Bmc Pregnancy Childb
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Bmc Pregnancy Childb · Jan 2009
Review Meta AnalysisReducing stillbirths: behavioural and nutritional interventions before and during pregnancy.
The vast majority of global stillbirths occur in low- and middle-income countries, and in many settings, the majority of stillbirths occur antenatally, prior to the onset of labour. Poor nutritional status, lack of antenatal care and a number of behaviours increase women's risk of stillbirth in many resource-poor settings. Interventions to reduce these risks could reduce the resulting burden of stillbirths, but the evidence for the impact of such interventions has not yet been comprehensively evaluated. ⋯ Antenatal care is widely used in low- and middle-income countries, and provides a natural facility-based contact through which to provide or educate about many of the interventions we reviewed. The impact of broader socially mediated behaviors, such as fertility decision-making, access to antenatal care, and maternal diet and exposures like tobacco and indoor air pollution during pregnancy, are poorly understood, and further research and appropriate interventions are needed to test the association of these behaviours with stillbirth outcomes. For most nutritional interventions, larger randomised controlled trials are needed which report stillbirths disaggregated from composite perinatal mortality. Many antepartum stillbirths are potentially preventable in low- and middle-income countries, particularly through dietary and environmental improvement, and through improving the quality of antenatal care - particularly including diagnosis and management of high-risk pregnancies - that pregnant women receive.
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Bmc Pregnancy Childb · Jan 2009
Review Meta AnalysisReducing stillbirths: interventions during labour.
Approximately one million stillbirths occur annually during labour; most of these stillbirths occur in low and middle-income countries and are associated with absent, inadequate, or delayed obstetric care. The low proportion of intrapartum stillbirths in high-income countries suggests that intrapartum stillbirths are largely preventable with quality intrapartum care, including prompt recognition and management of intrapartum complications. The evidence for impact of intrapartum interventions on stillbirth and perinatal mortality outcomes has not yet been systematically examined. ⋯ Although the global appeal to prioritise access to emergency obstetric care, especially vacuum extraction and Caesarean section, rests largely on observational and population-based data, these interventions are clearly life-saving in many cases of fetal compromise. Safe, comprehensive essential and emergency obstetric care is particularly needed, and can make the greatest impact on stillbirth rates, in low-resource settings. Other advanced interventions such as amnioinfusion and hyperoxygenation may reduce perinatal mortality, but concerns about safety and effectiveness require further study before they can be routinely included in programs.
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Bmc Pregnancy Childb · Jan 2009
ReviewAnti-fibrinolytic agents in post partum haemorrhage: a systematic review.
Post partum haemorrhage is a leading cause of maternal death worldwide. It also contributes to maternal morbidity as women may require a hysterectomy to control bleeding, or may require a blood transfusion, which can transmit viral infections. Anti-fibrinolytic agents have been proposed as a treatment for post partum haemorrhage. We conducted a systematic review to assess the effectiveness and safety of anti-fibrinolytic agents in post partum bleeding. ⋯ Tranexamic acid may reduce blood loss in post partum haemorrhage. However, the quality of the currently available evidence is poor. Adequately powered, high quality randomised controlled trials are needed.
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Bmc Pregnancy Childb · Jan 2009
Randomized Controlled TrialPessaries in multiple pregnancy as a prevention of preterm birth: the ProTwin Trial.
Multiple pregnancies are at high risk for preterm birth, and therefore an important cause of infant mortality and morbidity. A pessary is a simple and potentially effective measure for the prevention of preterm birth. Small studies have indicated its effectiveness, but large studies with sufficient power on the subject are lacking. Despite this lack of evidence, the treatment is at present applied by some gynaecologists in The Netherlands. ⋯ This trial will provide evidence on whether a cervical pessary will decrease the incidence of early preterm birth and its concomitant bad neonatal outcome in multiple pregnancies.
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One of the major success stories of modern obstetrics in high-income countries in the last 5 decades is the reduction of stillbirths from rates as high as 50 per 1000 births to about 5 per 1000 births today. Fetal mortality associated with obstructed labour, asphyxia, hypertension, diabetes, Rh disease, placental abruption, post-term pregnancies and infections such as syphilis all have declined. Much of this success has occurred in term births in the intrapartum period so that most stillbirths in high-income countries now occur in the antepartum period and are pre-term. ⋯ Those stillbirths should be relatively easy to prevent by known risk assessment methods and prompt delivery, often by Cesarean section. This commentary addresses an extensive six-paper review of stillbirths with an emphasis on low- and middle-income countries. Among the conclusions are that while a number of interventions have been shown to be effective in reducing stillbirths, unless there is a functioning health system in which these interventions can be implemented, the potential for a sustainable and substantial reduction in stillbirth rates will not be reached.