiety in CAMH's Campbell Family Mental Health Research Institute. Developing successful nutrition-based treatments, based on neurobiology, is rare in psychiatry,’ says Dr. Meyer. ‘We believe our approach represents a promising new avenue for creating other new dietary supplements for medicinal use’. The nutritional kit consists of three supplements, carefully selected to compensate for a surge in the brain protein MAO-A, which occurs in the early postpartum phase, and which also resembles a brain change that persists for longer periods in clinical depression. MAO-A breaks down three brain chemicals that help maintain mood: serotonin, norepinephrine and dopamine. When these chemicals are depleted, it can lead to feelings of sadness. MAO-A levels peak five days after giving birth, the same time when postpartum blues are most pronounced. The kit includes tryptophan and tyrosine, which compensate for the loss of the three mood-regulating chemicals, as well as a blueberry extract for anti-oxidant effects. Dr. Meyer's team had also tested and confirmed that the tryptophan and tyrosine supplements, given in higher amounts than people would normally get in their diet, did not affect the overall concentrations in breast milk. The current study by research fellow Dr. Yekta Dowlati included 21 women who received the supplements and a comparison group of 20 who did not. The women knew they were receiving nutritional supplements. The supplements were taken over three days, starting on the third day after giving birth. On day five after giving birth the women underwent tests to assess the effect on mood. The testing included a measure of the
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ability to be resilient against sad events. The women read statements with sentiments that expressed pessimism, dissatisfaction and lethargy, and then listened to a sad piece of classical music. Before and after this test, researchers measured depressive symptoms. Women who were not taking the supplements had a significant increase in depression scores. In contrast, women taking the dietary supplements did not experience any depressed mood. ‘We believe this is the first study to show such a strong, beneficial effect of an intervention in reducing the baby blues at a time when postpartum sadness peaks,’ says Dr. Meyer. ‘Postpartum blues are common and usually resolve 10 days after giving birth, but when they are intense, the risk of postpartum depression increases four-fold’. The results support further research to replicate the effects in a larger sample in a randomized, controlled trial, and further assess the kit's ability to reduce both the postpartum blues as well as clinically diagnosed postpartum depression. Dowlati Y et al. Selective dietary supplementation in early postpartum is associated with high resilience against depressed mood. PNAS, doi: http://dx.doi.org/10.1073/pnas.1611965114, published online 13 March 2017.
Our data shows that PPCM is truly a global disease, and irrespective of where you live, what healthcare system you have, what nutrition you have, and what education you have, you can get this disease, said Professor Sliwa. ‘PPCM is to some extent a biological disease and women might have a genetic predisposition, which is probably a cellular and cardiac signalling abnormality. This is not a disease with marked differences between ethnic groups. We were surprised to see that there is a large percentage of women from the UK, for instance, and from Germany, countries which had not reported many cases so far, added Professor Sliwa. One month after diagnosis, 80% of the women with PPCM still had heart failure. About 7% of the women had blood clots - either a stroke, clot to the lung, or clot to the legs. ‘Despite good access to healthcare and good medical therapy, PPCM remains a very serious disease because many women remain in heart failure or develop blood clots,’ said Professor Sliwa. ‘PPCM occurs in all health systems and is probably underdiagnosed in many parts of the world,’ she continued. ‘More awareness needs to be created for this disease so that women can be given timely and appropriate treatment.’ The registry aims to recruit 1000 women with PPCM and will see if there are any differences in six month outcomes between ethnic groups.
