1
Introduction

The death of a mother, fetus, or neonate is tragic whenever it occurs. While relatively rare in the industrialized world, maternal, fetal, and neonatal deaths occur disproportionately in developing countries. In some industrialized countries, a woman’s lifetime risk of dying as a result of pregnancy in childbirth is 1 in 5,000. In the least-developed countries, a woman’s lifetime risk of maternal death is 1 in 11. Overall, developing countries account for the vast majority of the 515,000 maternal deaths (World Health Organization, United Nations Children’s Fund, United Nations Population Fund, 2001), 4 million fetal deaths (beyond 22 weeks’ gestation), and 4 million neonatal deaths that occur each year, according to conservative estimates (Save the Children, 2001). The majority of these deaths are preventable.

The crucial period discussed in this report, from late pregnancy through the first month of the child’s life, has received inadequate attention in the health care programs of most countries. Mother-child programs initially focused on infants and younger children at the expense of women’s health (Rosenfield and Maine, 1985). The Safe Motherhood Initiative began in 1987 to address this gap in programming. However, after more than a decade of increased attention to maternal health care in the developing world, maternal mortality rates have not measurably declined (Weil and Fernandez, 1999; World Health Organization, 1999; AbouZhar and Wardlaw, 2001). Moreover, the fate of the neonate has been neglected (Lawn et al., 2001; Stoll and Measham, 2001; The Child Health Research Project, 1999). Whereas significant reductions in under-5-year mortality



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World 1 Introduction The death of a mother, fetus, or neonate is tragic whenever it occurs. While relatively rare in the industrialized world, maternal, fetal, and neonatal deaths occur disproportionately in developing countries. In some industrialized countries, a woman’s lifetime risk of dying as a result of pregnancy in childbirth is 1 in 5,000. In the least-developed countries, a woman’s lifetime risk of maternal death is 1 in 11. Overall, developing countries account for the vast majority of the 515,000 maternal deaths (World Health Organization, United Nations Children’s Fund, United Nations Population Fund, 2001), 4 million fetal deaths (beyond 22 weeks’ gestation), and 4 million neonatal deaths that occur each year, according to conservative estimates (Save the Children, 2001). The majority of these deaths are preventable. The crucial period discussed in this report, from late pregnancy through the first month of the child’s life, has received inadequate attention in the health care programs of most countries. Mother-child programs initially focused on infants and younger children at the expense of women’s health (Rosenfield and Maine, 1985). The Safe Motherhood Initiative began in 1987 to address this gap in programming. However, after more than a decade of increased attention to maternal health care in the developing world, maternal mortality rates have not measurably declined (Weil and Fernandez, 1999; World Health Organization, 1999; AbouZhar and Wardlaw, 2001). Moreover, the fate of the neonate has been neglected (Lawn et al., 2001; Stoll and Measham, 2001; The Child Health Research Project, 1999). Whereas significant reductions in under-5-year mortality

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World rates and improvements in health indicators such as immunization rates were achieved during the 1990s (United Nations Children’s Fund, 2002), neonatal mortality rates, which currently account for half or more of infant mortality, have declined far less quickly (The Child Health Research Project, 1999; Rutstein, 2000). Over the past 15 years, agencies and researchers working in the field have acquired considerable knowledge about pregnancy and childbirth in low-resource settings. There is increasing agreement on which interventions are most likely to reduce maternal, late fetal, and neonatal mortality. This report reviews the individual—and to a large extent, interdependent—health risks and needs of mothers, fetuses, and neonates and identifies a limited number of interventions to significantly improve birth outcomes1 in developing countries. STUDY PURPOSE AND APPROACH The Centers for Disease Control and Prevention requested that the Institute of Medicine’s Board on Global Health undertake a study to examine the steps needed to improve birth outcomes in the developing world. The National Institute for Child Health and Human Development of the National Institutes of Health and the U.S. Agency for International Development joined the sponsorship of the project. The specific charge to the committee is: Birth outcomes worldwide have improved dramatically in the past 40 years. Yet there is still a large gap between the outcomes in developing and developed countries. This study will address the steps needed to reduce that gap. It will review the statistics of low birth weight and premature infants and birth defects; review current knowledge and practices, identify cost-effective opportunities for improving birth outcomes and supporting families with an infant handicapped by birth problems, and recommend priority research, capacity building, and institutional and global efforts to reduce adverse birth outcomes in developing countries. The committee will base its study on data and information from several developing countries, and provide recommendations that can assist the Centers for Disease Control and Prevention, the National Institute for Child Health and Human Development, and the U.S. Agency for International Development in tailoring their international programs and forging new partnerships to reduce the mortality and morbidity associated with adverse birth outcomes. 1   In this report, a successful birth outcome is defined as the birth of a healthy baby to a healthy mother.

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World The initial discussions of this study convinced the committee and the Board on Global Health of the importance and need for a broader study. As a result, the scope of the study was broadened from neonatal outcomes to maternal, neonatal, and fetal outcomes and building capacity in health care systems. In addition, the discussion of perinatal transmission of HIV/AIDS was expanded to a full chapter. The findings and recommendations of this study are intended to assist policymakers, ministries of health, nongovernmental organizations, and academics in developing countries as well as the four sponsors. The committee also wrote a companion report, Reducing the Impact of Birth Defects: Meeting the Challenge in the Developing World. To conduct the studies, the Institute of Medicine assembled a study committee with broad international expertise in public health, neonatology, obstetrics, genetics, epidemiology, pediatrics, and clinical research. The members of the committee were also chosen for their experience on birth outcomes in a range of developing countries. The committee members are listed at the beginning of the report, and their brief biographies are given in Appendix D. Many health services offered to pregnant women in developing countries are based on traditions and “common wisdom.” Relatively few of these have been demonstrated to be effective and safe. The goal of this study is to provide evidence-based recommendations founded on rigorous evaluations. The data for the study were assembled by the committee, consultants, and staff through bibliographic references on related topics and through databases such as Medline, university libraries, and Internet sites of organizations associated with research and services for birth outcomes. Although much of the published information on birth outcomes in developing countries was found in international and national journals and reports, some of the evidence has appeared in local journals, the proceedings of meetings, and unpublished reports. To tap this knowledge base, the committee enlisted experts with recent research or service experience in developing countries. Data and supportive evidence were provided by these experts through workshop presentations and technical consultation on the report chapters (see Appendix A). The framework for the committee’s examination of birth outcomes included an overview of epidemiological parameters; a review of the current knowledge base on interventions; and a review of the feasibility, cost, and impact of proposed interventions. The combined weight of such evidence, the committee believes, has produced an accurate account of the state of knowledge concerning the epidemiology of neonatal and maternal mortality and morbidity and fetal mortality, prevention and care in developing countries, and the capacity of health care systems to provide appropriate prevention and care with limited resources. Evaluation of the evidence base enabled the committee to identify gaps in knowledge and to propose strategies for a research

