IMPROVING BIRTH OUTCOMES

MEETING THE CHALLENGE IN THE DEVELOPING WORLD

Committee on Improving Birth Outcomes

Board on Global Health

Judith R. Bale, Barbara J. Stoll, and Adetokunbo O. Lucas, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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Improving Birth Outcomes: Meeting the Challenge in the Developing World IMPROVING BIRTH OUTCOMES MEETING THE CHALLENGE IN THE DEVELOPING WORLD Committee on Improving Birth Outcomes Board on Global Health Judith R. Bale, Barbara J. Stoll, and Adetokunbo O. Lucas, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Improving Birth Outcomes: Meeting the Challenge in the Developing World THE NATIONAL ACADEMIES PRESS 500 Fifth Sreet, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Centers for Disease Control and Prevention, the U.S. Agency for International Development, and the National Institute for Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services. The views presented in this report are those of the Institute of Medicine Committee on Improving Birth Outcomes and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Improving birth outcomes : meeting the challenge in the developing world / Committee on Improving Birth Outcomes, Board on Global Health ; Judith R. Bale, Barbara J. Stoll, and Adetokunbo O. Lucas, editors. p. ; cm. Includes bibliographical references. ISBN 0-309-08614-0, 0-309-52796-1 (PDF) 1. Infants (Newborn)—Developing countries—Mortality—Prevention. 2. Infants (Newborn)—Diseases—Developing countries—Prevention. 3. Fetal death—Developing countries—Prevention. 4. Fetus—Diseases—Developing countries—Prevention. 5. Mothers—Developing countries—Mortality—Prevention. 6. Infant health services—Developing countries. 7. Maternal health services—Developing countries. 8. Pregnancy—Complications—Developing countries—Prevention. [DNLM: 1. Pregnancy Complications—prevention & control. 2. Pregnancy Outcome. 3. Developing Countries. 4. Infant Mortality. 5. Maternal Mortality. WQ 240 I34 2003] I. Bale, Judith R. II. Stoll, Barbara J. III. Lucas, Adetokunbo O. IV. Institute of Medicine (U.S.). Committee on Improving Birth Outcomes. RJ60.D44I465 2003 362.1′989201′091724—dc22 2003014374 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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Improving Birth Outcomes: Meeting the Challenge in the Developing World THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Improving Birth Outcomes: Meeting the Challenge in the Developing World COMMITTEE ON IMPROVING BIRTH OUTCOMES ADETOKUNBO O. LUCAS (Co-Chair), Professor of International Health, Nigeria BARBARA J. STOLL (Co-Chair), Emory University School of Medicine, Atlanta, GA ANNA ALISJAHBANA, University of Pajajaran, Bandung, Indonesia ABHAY BANG, Society for Education, Action & Research in Community Health, Gadchiroli, India LAURA CAULFIELD, The Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD ROBERT GOLDENBERG, University of Alabama at Birmingham, Birmingham, AL MARGE KOBLINSKY, Mother Care/John Snow, Arlington, VA MICHAEL KRAMER, McGill University, Montreal, Quebec, Canada AFFETTE MCCAW-BINNS, University of the West Indies, Jamaica, WI KUSUM NATHOO, University of Zimbabwe Medical School, Harare, Zimbabwe HARSHAD SANGHVI, Maternal and Neonatal Health Program, JHPIEGO Corp., Baltimore, MD JOE LEIGH SIMPSON, Baylor College of Medicine, Houston, TX Staff JUDITH R. BALE, Board Director and Study Director (until October 2002) ALISON J. MACK, Consultant SHIRA H. FISCHER, Research Assistant JASON PELLMAR, Project Assistant STEPHANIE BAXTER-PARROTT, Project Assistant (until July 2000) LAURIE SPINELLI, Project Assistant (until July 2002)

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Improving Birth Outcomes: Meeting the Challenge in the Developing World BOARD ON GLOBAL HEALTH DEAN JAMISON (Chair), Director, Program on International Health, Education, and Environment, University of California at Los Angeles, and the World Health Organization, Geneva, Switzerland YVES BERGEVIN, Chief, Health Section, UNICEF, New York, NY PATRICIA DANZON, Professor, Health Care Systems Development, University of Pennsylvania, Philadelphia, PA RICHARD FEACHEM, Executive Director, The Global Fund, Geneva, Switzerland NOREEN GOLDMAN, Professor, Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, NJ MARGARET HAMBURG, Vice President for Biological Programs, Nuclear Threat Initiative, Washington, DC JEFF KOPLAN, Vice President for Academic Health Affairs, Emory University, Atlanta, GA ADEL A. F. MAHMOUD, President, Merck Vaccines, Whitehouse Station, NJ JOHN WYN OWEN, Secretary, Nuffield Trust, London, United Kingdom MARK L. ROSENBERG, Executive Director, The Task Force for Child Survival and Development, Emory University, Decatur, GA SUSAN SCRIMSHAW, Dean, School of Public Health, University of Illinois at Chicago, Chicago, IL JAIME SEPULVEDA AMOR, National Institute of Public Health, Mexico DAVID CHALLONER (Institute of Medicine Foreign Secretary), Vice President for Health Affairs, Emeritus, University of Florida, Gainesville, FL