Peripartum cardiomyopathy occurs globally and is not a disease of the poor Peripartum cardiomyopathy (PPCM) occurs worldwide, contrary to previous assumption, according to research published in the European Journal of Heart Failure. Cases were reported from many countries for the first time. ‘People have always thought PPCM was much more common and severe in Africans and that it was a disease of poverty but our study clearly shows that it's not,’ said lead author Professor Karen Sliwa, director of the Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa. The study was conducted by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) Study Group on PPCM under the EURObservational Research Programme (EORP). PPCM is a structural heart muscle disease that occurs in women either at the end of pregnancy or up to five months after giving birth. Patients were previously healthy and then present with shortness of breath and heart failure. In about one-third of women with PPCM the heart muscle spontaneously recovers, but about 10% die from the disease and over half have a weakened heart muscle for the rest of their lives. The baby is sometimes born smaller and earlier, and in rare cases it dies. Research has shown that women with PPCM produce an abnormal breastfeeding hormone that leads to programmed cell death (apoptosis) and damage to the heart muscle. Until recently it was assumed that PPCM occurred predominantly in African women. This registry study was conducted to find out whether PPCM occurs in other continents. Specifically, the researchers set out to discover how the disease presents, is diagnosed, and treated in different countries. The paper reports the baseline results of 411 patients from 43 countries, representing all continents. Data collected included demographic characteristics, co-morbidities, treatments, type of hospital, and specialisation of the treating physician. The researchers found cases of PPCM in all 43 countries studied. All women with PPCM presented at the same age, and with the same symptoms and heart size, despite different ethnic backgrounds and major disparities in socioeconomic factors and access to healthcare.
Sliwa K, et al. Clinical characteristics of patients from the worldwide registry on peripartum cardiomyopathy (PPCM). European Journal of Heart Failure, doi:10.1002/ejhf.780, published 8 March 2017.
The cost of a polluted environment: 1.7 million child deaths a year, says WHO More than 1 in 4 deaths of children under 5 years of age are attributable to unhealthy environments. Every year, environmental risks – such as indoor and outdoor air pollution, secondhand smoke, unsafe water, lack of sanitation, and inadequate hygiene – take the lives of 1.7 million children under 5 years, say two new WHO reports. The first report, Inheriting a Sustainable World: Atlas on Children's Health and the Environment reveals that a large portion of the most common causes of death among children aged 1 month to 5 years – diarrhoea, malaria and pneumonia – are preventable by interventions known to reduce environmental risks, such as access to safe water and clean cooking fuels. Harmful exposures can start in the mother's womb and increase the risk of premature birth. Additionally, when infants and pre-schoolers are exposed to indoor and outdoor air pollution and second-hand smoke they have an increased risk of pneumonia in childhood, and a lifelong increased risk of chronic respiratory diseases, such as asthma. Exposure to air pollution may also increase their lifelong risk of heart disease, stroke and cancer. A companion report, Don't pollute my future! The impact of the environment on children's health, provides a comprehensive overview of the environment's impact on children's health, illustrating the scale of the challenge. Every year:
570,000 children under 5 years die from respiratory infections,
such as pneumonia, attributable to indoor and outdoor air pollution, and second-hand smoke. 361,000 children under 5 years die due to diarrhoea, as a result of poor access to clean water, sanitation, and hygiene. 270,000 children die during their first month of life from conditions, including prematurity, which could be prevented through access to clean water, sanitation, and hygiene in health facilities as well as reducing air pollution.
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200,000 deaths of children under 5 years from malaria could be
prevented through environmental actions, such as reducing breeding sites of mosquitoes or covering drinking-water storage. 200,000 children under 5 years die from unintentional injuries attributable to the environment, such as poisoning, falls, and drowning.
Dr Maria Neira, WHO Director, Department of Public Health, Environmental and Social Determinants of Health, says ‘Investing in the removal of environmental risks to health, such as improving water quality or using cleaner fuels, will result in massive health benefits.’ In households without access to basic services, such as safe water and sanitation, or that are smoky due to the use of unclean fuels, such as coal or dung for cooking and heating, children are at an increased risk of diarrhoea and pneumonia.