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World agenda that would fill these gaps. The findings, strategies, and recommendations included in the report were developed from this broad base of evidence; areas are noted in which the data are inadequate to support definitive conclusions. While the committee explicitly searched for the best evidence available on interventions with the potential to improve birth outcomes, and has built its recommendations on this scientific foundation, a note of caution is in order with regard to the nature and adequacy of the evidence base. The best available evidence is sometimes inadequate for a satisfactory evaluation of the cost and effectiveness of promising health care interventions in developing countries. It is often difficult to generalize the results of studies carried out in developed countries to developing country settings. The results of an intervention can differ from one setting to another, and the delivering of interventions is likely to vary considerably across settings. Thus the committee’s recommendations regarding the effectiveness of certain interventions in different health care systems are informed by expert judgment as well as scientific research. The committee’s research recommendations emphasize the operational research to recognize priority reproductive health problems, identify effective interventions to address these problems, implement the interventions, monitor and assess their effectiveness in diverse settings, and tune them for maximal clinical- and cost-effectiveness. THE SOCIAL, CULTURAL, AND ECONOMIC CONTEXT Reproductive health is defined as a condition in which the reproductive process is accomplished in a state of complete physical, mental, and social well-being, not merely as the absence of disease or disorders (Sciarra, 1993). A decade ago, the introduction of this concept raised awareness of the broad social context in which pregnancy and childbirth take place (Donnay, 2000; Sciarra, 1993; Fathalla, 1991). Clearly, health conditions are influenced by the social and political context of countries and communities, which may directly or indirectly contribute to adverse birth outcomes (Tinker, 2000). While acknowledging the profound influence of sociopolitical factors on birth outcomes and supporting efforts to counteract negative effects, this report focuses on improvements in health care and medical interventions that can produce a more rapid reduction in maternal, neonatal, and fetal mortality. However, it is clear that to be successful, such interventions must be not only clinically effective but also appropriate to the setting in which they are implemented. The following general descriptions of the major social, cultural, and economic influences on birth outcomes are therefore intended to set the stage for the specific discussions of interventions that

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World appear in subsequent chapters of this report, and to place the committee’s recommendations within a broader context. Poverty Economic factors operating at all levels—from the international to the personal—affect the health status of individuals (Hales et al., 1999). The immediate effects of weak national and local economies on birth outcomes are predictable: limited resources typically reduce the availability of good-quality health services, including obstetric and neonatal care (The Prevention of Maternal Mortality Network, 1992). Family income has been shown to be highly correlated with perinatal mortality in India (Saksena and Srivastava, 1980) and Brazil (Barros et al., 1987), with women from the poorest families having a fetal death rate two to four times higher than that of women from the richest families. A study of 11 Latin American countries found that the late fetal death (stillbirth) rate in free hospitals was nearly twice that in hospitals requiring payment for services (Gadow et al., 1991). And high infant mortality is, not surprisingly, associated with low per capita gross domestic product (GDP) and with income inequalities (Hales et al., 1999). Yet a few countries with low per capita GDP have developed good health services and low infant mortality rates (IMRs). Sri Lanka is a particularly strong example, with a per capita GDP of US$700, a high female literacy rate, and an IMR of 16 per 1,000 live births (Robinson and Wharrad, 2000). Cuba, the poorest country after Haiti in Latin America and the Caribbean, reduced infant mortality from 47 per 1000 live births in 1969 to 19 in 1981 and to 11 in 1990 (Swanson et al., 1995). A program for diagnosis and prevention of genetic diseases was introduced in 4 provinces in 1981 and expanded to include all 14 provinces by 1990. Infectious disease Two health problems that profoundly affect birth outcomes—exposure to infectious disease and poor nutrition—are both strongly associated with poverty. At a national level, limited resources for health care restrict prevention and treatment of infectious diseases. Even where health services are available, many women may not be able to afford them. The burden of infectious disease affecting pregnant women is high in developing countries. A strong association has been found between unhygienic conditions, which increase the risk of infection, and maternal and infant mortality (Hertz et al., 1994). HIV infection is a worldwide crisis, but its prevalence and lack of treatment are most significant in developing countries. Other reproductive tract infections associated with poor outcomes, including sexually transmitted diseases (STDs) and vaginal infections, are also highly prevalent in

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World developing countries (National Research Coucil, 1997). Some family planning, antenatal, and maternal and child health clinics in the developing world report that as many as two women in every ten treated are infected with an STD (Cooperative for Assistance and Relief Everywhere, 1997). Moreover, the level of non-STD reproductive tract infections, such as bacterial vaginosis, is thought to be considerably higher than that of traditional STDs among women in developing countries (Bang et al., 1989; National Research Council, 1997; Singh et al., 1995; Younis et al., 1993). Poverty, low status, racism, social upheaval, and migration all contribute to high-risk sexual behaviors that lead to STDs (Aral and Holmes, 1990). Demographic and social characteristics such as young age, living in a community where women outnumber men (because of war or the lack of local employment), and gender inequality in sexual relationships further compound the risk for STDs. Poverty is associated with additional risk factors for reproductive tract infections: substance abuse, commercial sex, poor access to health care, and young age at the time of first intercourse (National Research Council, 1997). Nutrition A healthy diet has long been associated with a successful pregnancy. Malnourished mothers are at increased risk for complications and death during pregnancy and childbirth. In addition, their children are likely to have low birth weight, fail to grow at a normal rate, and have higher rates of disease and early death (Tinker, 2000; United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition, 1994). Poor maternal nutritional status, characterized by low energy intake, low gestational weight gain, low maternal prepregnancy body-mass index (BMI), and short stature, are major contributors to IUGR in developing countries (Allen et al., 1994). A longitudinal study in rural India found that a combination of poverty and a low-quality diet—conditions that tend to occur together—was associated with a significant risk for fetal death (Agarwal et al., 1998). Women’s Education and Socioeconomic Status Maternal education, literacy, and overall socioeconomic status are powerful influences on the health of both mother and newborn (Biciego and Boerma, 1993; Victora et al., 1992; World Bank, 1993; van Ginneken et al., 1996; Harrison, 1985). Formal and health education of girls can guide women of reproductive age to seek preventive services, increase food intake during pregnancy, reduce tobacco and alcohol use, understand the implications of danger signs during labor and delivery, and seek referral care for