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: CARLA ABOUZHAR, World Health Organization H. DAVID BANTA, Consultant in Health Care Technology Assessment, Paris FERNANDO C. BARROS, PAHO/WHO Latin American Center for Perinatology and Human Development, Montevideo, Uruguay CYNTHIA BEALL, Case Western Reserve University ZULFIQAR A. BHUTTA, The Aga Khan University HOOSEN M. COOVADIA, University of Natal ANTHONY COSTELLO, Institute of Child Health at Great Ormond Street, University College, London LUELLA KLEIN, Department of Gynecology and Obstetrics, Emory University School of Medicine ANVER KULIEV, Reproductive Genetics Institute

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Improving Birth Outcomes: Meeting the Challenge in the Developing World ALLAN ROSENFIELD, Columbia University HELEN SMITS, Universidade Eduardo Mondlane ANN TINKER, Save the Children Foundation Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by ELAINE L. LARSON, Columbia University, New York, New York, and by ELENA NIGHTINGALE, National Research Council, Washington, DC. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Acknowledgments The Institute of Medicine acknowledges the committee for undertaking the development of both this comprehensive report and the companion report, Reducing the Impact of Birth Defects: Meeting the Challenge in the Developing World. The successful completion of this report has required the input of many experts. The committee thanks the researchers and public health professionals who presented papers and provided insights at the workshop held in conjunction with the first committee meeting (see Appendix A). The committee also thanks the many experts who provided technical review and suggestions during the development of the report: Carlos Barros; Charles Carpenter; Myron Essex; Jean-Pierre Habicht; Joy Lawn; Reynaldo Martorell; and Catherine Wilfert. The committee would like to thank staff and consultants in the Institute of Medicine whose contributions were instrumental to developing and producing this report: Judith Bale, who coordinated committee and other expert input; Alison Mack, who transformed report text; Pamela Mangu, who organized the first committee meeting; and Laurie Spinelli and Shira Fischer for their superb support at different stages of the report. Also valuable in the early development of the report was consultation with Helen Gelband, a paper prepared by Jeffrey Stringer, research provided by Patricia Cuff, Katherine Oberholtzer, Vanessa Larson, and interns Kevin Crosby, Nikki Williams, and Maria Vassileva. Appreciation is extended to Rona Briere for her expert editing of the report. Other staff who were instrumental in the final stages of this report include Bronwyn Schrecker,

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Janice Mehler (National Academies), Jennifer Otten, Jennifer Bitticks, Stacey Knobler, and the NAP production staff. Andrea Cohen is acknowledged for her careful monitoring of study finances. The committee appreciates the financial support for this report, which was provided by the Centers for Disease Control and Prevention, the U.S. Agency for International Development, and the National Institute for Child Health and Human Development, National Institutes of Health.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Contents Part I:   Meeting the Challenge in the Developing World         EXECUTIVE SUMMARY   3 1   INTRODUCTION   17      Study Purpose and Approach,   18      The Social, Cultural, and Economic Context,   20      Poverty,   21      Women’s Education and Socioeconomic Status,   22      Unintended Pregnancy,   23      Maternal Age and Parity,   24      Cultural Barriers to Obstetric and Neonatal Care,   26      Domestic Violence,   26      Natural Disasters and Political Conflicts,   26      Adverse Birth Outcomes,   27      Inadequate Data on Birth Outcomes,   27      Maternal, Fetal, and Neonatal Mortality,   28      Linking the Mother, Fetus, and Neonate,   29      Access to Care,   29      Three Additional Neonatal Challenges,   30      Child Survival and Safe Motherhood,   31      The Child,   31      The Mother,   32      The (Missing) Neonate and Fetus,   33      Organization of the Report,   34      References,   35

