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Born too soon: care during pregnancy and childbirth to reduce preterm deliveries and improve health outcomes of the preterm baby.

ABSTRACT: Pregnancy and childbirth represent a critical time period when a woman can be reached through a variety of mechanisms with interventions aimed at reducing her risk of a preterm birth and improving her health and the health of her unborn baby. These mechanisms include the range of services delivered during antenatal care for all pregnant women and women at high risk of preterm birth, services provided to manage preterm labour, and workplace, professional and other supportive policies that promote safe motherhood and universal access to care before, during and after pregnancy. The aim of this paper is to present the latest information about available interventions that can be delivered during pregnancy to reduce preterm birth rates and improve the health outcomes of the premature baby, and to identify data gaps. The paper also focuses on promising avenues of research on the pregnancy period that will contribute to a better understanding of the causes of preterm birth and ability to design interventions at the policy, health care system and community levels. At minimum, countries need to ensure equitable access to comprehensive antenatal care, quality childbirth services and emergency obstetric care. Antenatal care services should include screening for and management of women at high risk of preterm birth, screening for and treatment of infections, and nutritional support and counselling. Health workers need to be trained and equipped to provide effective and timely clinical management of women in preterm labour to improve the survival chances of the preterm baby. Implementation strategies must be developed to increase the uptake by providers of proven interventions such as antenatal corticosteroids and to reduce harmful practices such as non-medically indicated inductions of labour and caesarean births before 39 weeks of gestation. Behavioural and community-based interventions that can lead to reductions in smoking and violence against women need to be implemented in conjunction with antenatal care models that promote women's empowerment as a strategy for reducing preterm delivery. The global community needs to support more discovery research on normal and abnormal pregnancies to facilitate the development of preventive interventions for universal application. As new evidence is generated, resources need to be allocated to its translation into new and better screening and diagnostic tools, and other interventions aimed at saving maternal and newborn lives that can be brought to scale in all countries.

SUBMITTER: Requejo J

PROVIDER: S-EPMC3842748 | biostudies-other | 2013

REPOSITORIES: biostudies-other

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Born too soon: care during pregnancy and childbirth to reduce preterm deliveries and improve health outcomes of the preterm baby.

Requejo Jennifer J Merialdi Mario M Althabe Fernando F Keller Matthais M Katz Joanne J Menon Ramkumar R

Reproductive health 20131125

Pregnancy and childbirth represent a critical time period when a woman can be reached through a variety of mechanisms with interventions aimed at reducing her risk of a preterm birth and improving her health and the health of her unborn baby. These mechanisms include the range of services delivered during antenatal care for all pregnant women and women at high risk of preterm birth, services provided to manage preterm labour, and workplace, professional and other supportive policies that promote ...[more]

PMID: 24625215

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Project description:As part of a supplement entitled “Born Too Soon”, this paper focuses on care of the preterm newborn. An estimated 15 million babies are born preterm, and the survival gap between those born in high and low income countries is widening, with one million deaths a year due to direct complications of preterm birth, and around one million more where preterm birth is a risk factor, especially amongst those who are also growth restricted. Most premature babies (>80%) are between 32 and 37 weeks of gestation, and many die needlessly for lack of simple care. We outline a series of packages of care that build on essential care for every newborn comprising support for immediate and exclusive breastfeeding, thermal care, and hygienic cord and skin care. For babies who do not breathe at birth, rapid neonatal resuscitation is crucial. Extra care for small babies, including Kangaroo Mother Care, and feeding support, can halve mortality in babies weighing <2000 g. Case management of newborns with signs of infection, safe oxygen management and supportive care for those with respiratory complications, and care for those with significant jaundice are all critical, and are especially dependent on competent nursing care. Neonatal intensive care units in high income settings are de-intensifying care, for example increasing use of continuous positive airway pressure (CPAP) and this makes comprehensive preterm care more transferable. For health systems in low and middle income settings with increasing facility births, district hospitals are the key frontier for improving obstetric and neonatal care, and some large scale programmes now include specific newborn care strategies. However there are still around 50 million births outside facilities, hence home visits for mothers and newborns, as well as women’s groups are crucial for reaching these families, often the poorest. A fundamental challenge is improving programmatic tracking data for coverage and quality, and measuring disability-free survival. The power of parent’s voices has been important in high-income countries in bringing attention to preterm newborns, but is still missing from the most affected countries.

Project description:BackgroundReducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required.MethodsA systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted.Results179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions.ConclusionsEvidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.

Project description:Introduction: Prematurity (birth before 37 +0 weeks' gestation) is associated with wide-ranging neurodevelopmental impairment. Prognosis among moderate to late (32 +0 to <37 +0 weeks' gestation) preterm infants (MLPT) is better compared to their counterparts born very preterm (<32 +0 weeks' gestation). However the risk of developmental impairment among MLPT, who make up about 84% of all preterm infants, is 2-3 times higher when compared to infants born at term. Early interventions have aimed to improve outcomes in preterm infants generally, but there are limited data on their need and effect in MLPT specifically. Prioritising research, long-term follow-up and early interventions targeted at ameliorating the impact of preterm birth among MLPT is required. Objectives: To conduct a systematic review of the type of early childhood interventions (from birth until 4 years of age) offered to MLPT children and to evaluate their impact on neurodevelopmental outcomes (cognitive, neurobehavioural and motor) as assessed in these children during childhood (until 18 years of age). Methods and analysis: A systematic literature search in Web of Science, Medline Ovid, PsycINFO, CINAHL and EMBASE will be conducted. Data on MLPT children receiving developmental interventions until the age of 4 years will be evaluated. Interventions may involve parents or primary caregivers. Primary outcomes are cognitive, neurobehavioural and motor development as measured from birth until the age of 18 years. The Cochrane Risk of Bias Assessment Tool will be used to evaluate the methodological quality of randomised controlled trials (RCTs) included in the review and will be graded as low, high or unclear risk of bias. The quality of non-RCTs will be evaluated with the Newcastle-Ottawa Scale. The quality of evidence for each outcome will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation Approach. Publication and reporting bias will be assessed using Egger's test and funnel plots respectively.