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World obstetric and/or newborn complications. Moreover, the benefits of girls’ education extend from one generation to the next, because the children of educated women tend to be healthier and better educated (Hertz et al., 1994). In particular, female literacy has been found to be a strong predictor of family size and birth spacing, which, as discussed below, strongly affect birth outcomes (Hertz et al., 1994). The gap between female and male literacy in the developing world is significant; in 1990, 18 countries were found to have a female literacy rate less than half that of males (United Nations Children’s Fund, 1995). Multiple regression analyses of global data compiled by the United Nations revealed that the combination of GDP and female literacy accounted for 80 percent of the variation in infant mortality rates among 155 countries, and that female literacy appeared to be a factor underlying global variation in the proportion of health personnel (physicians and nurses) in populations (Robinson and Wharrad, 2000). The educational level of women relative to men in a society both determines and is determined by the degree of autonomy and power of women. These circumstances also influence societal trends (discussed below) in age at marriage and pregnancy, planned or intended pregnancy, and domestic violence. A cross-national analysis of status indicators, such as women’s level of education relative to men, age at first marriage, and contraceptive prevalence, showed that all of these factors are in large measure associated with maternal mortality, even after controlling for wealth and economic growth (Shen and Williamson, 1999). Where women’s socioeconomic status is low, maternal mortality tends to be higher, and fewer provisions are made for obstetric emergencies (Shen and Williamson, 1999; The Prevention of Maternal Mortality Network, 1992). Gender inequality has also been demonstrated in child mortality rates, nutrition, and health-seeking behavior in developing countries (Institute of Medicine, 1996; Tursz and Crost, 1999). Unintended Pregnancy Unintended pregnancy is a global problem with many ramifications that include adverse birth outcomes. Worldwide estimates indicate that between 100 and 150 million married women want to postpone or stop childbearing, but lack access to family planning services (Germain, 2000; Cooperative for Assistance and Relief Everywhere, 1997; Dixon-Mueller and Germain, 1992). If women who want no more children could stop having them, it has been estimated that the number of births would be reduced by an average of 35 percent (4.4 million annually) in Latin America, 33 percent (24.4 million) in Asia, and 17 percent (4 million) in Africa. Maternal and infant mortality would also be expected to decline because

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World many of the prevented pregnancies would have produced high-risk births, or been terminated by unsafe abortion (Sciarra, 1993). Many barriers, including a lack of quality family planning services, prevent women from controlling their own reproduction. These include poverty, lack of education, and low social status (Germain, 2000). A study based on data from the Demographic and Health Surveys revealed that, because of the combination of a lack of information on family planning, inadequate services, and low literacy, many women do not know enough about the health effects of various contraceptive measures to make informed choices (Bongaarts and Bruce, 1995). In several surveys, women frequently reported that they did not use contraception because of their husband’s disapproval (National Research Council, 1997). Although conventional family planning services are available in many developing countries, the contraceptive measures most frequently provided—contraceptive sterilization and intrauterine devices (IUDs)—are inappropriate for adolescents (Germain, 2000). The most direct consequence of unplanned pregnancy is the estimated 20 million unsafe abortions performed each year (Berer, 2000). About 90 percent of unsafe abortions occur in developing countries (World Health Organization, 1994). Complications from unsafe abortions are thought to cause about 80,000 or more maternal deaths per year (Berer, 2000). The legal status of the procedure is the most important determinant of access to safe abortion. More than 170 million women live in developing countries where most abortions are illegal; these include countries in Central and West Africa, South Asia (other than India), the Middle East, and South America (National Research Council, 1997). Maternal Age and Parity Four social factors have been associated with an increased risk of infant death: a mother older than 35; a very young (early adolescent) mother; birth intervals of less than 2 years; and four or more older children (Cooperative for Assistance and Relief Everywhere, 1997). Advanced maternal age has consistently been associated with increased risk for fetal and early neonatal deaths (Nybo Andersen et al., 2000; Murphy et al., 1987; Onadeko et al., 1996; Stanley and Stratton, 1981; Saksena and Srivastava, 1980; Barros et al., 1987). A significant proportion of fetal deaths is caused by chromosomal anomalies, which are more prevalent in the offspring of women older than 35. In some developing countries, many women—due to cultural norms, lack of access to birth control, or both—continue to bear children until they reach menopause, resulting in an increase in the crude prevalence of autosomal trisomies such as Down syndrome. Uterine dysfunction, which can result in obstructed labor (an important cause of maternal, fetal, and neonatal morbidity and mortality), also increases after age 25 (Main et al., 2000).

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World Young maternal age has been associated with increased risk for early neonatal death (Barros et al., 1987; Saksena and Srivastava, 1980) and infant death (Murphy et al., 1987), but the relationship between young maternal age and fetal death is uncertain (Onadeko et al., 1996; Saksena and Srivastava, 1980). Poor pregnancy outcomes in teenage mothers may result from social and behavioral influences, rather than from a direct biological effect (Hardy et al., 1987), though biological factors may play a role in very young mothers. Traditions in many developing countries promote early marriage and frequent childbearing. In the least-developed countries, fertility rates exceed five births per woman (United Nations Population Fund, 2002). Over the years research findings have suggested an association between longer birth intervals of at least 2 years and reduced infant and child mortality. In recent years, there has been a renewed interest in examining the potential association of birth intervals with infant/child/maternal mortality, morbidity, and nutrition status. Several new studies, some with conflicting findings, have examined the association of longer birth intervals with perinatal and neonatal health. Controlling for demographic and SES variables, and using global data, Rutstein found that birth intervals defined as birth to birth of three to five years are associated with improvements in infant/child survival and nutrition status (Rutstein, 2000). The analysis found that at intervals of two years, infants and children are still at risk. This study was based on data from 18 countries and assessed the outcomes of more than 430,000 pregnancies. Conde-Agudelo analyzed the relationship between pregnancy intervals and perinatal health. The study found that birth intervals of 27–32 months compared to shorter intervals are associated with reduced risk of very preterm and preterm delivery, fetal death, low birth weight, and early neonatal death. This analysis used CLAP data on over 1 million pregnancies (Conde-Agudelo, 2000; Setty-Venugopal and Upadhyay, 2002). Similarly, a recent study by Smith and colleagues based on Scottish data found that a short interpregnancy interval (less than 6 months) was an independent risk factor for extremely preterm birth, moderately preterm birth and neonatal death unrelated to congenital abnormality (Smith et al., 2003). Another study in Sweden has found that short interpregnancy intervals appear not to be causally associated with increased risk of stillbirth and early neonatal death, whereas long interpregnancy intervals were associated with increased risk of stillbirth and possibly early neonatal death (Stephansson et al., 2003). With respect to the association of birth intervals with maternal mortality and morbidity, only one large-scale analysis has been undertaken. This study (Conde-Agudelo, 2000), using data from the Latin American Center for Perinatalogy and Human Development, found that birth intervals of less than 15 months are associated with increased risk (150 percent) of