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Reducing air pollution inside and outside households, improving safe water and sanitation and improving hygiene (including in health facilities where women give birth), protecting pregnant women from second-hand tobacco smoke, and building safer environments, can prevent children's deaths and diseases. Under the Sustainable Development Goals (SDGs) countries are working on a set of targets to guide interventions for children's environmental health, as well as to end preventable deaths of newborns and children under five by 2030. In addition to SDG 3, which aims to ensure healthy lives and promote well-being for all, other SDGs work to improve water, sanitation and hygiene, transition to clean energy to reduce air pollution, and reverse climate change – all of which will have an impact on children's health. http://www.who.int/mediacentre/news/releases/2017/pol lution-child-death/en/.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
International News
International news – June 2017 Elizabeth Duff (International News Editor)
Midwives, mothers and families: partners for life! The theme for the International Day of the Midwife (IDM) 2017 was ‘Midwives, Mothers and Families: Partners for Life!’. The International Confederation of Midwives (ICM), promoting the importance of the day, said: ‘Midwives everywhere understand that by working in partnership with women and their families they can support them to make better decisions about what they need to have a safe and fulfilling birth. Midwives were invited and encouraged to share views, photos, stories using the phrase ‘I believe in partnership’ on all ICM information platforms as a celebration of the wonderful work that midwives do around the globe. An example of action was Ugandan midwives who organised a symposium, saying: ‘We want to celebrate and promote the good work that Ugandan Midwives do every day. IDM … is an ideal opportunity to showcase the work of midwives in Uganda’. The IDM celebrations took place in Fort Portal, Kabarole District, Uganda. Midwives presented talks or posters on a study undertaken, a systematic review of a particular subject or a midwifery practice innovation on one of the selected themes: midwifery leadership: opening doors for the family voice in their health care system; innovative teaching strategies to strengthen family partnerships; using evidence-based practice in midwifery. http://unmc.ug/download/IDM-2017.pdf.
Draft statement on skilled attendant at birth The critical progress indicator explicitly adopted by the Sustainable Development Goals (SDG) and the Global Strategy for Women's, Children's and Adolescents' Health, 2016–2030 agendas is the ‘percentage of births delivered by a skilled attendant at birth (SAB)’. In 2004, WHO/FIGO/ICM issued a joint statement that clearly defined SAB and its core functions. Actual practice at country level, however, is challenged by a lack of clear guidelines, standardization of names and functions, and task shifting. In addition, many countries have found that there is a large gap between the defined standards and the skill set/competence of existing birth attendants who are able to correctly manage common obstetric and neonatal complications. Improved, simple and operational definitions and a meta-data E-mail address: [email protected] http://dx.doi.org/10.1016/j.midw.2017.05.002 0266-6138/
analysis of various cadres of birth attendants (skilled and not so skilled) in each low- and middle-income country are urgently needed to support improved measurement of coverage of SAB. WHO, UNFPA and UNICEF have set up a taskforce to harmonize the definition and measurement of maternal health indicators, with special focus on SAB and in consultation with FIGO, ICM, ICN, and IPA. The draft definition of the competent health care provider in maternal and newborn health reads: Quality maternal and newborn health care (QMNHC) is the provision of quality care for women of reproductive age, their newborns and families, before and during pregnancy, birth, and the postnatal period and beyond. This care is provided by competent qualified maternal and newborn health care professionals (QMNHCP) who are educated and regulated as per international and national standards and who work as a team within an enabling and supportive environment. The statement will be finalised by the taskforce after taking account of comments received during the consultation. A background paper explains more about the terms and definitions used and makes clear, for example, that: The term ‘competencies’ is used as the knowledge, skills and behaviours which value respect, communication, community knowledge and understanding required of the health care professional for safe practice in any setting along the continuum of care. This continuum ranges from pre-pregnancy, to pregnancy, intrapartum, post-natal and beyond. They are tailored to women's, newborns and family's circumstances and needs. ‘Competent attendance in maternal and newborn health: the definition of the competent health care provider in maternal and newborn health’ the draft statement and background document to the joint statement can be downloaded at http://www.who. int/reproductivehealth/skilled-birth-attendant/en/.
