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Improving Birth Outcomes: Meeting the Challenge in the Developing World 9 Summing Up: The Way Forward How can procreation in developing countries be made a safe event that results in the birth of a healthy baby to a healthy mother? This is the fundamental challenge for this committee and for readers of this report. Over the last 50 years, the survival of young children has been significantly improved; now it is time to address the health of mothers, fetuses, and neonates. The interventions recommended in this report provide a set of tools for the first stage of this formidable task, focusing on the vast—and to a considerable extent, uncounted—numbers of maternal, neonatal, and fetal deaths that occur in developing countries. The committee’s findings and recommendations are supported by broad knowledge. Some of its conclusions draw on rigorous reviews of randomized trials of individual interventions, while some are founded on less rigorous observational studies of the effectiveness of one or several interventions in health systems. Many of the recommended interventions have been undertaken successfully in countries with limited resources, such as Sri Lanka and Cuba. PRIORITIES Reproductive health care priorities vary with mortality rates and local needs for obstetric and neonatal care and the resources that can be mobilized to meet these needs. Ideally, each country will identify and implement the interventions to improve birth outcomes that best meet its needs and resources. In many settings, it is not realistic to expect that all or even most
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Improving Birth Outcomes: Meeting the Challenge in the Developing World of the strategies recommended in this report can be undertaken simultaneously. Highest priority should then be accorded the report’s first two recommendations, which call for skilled attendance at delivery and, in the event of complications, timely access to good-quality essential obstetric and neonatal care. These interventions address key weaknesses in the health services of many countries that result in high maternal, neonatal, and fetal mortality. These strategies can be further supported through programs of effective antenatal and postpartum care, as specified in two subsequent recommendations. These four recommendations have the potential to greatly improve birth outcomes and can be implemented now. The challenge for developing countries, given their limited resources and important health care needs, is how to most effectively and widely undertake these interventions. The implementation of interventions and development of next steps is addressed in the committee’s final three recommendations, which establish a framework for long-term improvement of birth outcomes based on promising strategies and committed leadership, surveillance of pregnancy- and birth-related mortality and morbidity, and the public health capacity for implementing interventions and monitoring them for clinical- and cost-effectiveness. Surveillance of adverse birth outcomes enables the identification, prioritization, and evaluation of interventions based on evidence of their effectiveness. This process is key to making wise choices among alternative interventions and programs to improve birth outcomes, and is even more crucial where resources are limited. Each country will also need to conduct operational research, as its resources permit, to identify and improve interventions to meet specific needs and expectations. THE SKILLED BIRTH ATTENDANT In this report a “skilled birth attendant” is defined as a midwife, physician, or nurse who has completed nationally recognized professional training and is proficient in basic techniques for clean and safe delivery; recognition and management of prolonged labor, infection, and hemorrhage; and recognition and resuscitation of neonates who fail to initiate respiration at birth. In countries with sufficient resources, the most effective way to reduce maternal, neonatal, and fetal mortality is through education, training, and oversight on clean and safe labor and delivery for qualified health staff and recognition and referral of complicated deliveries. It is important to recognize that past efforts to train and supervise traditional birth attendants (TBAs) have generally not produced birth attendants with the knowledge, skills, and caseload required to manage a normal delivery safely or the ability to promptly address complications by referral to appropriate medi-
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Improving Birth Outcomes: Meeting the Challenge in the Developing World cal care. As a result, high rates of maternal, neonatal, and fetal mortality have continued unabated in primary care programs that rely on TBAs. In some countries it is not possible at this time to provide a midwife, physician, or nurse to attend every birth, and researchers continue to look for ways to provide effective, low-cost care for uncomplicated childbirth. Such services could potentially be provided by caregivers with less formal education and training than a skilled birth attendant, if these caregivers are supervised by skilled staff and under conditions where essential obstetric care is readily accessible. However, any savings gained by reducing the educational requirements for attendance at childbirth may be offset by the attendants’ greater need for supervision, higher demands on essential obstetric care, or inability to reduce mortality during childbirth. A promising trial has been conducted in rural India using trained, supervised village health workers to provide home-based neonatal care (see Box 3-1). Countries seeking the least expensive means to improve birth outcomes are encouraged to undertake similar rigorous trials to determine whether the findings for the rural India trial can be extended to include maternal, as well as neonatal care, and to determine whether this model or some modification thereof can be effective for labor and delivery in different settings. It should be emphasized that the Indian village health workers had 5 to 10 years of formal education; received intensive training in neonatal care, including the identification and treatment of neonatal infections; and were well supervised. The intensively monitored setting of this model is likely to have contributed to its effectiveness. By contrast, there is no rigorous evidence that TBAs (who lack the education, close supervision, and sometimes the training of the village health workers) can be effective in substantially reducing maternal, neonatal, and fetal mortality. ESSENTIAL OBSTETRIC AND NEONATAL CARE Because complications of childbirth are not predictable and increase the risk for adverse outcomes, timely access to good-quality essential obstetric care must be provided to reduce maternal, neonatal, and fetal mortality. The goal of basic and comprehensive essential obstetric care, and of neonatal care emphasizing the diagnosis and treatment of infection, is the prevention of maternal, neonatal, and fetal death. This is in contrast to routine hospitalization for delivery, which is not affordable in many countries where health care resources are severely limited. Basic essential obstetric and neonatal care could be provided in clinics that already exist in many countries if personnel received adequate training. However, significant barriers must be overcome to increase the awareness and need for safe deliveries, especially among women living in rural areas. Successful referral systems in these areas must therefore build good-quality