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World maternal mortality. Intervals of more than 5 years are associated with increased risk of eclampsia. This study was based on pooled data from 19 countries, with a sample size of just over 450,000 women, and took into account approximately 15 confounding factors. Cultural Barriers to Obstetric and Neonatal Care Life-threatening pregnancy and childbirth complications frequently go unrecognized in developing countries. Pregnancy is widely considered to be a time of well-being; complications may be viewed as fated, or even brought on by a woman’s misbehavior. Where such beliefs prevail, women and traditional birth attendants tend to perceive obstetric complications as supernatural in origin, and best treated through traditional means (National Research Council, 1997; The Prevention of Maternal Mortality Network, 1992). Because of the expectation of high fetal and neonatal mortality, parents in developing countries may not seek care for their very young offspring. When women and their families recognize the need to seek obstetric or neonatal care, the concern that care will be of poor quality is a barrier to seeking treatment (Ross, 1998; National Research Council, 1997). Those who reach an appropriate medical facility may also find that differences in language, behavior, and expectations between a woman experiencing complications and the medical staff can limit her access to care (The Prevention of Maternal Mortality Network, 1992). Domestic Violence Domestic violence is shockingly pervasive, yet hidden in most societies (Bunch 1997; Shaikh, 2000; Jewkes, 2000). A recent global survey of data on the sexual coercion and abuse of women in marriage and other intimate relationships revealed that at least one woman in three has been beaten, coerced into sex, or abused—most often by a member of her family (Germain, 2000). In addition to violating a woman’s fundamental rights, such violence may inhibit her use of contraceptives, keep her from seeking health services, or cause her to become infected with a sexually transmitted disease, among other health risks (Germain, 2000). Violence has been linked to increased risk of pregnancy complications, including fetal death, preterm labor, fetal distress, and preterm birth, as well as to teenage pregnancy (Jewkes, 2000; Murphy et al., 2001; Bullock and McFarlane, 1989; Jejeebhoy, 1998; World Bank, 1993; Jewkes et al., 2001). Natural Disasters and Political Conflicts In 1999, about one-third of the world’s population was affected by floods, earthquakes, and other natural disasters; nearly 14 million people

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World were estimated to be living as refugees and another 20 million displaced within their own countries, largely as a result of political conflict (World Health Organization, 2001). Such crises undoubtedly compound the effects of poverty on maternal, fetal, and neonatal mortality as a result of hardship and suffering, as well as by further limiting access to health care. The magnitude of this problem is poorly documented, however. Most refugees from armed conflict flee from one developing country to another that can ill afford to provide health care for a refugee population (Southall and Abbasi, 1998). Approximately one-quarter of refugees are women of reproductive age (Jamieson et al., 2000). One of the few studies of pregnancy outcomes among refugee women found that poor outcomes were common in a Burundian refugee camp in Tanzania, with neonatal and maternal deaths accounting for 16 percent of all mortality. More than 22 percent of births to refugees were low birth weight, as compared with the Tanzanian national average of 14 percent (Jamieson et al., 2000). Poor health and birth outcomes have also been shown in Sarajevo (Carballo et al., 1996). As a result of such findings, reproductive health is increasingly recognized as an important component of refugee health. The United Nations High Commissioner for Refugees has stated that “while food, water and shelter remain a priority, reproductive health care is among the crucial elements that give refugees basic human welfare and dignity that is their right” (Marie Stopes International, 1998). ADVERSE BIRTH OUTCOMES Inadequate Data on Birth Outcomes The true magnitude of death, disease, and injury associated with poor birth outcomes in developing countries is not known. Most of the countries with the highest estimated maternal and perinatal mortality rates also have the lowest vital registration coverage (The Child Health Research Project, 1999). Only about one-quarter of the world’s births (and if China were excluded, less than 7 percent) are recorded by civil registration systems for the purpose of monitoring maternal mortality (AbouZhar and Wardlaw, 2001). Similarly, the majority of early neonatal deaths and almost all fetal deaths in developing countries—many of which occur at home—are not registered, rendering them invisible to health leaders (Jewkes and Wood, 1998; Lumbiganon et al., 1990; McCaw-Binns et al., 1996). This situation is further complicated by a lack of consistent international definitions of neonatal mortality and by local cultural practices regarding the recognition of early deaths (Jewkes and Wood, 1998; Lumbiganon et al., 1990). In some settings, for example, children are not named nor are their births recognized until after they have survived for up to 40 days (Lawn et al., 2001; Stoll and Measham, 2001). As a result of all of these factors, preg-

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World and even if they are, many women in rural areas lack access to a medical facility with good quality obstetric services (World Health Organization, 1998). Their way may be barred by the lack of 24-hour, good-quality essential services and the lack of affordable transportation, lack of recognition of the need for skilled medical care, or the cost of needed services. Or, having reached a medical facility, they may receive inappropriate care due to inadequate staffing, training, or medical supplies. Similarly, few neonates in the rural areas of developing countries receive medical care (Bang et al., 2001). Building accessible, acceptable, cost-effective health services capable of improving birth outcomes will require appropriate models of health care, national leadership, and support at all levels, from individual communities to international collaborations. Surveillance of maternal, fetal, and neonatal mortality is needed to establish the magnitude of the problem and support the identification and evaluation of interventions to improve birth outcomes. Three Additional Neonatal Challenges This report includes discussions of three conditions that pose additional challenges to neonatal health in developing countries: low birth weight (LBW), birth defects, and HIV/AIDS. Each is associated with medical, social, and cultural risk factors that influence its prevalence and severity. In that sense, these conditions can be viewed not simply as isolated causes of neonatal death but as embodiments of the broad range of circumstances that contribute to poor birth outcomes in developing countries. Data on the worldwide prevalence of LBW (birth weight of <2500 grams) are limited. Estimates based on UNICEF and WHO data for 1995-1999 indicate that 20.4 million LBW infants were born each year (Save the Children, 2001). WHO estimates that LBW affects 17 percent of neonates in developing countries and 6 percent in developed countries (Save the Children, 2001). An infant may be LBW as a result of either intrauterine growth restriction (IUGR) or preterm delivery (<37 weeks). Where LBW rates are highest, the proportion of LBW due to IUGR is also highest (World Health Organization, 1995). IUGR increases the risk of fetal and infant mortality, can negatively affect health and development during infancy and childhood, and may increase the risk of developing certain chronic diseases during adulthood (Barker, 1992; Leon, 1998; Woelk et al., 1998). More than 4 million children are born each year with birth defects. As infant mortality and morbidity are reduced through the control of infectious diseases, birth asphyxia, and other causes, the relative contribution of birth defects to the burden of disease in developing countries is expected to