New multinational fetal growth charts from WHO A study, published by PLOS Medicine, shows that there is significant variation in fetal growth between countries. Fetal growth was also shown to some extent influenced by maternal age, height, weight, parity and by fetal sex. The article (which is open access) also provides new WHO charts for estimating fetal growth and should be particularly useful for countries who may not have resources to develop their own charts. The research, including 1387 healthy women with low-risk pregnancies, was a collaboration between WHO's Department of
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Reproductive Health and Research and the Special Programme of Research (HRP) together with investigators from 10 countries (Argentina, Brazil, Democratic Republic of Congo, Denmark, Egypt, France, Germany, India, Norway and Thailand). Using repeated ultrasound measurements the researchers were able to establish fetal growth charts for head and abdominal circumference, length of thigh bone and fetal weight. Estimating fetal weight is important as small size at birth is associated with perinatal mortality and child morbidity as well as longer-term health risks as an adult. Ultrasound estimation of fetal weight is a key tool in identifying high-risk pregnancies. Many countries, however, use fetal growth charts based on a single population from high-income countries. The differences observed between countries in the WHO study, with regard to maternal factors and fetal sex, indicate that local diagnosis may be improved when these factors are taken into account. Using the new WHO internationally-adjusted fetal growth charts is therefore recommended. The study includes an example of fetal growth charts that have been adjusted for sex. The authors suggest that these WHO charts for growth in estimated fetal weight are more suitable for international use than those commonly applied today. However, the differences between countries, with maternal factors and fetal sex also having an effect, mean that these growth charts may need to be adjusted for local clinical use to increase their diagnostic and predictive performance. The considerable variation in fetal growth and birthweight which occurs even under optimal conditions, and which is not explicable in terms of maternal and population factors, may suggest, first, that such natural variation in offspring size is a collective adaptive strategy that has proved extremely successful from an evolutionary point of view and, second, that major determinants of variation in human development before birth are still to be determined. Although the present study encompasses 10 countries, it still represents only a small selection of population groups when the substantial anthropometric variations existing even within continents are taken into account. Building on the results of this study, WHO is currently developing guidance that will allow countries to develop fetal growth charts specific to their own country. Kiserud T et al. (2017) The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight. PLoS Med 14(1), e1002220.
Women at the centre in new WHO guidance on health and rights of women living with HIV The World Health Organization (WHO) has launched the Consolidated guideline on sexual and reproductive health and rights of women living with HIV, which takes a woman-centred approach throughout to effectively address and represent the needs of girls and women, as well as those of their families and communities. A woman-centred approach to healthcare is one that consciously adopts the perspectives of women, their families and communities. This means that health services see women as active participants in, as well as beneficiaries of, trusted health systems that respond to women's needs, rights and preferences in humane and holistic ways. Such an approach to healthcare is crucial when working to safeguard the sexual and reproductive health and rights of women living with HIV. In 2015, there were an estimated 17.8 million
women aged 15 and older living with HIV in 2015, constituting 51 percent of all adults living with HIV. HIV is not only driven by gender inequality, but also further entrenches inequalities, leaving girls and women more vulnerable to its impact. Girls and women often do not have equal access to health services and information and can also face additional negative health impacts as a result of living with HIV – including stigma, shame, violence and abuse. Manjulaa Narasimhan, Scientist at WHO, commented ‘Supporting evidence-based recommendations and building an enabling environment will help advance the health and well-being of women living with HIV in all their diversity.’ Taking this approach, the process adopted for the development of the guidelines was unique in its meaningful engagement of communities of women living with HIV. In taking a woman-centred approach, the new WHO guidelines are founded upon the principles of human rights and gender equality: ‘When human rights are safeguarded, and gender inequalities are addressed, interventions to improve the sexual and reproductive health of women living with HIV can then, and only then, effectively meet their needs,’ said Ian Askew, Director of WHO Department of Reproductive Health and Research. An integrated approach to health and human rights lies at the heart of ensuring the dignity and well-being of women living with HIV. This includes, but is not limited to, the right to the highest attainable standard of health; the right to life and physical integrity, including freedom from violence; the right to equality and nondiscrimination on the basis of sex; and the right to freedom from torture or cruel, inhuman or degrading treatment. The right to SRH is an integral part of the right to health, enshrined in article 12 of the International Covenant on Economic, Social and Cultural Rights. The promotion of gender equality is central to the achievement of SRHR of all women, including women living with HIV in all their diversity. This means recognizing and taking into account how unequal power in women's intimate relationships, harmful gender norms and women's lack of access to and control over resources affect their access to and experiences with health services. http://www.who.int/reproductivehealth/topics/gender_ rights/women-living-with-hiv/en/.
Is birth weight a good proxy for population health? Despite dramatic improvements in human health, babies' average birth-weights have not increased over the last 150 years. Research from the London School of Economics and Political Science (LSE) reveals that average birth weights, as well as the proportions of babies born at different birth weights, are very similar today to the numbers recorded in the nineteenth century in Europe and North America. In contrast, average adult height and life expectancy has increased dramatically. Dr Eric Schneider, Assistant Professor of Economic History at LSE and author of the paper, said: ‘Birth weights are used by health care professionals as a proxy for the health of babies in the womb, so there is an implicit assumption that they have increased historically as our overall health has improved. This is why my findings are so surprising and begs the question - are we looking at the right things when trying to measure fetal health, at both the individual and population level, in this way?’. Understanding the conditions for the unborn baby in the womb is a significant endeavour because recent research has found that they can affect children's health across their entire life, even into old age. These findings raise questions about the international birth weight standards that determine the 'ideal' weight that a baby should be.