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Part II:   Addressing Maternal, Neonatal, and Fetal Mortality and Morbidity     2   REDUCING MATERNAL MORTALITY AND MORBIDITY   43      Causes of Maternal Morbidity and Mortality,   44      Hemorrhage,   46      Infections,   48      Sepsis,   48      Unsafe Abortion,   49      Hypertensive Disease of Pregnancy,   51      Obstructed Labor,   51      Interventions,   52      Interventions Involving Behavioral Change,   52      Antenatal Care,   54      Skilled Attendance at Childbirth,   58      Management of Childbirth,   65      Overused or Inappropriate Interventions,   76      Recommendations,   77      Research Needs,   78      Conclusion,   80      References,   81 3   REDUCING NEONATAL MORTALITY AND MORBIDITY   91      Causes of Neonatal Morbidity and Mortality,   91      Infectious Diseases,   92      Noninfectious Conditions,   99      Interventions,   102      Antenatal Care,   102      Care During Labor, Delivery, and the Very Early Neonatal Period,   107      Neonatal Care,   112      Recommendations,   116      Research Needs,   117      Conclusion,   119      References,   120 4   REDUCING FETAL MORTALITY   135      Factors Contributing to Late Fetal Deaths,   138      Intrapartum Fetal Deaths,   138      Antepartum Fetal Deaths,   141      Interventions,   148      Intrapartum Care,   149      Preconceptional and Antenatal Care,   150      Recognition of Fetal Deaths,   152

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Improving Birth Outcomes: Meeting the Challenge in the Developing World      Recommendations,   153      Research Needs,   153      Conclusion,   153      References,   154 Part III:   Improving Health Care Systems     5   IMPROVING BIRTH OUTCOMES WITHIN HEALTH CARE SYSTEMS   165      The Evidence Base,   166      Primary Care and Referral,   166      Models of Care for Labor and Delivery,   168      Improving Access to Referral Care for Labor and Delivery,   176      Building Capacity for Reproductive Health Care,   178      Staff Development and Training,   179      The Role of the Private Sector,   180      Financing,   182      Health Care Reforms,   183      Managing Health Care Systems,   184      Surveillance,   185      Evaluation,   189      Recommendations,   191      Research Needs,   193      Conclusion,   193      References,   194 Part IV:   Additional Causes of Neonatal Mortality and Morbidity     6   THE PROBLEM OF LOW BIRTH WEIGHT   205      Patterns of Occurrence,   205      Causes of IUGR and Preterm Birth,   207      Consequences of IUGR and Preterm Birth,   212      Effects on Mortality,   212      Effects on Morbidity, Growth, and Development,   214      Interventions to Prevent Preterm Birth and IUGR,   217      Sources of Evidence,   217      Prepregnancy Energy/Protein Supplementation,   217      Energy/Protein Supplementation During Pregnancy,   218      Nutritional Advice,   218      Micronutrient Supplementation,   219      Treatment of Genitourinary Infection,   220      Smoking Cessation,   221      Malaria Prophylaxis and Treatment,   221      Other Interventions,   222

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Improving Birth Outcomes: Meeting the Challenge in the Developing World      Recommendations,   223      Research Needs,   224      Conclusion,   224      References,   225 7   REDUCING MORTALITY AND MORBIDITY FROM BIRTH DEFECTS   237      Patterns of Occurrence,   238      Causes of Birth Defects,   238      Genetic Birth Defects,   240      Birth Defects of Environmental Origin,   242      Birth Defects of Complex and Unknown Origin,   245      Reducing the Impact of Birth Defects,   248      A Multistage Process,   248      Stage One: Low-Cost Preventive Strategies,   248      Stage Two: Early Diagnosis and Treatment of Birth Defects,   250      Stage Three: Screening for Genetic Disorders,   251      Recommendations,   254      Research Needs,   254      Conclusion,   255      References,   255 8   PREVENTING PERINATAL TRANSMISSION OF HIV   263      The HIV/AIDS Epidemic,   263      HIV in Women of Childbearing Age,   264      Perinatal Transmission of HIV,   266      Interventions to Prevent HIV Transmission,   267      Antiretroviral Strategies,   267      Nonantiretroviral Strategies,   277      Comparing Preventive Interventions,   278      Barriers to Implementing Antenatal Screening,   279      Guidelines for Antenatal HIV Screening,   283      Recommendations,   284      Research Needs,   285      Conclusion,   286      References,   286 9   SUMMING UP: THE WAY FORWARD   293      Priorities,   293      The Skilled Birth Attendant,   294      Essential Obstetric and Neonatal Care,   295      Conclusion,   296

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Improving Birth Outcomes: Meeting the Challenge in the Developing World APPENDIXES     A   Workshop Agenda   301 B   Defining Developing Countries   305 C   The Essential Competencies of a Skilled Birth Attendant   310 D   Committee Biographies   314 E   Dissenting Note   320 GLOSSARY   324 ACRONYMS   334 INDEX   337

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Improving Birth Outcomes: Meeting the Challenge in the Developing World IMPROVING BIRTH OUTCOMES MEETING THE CHALLENGE IN THE DEVELOPING WORLD

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