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World increase. Risk factors for birth defects that may be higher in developing countries include infectious diseases and nutrient deficiencies (Van Allen and Hall, 1996; Population Reference Bureau, 2002). Worldwide, half of HIV-infected adults are women, mostly of childbearing age (Joint United Nations Programme on HIV/AIDS, 2002) who can transmit HIV to their children in utero, during childbirth, or through breastfeeding. Mother-to-child transmission results in an estimated 800,000 new HIV infections each year (Mofenson, 1997; Joint United Nations Programme on HIV/AIDS, 2002). In sub-Saharan Africa and other regions with high HIV prevelance, about one in three children born to mothers with HIV become infected (Brocklehurst, 2002; De Cock et al., 2000); by contrast, vertical transmission of HIV in developed countries can be reduced to less than 5 percent through antenatal HIV testing and antiretroviral therapy (Carneiro et al., 2001; Bulterys and Fowler, 2000). Child Survival and Safe Motherhood Leaders and policymakers concerned with maternal and child health have long emphasized the need to reduce both early childhood mortality and, more recently, maternal mortality. A brief history of the two major initiatives toward these goals—those in child survival and safe motherhood—is provided here, as this study recommends building on their successes. This report highlights the common ground between these historically separate initiatives and recognizes the interdependence of maternal and child health during pregnancy, childbirth, and early infancy. It also emphasizes the fates of the fetus and neonate, which have been largely overlooked by child and maternal health programs. The Child Before the 1980s, international health care programs emphasized primary health care for a broad range of ages, diseases, and levels of clinical care. A shift in the early 1980s toward strategies targeting diseases that caused the highest percentage of death and illness and for which effective prevention and treatment measures existed, and toward populations with disproportionately high mortality rates, resulted in an increased flow of health resources to children and infants (Murphy et al., 1997). Under this approach, and aided by overall improvements in sanitation and access to health care, under-5 child mortality declined by more than one-third in two decades beginning in the late 1970s (Tulloch, 1999). Amid these gains, however, it became clear that child health programs needed to go beyond single diseases and address the overall health of the child. The child survival initiative focused at first on growth monitoring,

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World oral rehydration, breastfeeding, and immunization, then expanded to encompass food, female education, and family planning (United Nations Children’s Fund, 1997). WHO, working with UNICEF and other agencies, institutions, and individuals, also developed a strategy for the combined treatment of major childhood illnesses in children under 5 known as Integrated Management of Childhood Illness (IMCI) (Tulloch, 1999). The IMCI strategy includes a basic set of prevention, early diagnosis, and treatment measures for acute respiratory infections (ARI), diarrhea, measles, malaria, and malnutrition (Pan American Health Organization, 1999; Tulloch, 1999). A community component of the program coordinates efforts to promote child health and assists families in caring for sick children at home (Pan American Health Organization, 1999). Although IMCI began in 1995 and is underway in more than 41 countries (World Health Organization, 1997), published trials have yet to demonstrate the effectiveness of IMCI measures in reducing child mortality. Although infant mortality has decreased along with mortality of under-5-year-olds, most gains have been made among children of more than 2 months of age. Since its outset, IMCI has addressed few of the major causes of neonatal and fetal mortality. The most recent guidelines on the integrated management of pregnancy and childbirth include health priorities for infants as young as one week (Gupta et al., 2000). However, these guidelines do not address the major causes of mortality for neonates in the first week of life, nor do they address fetal mortality. The Mother In 1985, Rosenfield and Maine published an influential article entitled “Where is the ‘M’ in MCH?” They asserted that the problem of pregnancy-related deaths in developing countries had been neglected by maternal and child health (MCH) care. To focus on the problem of maternal deaths, the Safe Motherhood Initiative was launched at a Nairobi conference in 1987. Partners in the initiative included UNICEF, the United Nations Development Program (UNDP), the United Nations Population Fund, the World Bank, WHO, the International Planned Parenthood Federation, and the Population Council. Together these agencies set an ambitious goal of reducing maternal mortality worldwide by 50 percent within a decade. They proposed meeting this goal by implementing an integrated approach to maternal health care within primary care, with an emphasis on care and education at the community level (World Health Organization, 1998). While the Child Survival Initiative through the United States Agency for International Development (USAID) has a specific focus, safe motherhood issues are much broader, encompassing family planning, antenatal care, clean and safe delivery, essential obstetric care, basic maternity care, primary health care, and equity for women. Within numerous maternal and

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World child health care programs, this lack of a strategic focus has contributed to the lack of progress toward reducing maternal mortality (Maine and Rosenfield, 1999; Weil and Fernandez, 1999). Additional reasons include the pursuit of some strategies that proved ineffective (such as large-scale training of traditional birth attendants and the focus on antenatal screening alone to identify high-risk pregnancies) and a lack of political commitment and resources (World Health Organization, 2000). It is important to note, however, that the measurement of maternal mortality has improved in recent years, so direct comparisons cannot be made between today’s more accurate estimates and previous underestimates of this indicator (as discussed above) (AbouZhar and Wardlaw, 2001). Recognizing the importance of integrating maternal and neonatal care, WHO introduced the Mother-Baby Package, a cluster of interventions including family planning to prevent unwanted and mistimed pregnancies, basic maternity care for all pregnancies, special care for the prevention and management of complications during pregnancy, and delivery and postpartum care for mother and newborn (World Health Organization, 1998). In 2000, drawing on the research findings and evaluations of the safe motherhood initiative, WHO launched a 5-year program, the Making Pregnancy Safer initiative. This initiative stresses specific health sector actions, including family planning, antenatal care, the presence of a skilled attendant at every birth, referral centers providing good-quality obstetric services, and basic postpartum care (World Health Organization, 2000). These interventions focus on essential care during pregnancy and childbirth, and bring attention to the fetus and neonate. The (Missing) Neonate and Fetus Increasing numbers of children are surviving their first year, but these gains have mostly favored infants of more than a month, and certainly more than a week old (The Child Health Research Project, 1999). Based on data from the Demographic and Health Surveys from 1986 through 1998, approximately two-thirds of under-5 deaths in developing countries occurred to infants (less than 1 year old); among these infants, nearly two-thirds were neonates (less than 1 month old); and among these neonates, nearly two-thirds were less than 1 week old (World Health Organization, 1996). These figures approximate recent estimates by WHO based on data from 1995, which indicate that neonatal mortality accounts for nearly 60 percent of infant mortality (Save the Children, 2001). The importance of reducing neonatal and fetal mortality has only recently begun to be acknowledged, however. Very few field programs have addressed the neonate and estimates of the global burden of disease do not include late fetal deaths as a component of the burden. Early steps are being taken toward an initiative that would specifically