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Dr Schneider said: ‘In Pakistan 32 per cent of babies are born at a low birth weight, meaning that they weigh in at less than 2500 g, and it is assumed that if health conditions improve, average birth weights will rise. However, given that this did not happen in Western Europe and the United States, despite significant historical improvements to maternal health care, it's possible that birth weights in Pakistan will not increase to the level set by the standards.’. Dr Schneider added: ‘My results do not in any way downplay the very real health risks low birth weight babies face or the fact that children developing in the womb are extremely sensitive to poor conditions, such as a lack of key nutrients or infection. I look at statistics at a population level to analyse what they can tell us on the general rather than the individual level.’. Schneider analysed birth weights recorded in historical maternity records that have survived for a number of European and North American maternity hospitals. Schneider EB. Fetal health stagnation: Have health conditions in utero improved in the United States and Western and Northern Europe over the past 150 years? Social Science and Medicine, doi: http://dx.doi.org/10.1016/j.socscimed.2017.02.018, published online 17 February 2017.
Mistreatment of women during childbirth: a sad reality worldwide Women worldwide face diverse forms of mistreatment during childbirth by health-care providers. Recent evidence, which has been generated through the HRP Alliance research capacity strengthening programme, suggests that this unacceptable mistreatment can include physical and verbal abuse, violations of privacy, stigma and discrimination, and neglect and abandonment. Health-care providers should ensure high quality, evidencebased and respectful care to women and their infants during childbirth and labour, but evidence shows that some providers have misconceptions about what constitutes acceptable behaviour. In the first known qualitative studies of their kind to be conducted in Guinea, it became clear that the mistreatment of women during childbirth in the country is a reality. This research, which was led by scientists from the Cellule de recherche en santé de la reproduction en Guinée (CERREGUI), University National Hospital-Donka and WHO, was published in the journal BMC Reproductive Health. The authors of one article note that this can include, ‘physical abuse such as slapping, pinching and excessive fundal pressure. Women also experience verbal abuse, neglect and abandonment during childbirth’. The research highlighted how some health-care providers considered different forms of abuse as acceptable. What is more, some women also accepted some forms of mistreatment. In one article, the authors note, ‘Midwives and doctors may use abusive techniques to get women to cooperate, and paradoxically some women accept such mistreatment if they believe it will benefit their health or their baby's health.’. Mistreatment of women during childbirth occurs in countries across the world and puts the lives and well-being of women at risk. It also constitutes a violation of the right to the highest attainable standard of health, which includes the right to dignified, respectful healthcare throughout pregnancy and childbirth, as well as the right to be free from violence and discrimination. These research articles were co-authored by researchers from Guinea and staff working at the WHO Department of Reproductive Health and Research including HRP.
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CERREGUI, the research institution based in Guinea, received support from the HRP Alliance research capacity strengthening programme for this research. The articles form part of a multi-country study on mistreatment of women during childbirth in four countries: Guinea, Ghana, Nigeria and Myanmar. They come from the first qualitative stage of the study, which aims to better understand contributing factors to mistreatment during childbirth, and to pinpoint areas for action. High quality and respectful healthcare is crucial to prevent maternal death and to make progress towards achieving the sustainable development goals, as well as the aims of the aligned Global Strategy for Women's, Children's and Adolescents’ Health. The mistreatment of women during childbirth is therefore a significant barrier to reducing maternal mortality in countries worldwide. http://www.who.int/reproductivehealth/topics/maternal_ perinatal/mistreatment-during-childbirth/en/.