Project description:To evaluate the impact of maternal hypertensive disorders of pregnancy (HDP) on mortality and neurological outcomes in extremely and very preterm infants using a nationwide neonatal database in Japan. This population-based retrospective study was based on an analysis of data collected by the Neonatal Research Network of Japan from 2003 to 2015 of neonates weighing 1,500 g or less at birth, between 22 and 31 weeks' gestation. A total of 21,659 infants were randomly divided into two groups, HDP (n = 4,584) and non-HDP (n = 4,584), at a ratio of 1:1 after stratification by four factors including maternal age, parity, weeks of gestation, and year of delivery. Short-term (neonatal period) and medium-term (3 years of age) mortality and neurological outcomes were compared between the two groups by logistic regression analyses. In univariate analysis, HDP was associated with an increased risk for in-hospital death (crude odds ratio [OR], 1.31; 95% confidence interval, 1.04-1.63) and a decreased risk for severe intraventricular haemorrhage (0.68; 0.53-0.87) and periventricular leukomalacia (0.60; 0.48-0.77). In multivariate analysis, HDP was significantly associated with a lower risk for in-hospital death (adjusted OR, 0.61; 0.47-0.80), severe intraventricular haemorrhage (0.47; 0.35-0.63), periventricular leukomalacia (0.59; 0.45-0.78), neonatal seizures (0.40; 0.28-0.57) and cerebral palsy (0.70; 0.52-0.95) at 3 years after adjustment for covariates including birth weight. These results were consistent with those of additional analyses, which excluded cases with histological chorioamnionitis and which divided the infants into two subgroups (22-27 gestational weeks and 28-31 gestational weeks). Maternal HDP was associated with an increased risk for in-hospital death without adjusting for covariates, but it was also associated with a lower risk for mortality and adverse neurological outcomes in extremely and very preterm infants if all covariates except HDP were identical.

Project description:BackgroundPerinatal anxiety is one of the most common conditions during pregnancy and is associated with adverse maternal and neonatal outcomes. Interventions that are focused on childbirth education and health literacy have been shown to help decrease pregnancy-related anxiety. These programs, however, have limitations. Transportation, childcare, and work conflicts pose barriers to patients. In addition, many of these programs have not been studied in high-risk patients, who are most at risk for pregnancy-related anxiety. Thus, it is uncertain whether an online childbirth education course can help to improve outcomes in a high-risk patient population.ObjectiveThis study aimed to compare an interactive online platform for childbirth education (Birthly) with usual prenatal education on anxiety, emergency healthcare utilization, and delivery outcomes for high-risk pregnancies.Study designWe performed a randomized trial comparing an interactive online childbirth education platform combined with usual prenatal education (intervention) with usual prenatal education alone (usual care). Nulliparous, English-speaking patients with internet access and a high-risk pregnancy (medical or mental health disorders) were included. Patients in 2 urban clinics that serve underresourced patients were enrolled at <20 weeks of gestation. The intervention included 3 interactive courses (prenatal bootcamp, breastfeeding, newborn care) and access to a clinician-moderated online community. Pregnancy-related Anxiety Scale questionnaires were administered at randomization and at 34 to 40 weeks. The primary outcome was third-trimester Pregnancy-related Anxiety Scale score. Secondary outcomes included change in Pregnancy-related Anxiety Scale score, unscheduled emergency visits, delivery, and postpartum outcomes. To demonstrate a 15% decrease in Pregnancy-related Anxiety Scale score, 37 patients would be needed per group. Accounting for a 20% loss to follow-up rate, we planned to recruit 90 total patients or 45 per group.ResultsA total of 90 patients were randomized with no differences in demographics or baseline Pregnancy-related Anxiety Scale scores. Most patients self-identified as Black and were publicly insured. More than 60% of patients (62.2%) in the intervention arm completed at least 1 Birthly course. Patients in the intervention arm had significantly lower third-trimester Pregnancy-related Anxiety Scale scores (indicating lower anxiety) compared with those receiving usual care (44.6±7.3 vs 53.9±13.8; P<.01), with a decrease in score of 8.3 points vs 0.7 for usual care (P<.01). Patients in the intervention arm also had fewer emergency visits (1 [0-2] vs 2 [1-3]; P=.003). There were no differences in delivery outcomes. Patients in the intervention arm were more likely to breastfeed at delivery, although this was not different by the postpartum visit. Finally, patients who received the intervention were more likely to be satisfied with their childbirth education (94.6% vs 64.9%; P<.01).ConclusionAn interactive online childbirth education platform can reduce pregnancy-related anxiety and emergency healthcare utilization while improving satisfaction in a high-risk patient population.

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Born too soon: care during pregnancy and childbirth to reduce preterm deliveries and improve health outcomes of the preterm baby.

Publications

Born too soon: care during pregnancy and childbirth to reduce preterm deliveries and improve health outcomes of the preterm baby.

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