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World target neonatal and fetal mortality (The Child Health Research Project, 1999; Save the Children, 2000, 2003). Recent grants from the Bill and Melinda Gates Foundation support international programs directed at improving neonatal health, including UNICEF’s maternal and neonatal tetanus immunization program and the Saving Newborn Lives Initiative coordinated by Save the Children (Save the Children, 2001; Gates Foundation, 2003). This report recommends cost-effective interventions already shown to reduce neonatal and fetal mortality. Such interventions can be added to or emphasized in existing maternal and child health programs, but it will also be necessary to expand the current focus of the child survival and safe motherhood initiatives to fully recognize and address the issue of improving neonatal health. ORGANIZATION OF THE REPORT This report is organized in four parts. The Executive Summary and this introduction constitute Part I. Part II examines—in separate chapters—strategies to improve birth outcomes for mothers (Chapter 2) and neonates (Chapter 3) and to reduce the number of fetal deaths (Chapter 4). Chapters 2 and 3 examine the major causes of mortality and morbidity for mothers and neonates and present findings and interventions to reduce these adverse outcomes. Because the same risk factors underlie many late fetal and early neonatal deaths, and the great majority of them are directly related to the mother’s health during pregnancy and her access to skilled attendance and emergency care in the event of complications, it can be assumed that late fetal mortality would decline significantly if the interventions recommended in Chapters 2 and 3 were implemented. For this reason, the discussion of fetal outcomes follows those of the mother and neonate. Chapter 4 also describes the need for systems to recognize and report fetal deaths, an important first step toward identifying further interventions to reduce fetal mortality. To have the maximum impact on birth outcomes, the interventions recommended in Part II must be implemented within effective health care systems. Part III (Chapter 5) describes the major health care delivery issues related to pregnancy, childbirth, and the neonatal/postpartum period and addresses the implementation of recommended interventions within health care systems and maternal and child programs. Part IV focuses on LBW (Chapter 6), birth defects (Chapter 7), and HIV/AIDS (Chapter 8), three important specific causes of neonatal mortality and morbidity in developing countries. The committee’s findings and recommendations are presented with contextual information in the Executive Summary and the recommendations are highlighted in a box in chapter 9 along with concluding comments.

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World REFERENCES AbouZhar C, Wardlaw T. 2001. Maternal mortality at the end of a decade: signs of progress? Bulletin of the World Health Organization 79(3):561–573. Agarwal DK, Agarwal A, Singh M, Satya K, Agarwal S, Agarwal KN. 1998. Pregnancy wastage in rural Varanasi: relationship with maternal nutrition and sociodemographic characteristics. Indian Pediatrics 35(11):1071–1079. Allen LH, Lung’aho MS, Shaheen M, Harrison GG, Neumann C, Kirksey A. 1994. Maternal body mass index and pregnancy outcome in the Nutrition Collaborative Research Support Program. European Journal of Clinical Nutrition 48(suppl 3):S68–S76. Ananth CV, Berkowitz GS, Savitz DA, Lapinski RH. 1999. Placental abruption and adverse perinatal outcomes. Journal of the American Medical Association 282(17):1646–1651. Aral SO, Holmes KK. 1990. Epidemiology of sexual behavior and sexually transmitted diseases. In: Holmes KK, Mardh P, Sparling PF, Wiesner PJ (eds). Sexually Transmitted Diseases. 2nd edition. New York: McGraw-Hill. Pp. 19–36. Bang AT, Bang RA, Baitule S, Deshmukh M, Reddy H. 2001. Burden of morbidities and the unmet need for health care in rural neonates: a prospective observational study in Gadchiroli, India. Indian Pediatrics 38:952–965. Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O. 1989. High prevalence of gynaecological diseases in rural Indian women. Lancet 1(8629):85–88. Barker DP. 1992. Fetal growth and adult disease. British Journal of Obstetrics and Gynaecology 99(4):275–276. Barros FC, Victora CG, Vaughan JP, Estanislau HJ. 1987. Perinatal mortality in southern Brazil: a population-based study of 7,392 births. Bulletin of the World Health Organization 65(1):95–104. Berer M. 2000. Making abortions safe: a matter of good public health policy and practice. Bulletin of the World Health Organization 78(5):580–592. Biciego GT, Boerma JT. 1993. Maternal education and child survival: a comparative study of survey data from 17 countries. Social Science and Medicine 36(9):1207–1227. Bongaarts J, Bruce J. 1995. The causes of unmet need for contraception and the social content of services. Studies in Family Planning 26(2):57–75. Brocklehurst P. 2002. Interventions aimed at decreasing the risk of mother-to-child transmission of HIV infection. Cochrane Database of Systematic Review (2):CD000102. Bullock LF, McFarlane J. 1989. The birth-weight/battering connection. American Journal of Nursing 89(9):1153–1155. Bulterys M, Fowler MG. 2000. Prevention of HIV infection in children. Pediatric Clinics of North America 47(1):241–260. Bunch C. 1997. The intolerable status quo: violence against women and girls. In: UNICEF, The Progress of Nations 1997, Women Commentary. Available online at http://www.unicef.org/pon97/women1.htm. Carballo M, Simic S, Zeric D. 1996. Health in countries torn by conflict: lessons from Sarajevo. Lancet 348(9031):872–874. Carneiro M, Sanchez A, Maniero P, Angelosante W, Perez C, Vallee M. 2001. Vertical HIV-1 transmission: prophylaxis and pediatric followup. Placenta 22(suppl A):S13–S18. Conde-Agudelo A, Belizan, JM. 2000. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. British Medical Journal 321(7271):1255–1259. Available online at http://bmj.com/cgi/content/full/321/727/1255. Conde-Agudelo A, Belizan JM, Diaz-Rossello JL. 2000. Epidemiology of fetal death in Latin America. Acta Obstetricia et Gynecologia Scandinavica 79(5):371–378. Cooperative for Assistance and Relief Everywhere (CARE). 1997. CARE USA statement on population and reproductive health issues. Available online at http://www.care.org/programs/health/repro_policy.html.