Dietary kit reduces baby blues shown to be a precursor to postnatal depression A dietary supplement kit, created to counter mood-altering brain changes linked to depression, virtually eliminated the ‘baby blues’ among women in a new study at Toronto's Centre for Addiction and Mental Health (CAMH). Postpartum or ‘baby’ blues are common among women after giving birth. However, when severe, they substantially increase the risk of clinically diagnosed postpartum depression, which affects 13 per cent of new mothers and is the most common complication of child-bearing. The study, published in the Proceedings of the National Academy of Sciences (PNAS), was led by Dr. Jeffrey Meyer, who heads the Neuroimaging Program in Mood & Anxiety in CAMH's Campbell Family Mental Health Research Institute. Developing successful nutrition-based treatments, based on neurobiology, is rare in psychiatry,’ says Dr. Meyer. ‘We believe our approach represents a promising new avenue for creating other new dietary supplements for medicinal use’. The nutritional kit consists of three supplements, carefully selected to compensate for a surge in the brain protein MAO-A, which occurs in the early postpartum phase, and which also resembles a brain change that persists for longer periods in clinical depression. MAO-A breaks down three brain chemicals that help maintain mood: serotonin, norepinephrine and dopamine. When these chemicals are depleted, it can lead to feelings of sadness. MAO-A levels peak five days after giving birth, the same time when postpartum blues are most pronounced. The kit includes tryptophan and tyrosine, which compensate for the loss of the three mood-regulating chemicals, as well as a blueberry extract for anti-oxidant effects. Dr. Meyer's team had also tested and confirmed that the tryptophan and tyrosine supplements, given in higher amounts than people would normally get in their diet, did not affect the overall concentrations in breast milk. The current study by research fellow Dr. Yekta Dowlati included 21 women who received the supplements and a comparison group of 20 who did not. The women knew they were receiving nutritional supplements. The supplements were taken over three days, starting on the third day after giving birth. On day five after giving birth the women underwent tests to assess the effect on mood. The testing included a measure of the
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ability to be resilient against sad events. The women read statements with sentiments that expressed pessimism, dissatisfaction and lethargy, and then listened to a sad piece of classical music. Before and after this test, researchers measured depressive symptoms. Women who were not taking the supplements had a significant increase in depression scores. In contrast, women taking the dietary supplements did not experience any depressed mood. ‘We believe this is the first study to show such a strong, beneficial effect of an intervention in reducing the baby blues at a time when postpartum sadness peaks,’ says Dr. Meyer. ‘Postpartum blues are common and usually resolve 10 days after giving birth, but when they are intense, the risk of postpartum depression increases four-fold’. The results support further research to replicate the effects in a larger sample in a randomized, controlled trial, and further assess the kit's ability to reduce both the postpartum blues as well as clinically diagnosed postpartum depression. Dowlati Y et al. Selective dietary supplementation in early postpartum is associated with high resilience against depressed mood. PNAS, doi: http://dx.doi.org/10.1073/pnas.1611965114, published online 13 March 2017.
Our data shows that PPCM is truly a global disease, and irrespective of where you live, what healthcare system you have, what nutrition you have, and what education you have, you can get this disease, said Professor Sliwa. ‘PPCM is to some extent a biological disease and women might have a genetic predisposition, which is probably a cellular and cardiac signalling abnormality. This is not a disease with marked differences between ethnic groups. We were surprised to see that there is a large percentage of women from the UK, for instance, and from Germany, countries which had not reported many cases so far, added Professor Sliwa. One month after diagnosis, 80% of the women with PPCM still had heart failure. About 7% of the women had blood clots - either a stroke, clot to the lung, or clot to the legs. ‘Despite good access to healthcare and good medical therapy, PPCM remains a very serious disease because many women remain in heart failure or develop blood clots,’ said Professor Sliwa. ‘PPCM occurs in all health systems and is probably underdiagnosed in many parts of the world,’ she continued. ‘More awareness needs to be created for this disease so that women can be given timely and appropriate treatment.’ The registry aims to recruit 1000 women with PPCM and will see if there are any differences in six month outcomes between ethnic groups.