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, Alnwick DJ, Rogers M, Shaffer N. 2000. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. Journal of the American Medical Association 283(9):1175–1182. Dixon-Mueller R, Germain A. 1992. Stalking the elusive “unmet need” for family planning. Studies in Family Planning 23:330–335. Donnay F. 2000. Maternal survival in developing countries: what has been done, what can be achieved in the next decade. International Journal of Gynaecology and Obstetrics 70(1):89–97. Fathalla MF. 1991. Reproductive health: a global overview. Annuals of the New York Academy of Sciences 626:1–10. Gadow EC, Castilla EE, Lopez Camelo J, Queenan JT. 1991. Stillbirth rate and associated risk factors among 869,750 Latin American hospital births 1982-1986. International Journal of Gynaecology and Obstetrics 35(3):209–214. Gates Foundation. 2003. Available online under Global Health, Grants, 1994-1999, at http://www.gatesfoundation.org/. Germain A. 2000. Population and reproductive health: where do we go next? American Journal of Public Health 90(12):1845–1847. Gupta R, Sachdev HP, Shah D. 2000. Evaluation of the WHO/UNICEF algorithm for integrated management of childhood illness between the ages of one week to two months. Indian Pediatrics 37(4):383–390. Hales S, Howden-Chapman P, Salmond C, Woodward A, Mackenbach J. 1999. National infant mortality rates in relation to gross national product and distribution of income. Lancet 354(9195):2047. Hardy JB, King TM, Repke JT. 1987. The Johns Hopkins adolescent pregnancy program: an evaluation. Obstetrics and Gynecology 69:300. Harrison K. 1985. Childbearing, health and social priorities: a survey of 22,774 consecutive hospital births in Zaria, northern Nigeria. British Journal of Obstetrics and Gynaecology 92(suppl 5):1–119. Hertz E, Hebert JR, Landon J. 1994. Social and environmental factors and life expectancy, infant mortality, and maternal mortality rates: results of a cross-national comparison. Social Science and Medicine 39(1):105–114. Institute of Medicine (IOM). 1996. In Her Lifetime. Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: National Academy Press. Jamieson DJ, Meikle, SF, Hillis SD, Mtsuko D, Mawji S, Duerr A. 2000. An evaluation of poor pregnancy outcomes among Burundian refugees in Tanzania. Journal of the American Medical Association 283(3):397–402. Jejeebhoy SJ. 1998. Associations between wife-beating and fetal and infant death: impressions from a survey in rural India. Studies in Family Planning 29(3):300–308. Jewkes R. 2000. Violence against women: an emerging health problem. International Clinical Psychopharmacology 15(suppl 3):S37–S45. Jewkes R, Vundule C, Maforah F, Jordaan C. 2001. Relationship dynamics and teenage pregnancy in South Africa. Social Science and Medicine 52(5):733–744. Jewkes R, Wood K. 1998. Competing discourses of vital registration and personhood: perspectives from rural South Africa. Social Science and Medicine 46(8):1043–1056. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2002. Report on the global HIV/ AIDS Epidemic–July 2002. Geneva: UNAIDS. Available online at http://www.unaids.org/epidemic_update/report_july02/. Koblinsky M, Conroy C, Kureshy N, Stanton ME, Jessop S. 2000. Issues in Programming for Safe Motherhood. Arlington, VA: MotherCare/John Snow, Inc.

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World Lawn J, McCarthy BJ, Ross S. 2001. The Healthy Newborn: A Reference Manual for Program Managers. Atlanta, GA: CDC/CARE. Leon DA. 1998. Fetal growth and adult disease. European Journal of Clinical Nutrition 52:S72–S82. Li XF, Fortney JA, Kotelchuk M, Glover LH. 1996. The postpartum period: the key to maternal mortality. International Journal of Gynaecology and Obstetrics 54:1–10. Lumbiganon P, Panamonta M, Laopaiboon M, Pothinam S, Patithat N. 1990. Why are Thai official perinatal and infant mortality rates so low? International Journal of Epidemiology 19(4):997–1000. Main DM, Main EK, Moore DH II. 2000. The relationship between maternal age and uterine dysfunction: a continuous effect throughout reproductive life. Americam Journal of Obstetrics and Gynecology 182(6):1312–1320. Maine D, Rosenfield A. 1999. The Safe Motherhood Initiative: why has it stalled? American Journal of Public Health 89(4):480–482. Marie Stopes International. 1998. Reproductive Health Care in Refugee Settings. London: Marie Stopes International and the Women’s Commission for Refugee Women and Children. McCaw-Binns AM, Fox K, Foster-Williams KE, Ashley DE, Irons B. 1996. Registration of births, stillbirths and infant deaths in Jamaica. International Journal of Epidemiology 25(4):807–813. Mofenson LM. 1997. Mother-child HIV-1 transmission: timing and determinants. Obstetrics and Gynecology Clinics of North America 24(4):759–784. Murphy MFG, Botting BJ, Gedella B. 1987. Analysis of perinatal and infant mortality adjusted by exclusion of deaths from congenital malformations. Community Medicine 9:129–140. Murphy H, Stanton B, Galbraith J. 1997. Prevention: Environmental Health Interventions to Sustain Child Survival-Applied Study No. 3. Environmental Health Project. Washington, DC: USAID. Murphy CC, Schei B, Myhr TL, Du Mont J. 2001. Abuse: a risk factor for low birth weight? A systematic review and meta-analysis. Canadian Medical Association Journal 164(11): 1567–1572. National Research Council (NRC). 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: National Academy Press. Nybo Andersen AM, Wohlfart J, Christens P, Olsen J, Melbye M, 2000. Maternal age and fetal loss: a population-based register linkage study. British Medical Journal 320(7251): 1708–1712. Onadeko MO, Avokey F, Lawoyin TO. 1996. Observations of stillbirths, birthweight and maternal haemoglobin in teenage pregnancy in Ibadan, Nigeria. African Journal of Medicine and Medical Sciences 25(1):81–86. Pan American Health Organization (PAHO). 1999. Integrated management of childhood illness (IMCI) “Healthy Children: Goal 2002”. Epidemiology Bulletin. 20(4):3–6. Available online at http://www.paho.org/English/SHA/be994imci.htm#intro. Population Reference Bureau. 2002. 2002 World Population Data Sheet of the Population Reference Bureau: Demographic Data and Estimates for the Countries and Regions of the World. Ramakrishnan U, Martorell R, Schroeder DG, Flores R. 1999. Journal of Nutrition 129: 544S–549S. Robinson J, Wharrad H. 2000. Invisible nursing: exploring health outcomes at a global level. Relationships between infant and under-5 mortality rates and the distibution of health professsional, GNP per capita, and female literacy. Journal of Advanced Nursing 32(1): 28–40.

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World Rosenfield A, Maine D. 1985. Maternal mortality—a neglected tragedy. Where is the M in MCH? Lancet 2(8446):83–85. Ross SR. 1998. Promoting Quality Maternal and Newborn Care: A Reference Manual for Program Managers. Atlanta, GA: CARE. Rutstein, S. 2000. Effect of birth intervals on mortality and health: multivariate cross-country analyses. Macro International. Rutstein SO. 2000. Factors associated with trends in infant and child mortality in developing countries during the 1990s. Bulletin of the World Health Organization 78(10):1256–1270. Saksena DN, Srivastava JN. 1980. Biosocial correlates of perinatal mortality: experiences of an Indian hospital. Journal of Biosocial Science 12(1):69–81. Save the Children. 2000. Saving Newborn Lives. Strategic Workshop Summary Report. Washington, DC: Save the Children. Save the Children. 2001. State of the World’s Newborns. Web page. Available online at http://www.savethechildren.org/mothers/newborns/. Save the Children. 2003. The Saving Newborn Lives Initiative. Web Page. Available online at http://www.savethechildren.org/mothers/learn/newborn.htm. Sciarra JJ. 1993. Reproductive health: a global perspective. American Journal of Obstetrics and Gynecology 168(6 Pt 1):1649–1654. Seoud MA-F, Nassar AH, Usta IM, Melhem, Z, Kazma A, Khalil AM. 2002. Impact of advanced maternal age. American Journal of Perinatology 19(1):1–7. Setty-Venugopal V, Upadhyay UD. 2002. Birth spacing: three to five saves lives. Population Reports L(13). Shaikh MA. 2000. Domestic violence against women—perspective from Pakistan. Journal of the Pakistan Medical Association 50(9):312–314. Sheiner E, Hallak M, Shoham-Vardi I, Goldstein D, Mazor M, Katz M. 2000. Determining risk factors for intrapartum fetal death. Journal of Reproductive Medicine 45(5):419–424. Shen C, Williamson JB. 1999. Maternal mortality, women’s status, and economic dependency in less developed countries: a cross-national analysis. Social Science and Medicine 49(2):197–214. Singh V, Gupta MM, Satyanarayana L, Parashari A, Sehgal A, Chattopadhya D, Sodhani P. 1995. Association between reproductive tract infections and cervical inflammatory epithelial changes. Sexually Transmitted Diseases 22(1):25–30. Smith, GCS et al. 2003. Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. British Medical Journal 327:313. Southall D, Abbasi K. 1998. Protecting children from armed conflict: the UN convention needs an enforcing arm. British Medical Journal 316(7144):1549–1550. Stanley PJ, Stratton JAY. 1981. Teenage pregnancies in Western Australia. Medical Journal of Australia 31:468–470. Stephansson O et al. 2003. The influence of interpregnancy interval on the subsequent risk of stillbirth and early neonatal death. Obstetrics and Gynecology 102(1):101–108. Stoll BJ. 1997. The global impact of neonatal infection. Clinics in Perinatology 24(1):1–21. Stoll BJ, Measham AR. 2001. Children can’t wait: improving the future for the world’s poorest infants. Journal of Pediatrics 139(5):729–733. Swanson KA, Swanson JM, Ayesha EG, Walter C. 1995. Primary care in Cuba: a public health approach. Health Care for Women International 16:299–308. Thaddeus S, Maine D. 1994. Too far to walk: maternal mortality in context. Social Science and Medicine 38(8):1091–1110. The Child Health Research Project. 1999. Reducing Perinatal and Neonatal Mortality. Baltimore: Johns Hopkins School of Public Health.

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World The Prevention of Maternal Mortality Network. 1992. Barriers to treatment of obstetric emergencies in rural communities of West Africa. Studies in Family Planning 23(5):279–291. Tinker A. 2000. Women’s health: the unfinished agenda. International Journal of Gynaecology and Obstetrics 70(1):149–158. Tulloch J. 1999. Integrated approach to child health in developing countries. Lancet 354(suppl 2):SII16–SII20. Tursz A, Crost M. 1999. An epidemiologic study of health-seeking behavior of children under 5 years of age by sex in developing countries [in French]. Revue d’Epidemiologique et de Sante Publique 47(suppl 2):2S133–2S156. United Nations Children’s Fund (UNICEF). 1995. The Progress of Nations, 1995. Wallingford, UK: UNICEF. United Nations Children’s Fund (UNICEF). 1997. Sustainability of the World Summit for Children’s Goals. Concepts and Strategies. New York: UNICEF. United Nations Children’s Fund (UNICEF). 2001. Save the Children: The Saving Newborn Lives Initiative. Available online at http://www.savethechildren.org/mothers/learn/newborn.htm. United Nations Children’s Fund (UNICEF). 2002. The State of the World’s Children 2002. New York: UNICEF. Available online at http://www.unicef.org/sowc02/fullreport.htm. United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition (UNACC/SCN). 1994. Fourth Report on the World Nutrition Situation. Global and Regional Results. Geneva: UNACC/SCN. United Nations Population Fund. 2002. State of the World Population, 2002. Web site. Availble online at http://www.UNFPA.org/swp/swpmain.htm. van Ginneken JK, Lob-Levyt J, Gove S. 1996. Potential interventions for preventing pneumonia among young children in developing countries: promoting maternal education. Tropical Medicine and International Health 1(3):283–294. Van Allen MI, Hall JG. 1996. Congenital anomalies. In: Bennet JC, Plum F (eds). Cecil Textbook of Medicine. Philadelphia: W.B. Saunders Co. Victora CG, Huttly SR, Barros FC, Lombardi C, Vaughan JP. 1992. Maternal education in relation to early and late child health outcomes: findings from a Brazilian cohort study. Social Science and Medicine 34(8):899–905. Weil O, Fernandez H. 1999. Is safe motherhood an orphan initiative? Lancet 354(9182):940–943. Woelk G, Emanuel I, Weiss NS. 1998. Birth weight and blood pressure among children in Harare, Zimbabwe. Archives of Disease in Childhood. Fetal and Neonatal Edition 79:F119–F122. World Bank. 1993. World Development Report 1993. Investing in Health. New York: Oxford University Press. World Health Organization (WHO). 1994. Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion. Geneva: WHO. World Health Organization (WHO). 1995. Maternal anthropometry and pregnancy outcomes: WHO Collaborative Study. Bulletin of the World Health Organization 73(suppl):1–98. World Health Organization (WHO). 1996. Perinatal Mortality: A Listing of Available Information. Geneva: WHO. World Health Organization (WHO). 1997. Improving Child Health—IMCI: The Integrated Approach. Geneva: WHO. World Health Organization (WHO). 1998. Mother-Baby Package: Implementing Safe Motherhood in Countries. Geneva: WHO.

OCR for page 17
Improving Birth Outcomes: Meeting the Challenge in the Developing World World Health Organization (WHO). 1999. Reduction of Maternal Mortality: A Joint WHO/ UNFPA/UNICEF/World Bank Statement. Geneva: WHO. Available online at http://www.who.int/reproductive-health/publications/reduction_of_maternal_mortality/reduction_of_maternal_mortality_contents.htm. World Health Organization (WHO). 2000. Making Pregnancy Safer: A Health Sector Strategy for Reducing Maternal and Perinatal Morbidity and Mortality. Geneva: WHO. World Health Organization (WHO). 2001. Emergency and Humanitarian Action. Geneva: WHO. Available online at http://www.who.int/inf-fs/en/fact090.html. World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA). 2001. Maternal Mortality in 1995: Estimates Developed by WHO, UNICEF and UNFPA. Geneva: WHO. Younis N, Khattab H, Zurayk H, el-Mouelhy M, Amin MF, Farag AM. 1993. A community study of gynecological and related morbidities in rural Egypt. Studies in Family Planning 24(3):175–186. Zhu B-P, Rolfs RT, Nangle BE, Horan JM. 1999. Effect of the interval between pregnancies on perinatal outcomes. New England Journal of Medicine 340:589–594.