Peripartum cardiomyopathy occurs globally and is not a disease of the poor Peripartum cardiomyopathy (PPCM) occurs worldwide, contrary to previous assumption, according to research published in the European Journal of Heart Failure. Cases were reported from many countries for the first time. ‘People have always thought PPCM was much more common and severe in Africans and that it was a disease of poverty but our study clearly shows that it's not,’ said lead author Professor Karen Sliwa, director of the Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa. The study was conducted by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) Study Group on PPCM under the EURObservational Research Programme (EORP). PPCM is a structural heart muscle disease that occurs in women either at the end of pregnancy or up to five months after giving birth. Patients were previously healthy and then present with shortness of breath and heart failure. In about one-third of women with PPCM the heart muscle spontaneously recovers, but about 10% die from the disease and over half have a weakened heart muscle for the rest of their lives. The baby is sometimes born smaller and earlier, and in rare cases it dies. Research has shown that women with PPCM produce an abnormal breastfeeding hormone that leads to programmed cell death (apoptosis) and damage to the heart muscle. Until recently it was assumed that PPCM occurred predominantly in African women. This registry study was conducted to find out whether PPCM occurs in other continents. Specifically, the researchers set out to discover how the disease presents, is diagnosed, and treated in different countries. The paper reports the baseline results of 411 patients from 43 countries, representing all continents. Data collected included demographic characteristics, co-morbidities, treatments, type of hospital, and specialisation of the treating physician. The researchers found cases of PPCM in all 43 countries studied. All women with PPCM presented at the same age, and with the same symptoms and heart size, despite different ethnic backgrounds and major disparities in socioeconomic factors and access to healthcare.
Sliwa K, et al. Clinical characteristics of patients from the worldwide registry on peripartum cardiomyopathy (PPCM). European Journal of Heart Failure, doi:10.1002/ejhf.780, published 8 March 2017.
The cost of a polluted environment: 1.7 million child deaths a year, says WHO More than 1 in 4 deaths of children under 5 years of age are attributable to unhealthy environments. Every year, environmental risks – such as indoor and outdoor air pollution, secondhand smoke, unsafe water, lack of sanitation, and inadequate hygiene – take the lives of 1.7 million children under 5 years, say two new WHO reports. The first report, Inheriting a Sustainable World: Atlas on Children's Health and the Environment reveals that a large portion of the most common causes of death among children aged 1 month to 5 years – diarrhoea, malaria and pneumonia – are preventable by interventions known to reduce environmental risks, such as access to safe water and clean cooking fuels. Harmful exposures can start in the mother's womb and increase the risk of premature birth. Additionally, when infants and pre-schoolers are exposed to indoor and outdoor air pollution and second-hand smoke they have an increased risk of pneumonia in childhood, and a lifelong increased risk of chronic respiratory diseases, such as asthma. Exposure to air pollution may also increase their lifelong risk of heart disease, stroke and cancer. A companion report, Don't pollute my future! The impact of the environment on children's health, provides a comprehensive overview of the environment's impact on children's health, illustrating the scale of the challenge. Every year:
570,000 children under 5 years die from respiratory infections,
such as pneumonia, attributable to indoor and outdoor air pollution, and second-hand smoke. 361,000 children under 5 years die due to diarrhoea, as a result of poor access to clean water, sanitation, and hygiene. 270,000 children die during their first month of life from conditions, including prematurity, which could be prevented through access to clean water, sanitation, and hygiene in health facilities as well as reducing air pollution.
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200,000 deaths of children under 5 years from malaria could be
prevented through environmental actions, such as reducing breeding sites of mosquitoes or covering drinking-water storage. 200,000 children under 5 years die from unintentional injuries attributable to the environment, such as poisoning, falls, and drowning.
Dr Maria Neira, WHO Director, Department of Public Health, Environmental and Social Determinants of Health, says ‘Investing in the removal of environmental risks to health, such as improving water quality or using cleaner fuels, will result in massive health benefits.’ In households without access to basic services, such as safe water and sanitation, or that are smoky due to the use of unclean fuels, such as coal or dung for cooking and heating, children are at an increased risk of diarrhoea and pneumonia.
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Reducing air pollution inside and outside households, improving safe water and sanitation and improving hygiene (including in health facilities where women give birth), protecting pregnant women from second-hand tobacco smoke, and building safer environments, can prevent children's deaths and diseases. Under the Sustainable Development Goals (SDGs) countries are working on a set of targets to guide interventions for children's environmental health, as well as to end preventable deaths of newborns and children under five by 2030. In addition to SDG 3, which aims to ensure healthy lives and promote well-being for all, other SDGs work to improve water, sanitation and hygiene, transition to clean energy to reduce air pollution, and reverse climate change – all of which will have an impact on children's health. http://www.who.int/mediacentre/news/releases/2017/pol lution-child-death/en/.