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Improving Birth Outcomes: Meeting the Challenge in the Developing World essential care that can be available on a 24-hour basis and address care-seeking behavior, communication, transportation, and the cost of services. CONCLUSION This report defines the most pressing health care needs of women, neonates, and fetuses in developing countries. While it also demonstrates the potential to effectively and affordably address those needs, the means of achieving this potential within health care systems are multiple and the choices among them complex. Many factors limit the availability of good-quality health care in developing countries. These include limited financial and human resources for health care, particularly the lack of trained staff and adequate facilities; poverty, and its accompanying burden of infectious disease and malnutrition; illiteracy; widely dispersed populations; and certain cultural and traditional practices that impede effective care. These limitations must be recognized and reflected in the design and implementation of programs to improve maternal, neonatal, and fetal health. Such programs should be tailored to each country’s needs and resources, as well as to the social and cultural context of the health care setting. In general, however, the delivery of good-quality preconceptional, antenatal, obstetric, and neonatal services will require the overall strengthening of primary health care and systems of referral. At the same time, development of these services provides a capacity that strengthens the overall quality of health care. The improvement of birth outcomes therefore represents a key step toward the greater goal of health for all. BOX 9-1 Report Recommendations Improving Birth Outcomes Now Recommendation 1. Every delivery, including those that take place in the home, should be assisted by a skilled birth attendant (a midwife, physician, or nurse) who has been trained to proficiency in basic techniques for a clean and safe delivery; recognition and management of prolonged labor, infection, and hemorrhage; and recognition and resuscitation of neonates who fail to initiate respiration at birth. Where necessary, the birth attendant should also be prepared to stabilize and swiftly refer the mother and/or neonate to a facility providing essential obstetric and neonatal care (Chapters 2 and 3).1 Recommendation 2. Essential obstetric and neonatal care should be accessible to address all complications of childbirth that cannot be managed by a skilled birth 1 This issue is also discussed in Appendix E, Dissenting Note by Dr. Abhay Bang.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World attendant. This requires a network of good quality essential care facilities that provide basic essential obstetric care: administration of antibiotic, oxytocic, and anticonvulsant drugs; manual removal of the placenta; removal of retained products of conception; and assisted vaginal deliveries. Comprehensive essential obstetric care facilities have the capacity to perform these basic services and also surgery and blood transfusion. Services for essential neonatal care should emphasize the diagnosis and treatment of infection. Access for the majority of a population to the appropriate level of care also requires strong referral systems that include communication with, and transportation to, referral facilities (Chapters 2, 3, and 5). Recommendation 3. Postpartum care is critical during the first hours after birth and important throughout the first month. Such care should emphasize: for the mother, the prevention, timely recognition, and treatment of infection, postpartum hemorrhage, and complications of hypertensive disease of pregnancy; and, for the neonate, the prevention, timely recognition, and treatment of infection, thermal control, and promotion and support of early and exclusive breastfeeding (Chapters 2 and 3).2 Recommendation 4. The following strategies are recommended for incorporation into preconceptional and antenatal care: Greater access for women and men of reproductive age to family planning services that provide effective contraception along with counseling on the risks for adverse birth outcomes (Chapter 2). Women should be discouraged from reproducing after age 35 to minimize the risk of chromosomal birth defects such as Down syndrome (Chapter 7). Immunization against rubella for women before they reach reproductive age (Chapter 7). Routine and continuous provision of 400 micrograms of folic acid per day for all women of reproductive age (Chapter 7). Universal iodine fortification of salt (20-50 milligrams of iodine per kilogram of salt) (Chapter 7). Immunization against tetanus for all women of reproductive age (Chapter 3). Intermittent prophylactic and early treatment of malaria especially for primiparae (Chapters 2 and 6). Early detection and timely management of syphilis and other STDs, asymptomatic bacteriuria/urinary tract infection, and tuberculosis (Chapter 3). Counseling of women to limit alcohol consumption during pregnancy (Chapter 7). Intensive counseling and other forms of support to stop smoking during pregnancy (Chapter 6). Early detection and timely management of hypertensive disease of pregnancy (Chapter 2). Counseling of women and their health care providers on locally relevant teratogenic medications to be avoided during pregnancy (Chapter 7). In areas where HIV is a public health problem (seroprevalence exceeds 1 percent), antenatal screening for HIV should be provided to women who, after counseling, give their informed consent. Women who test positive should re 2 See also recommendation 4 with respect to HIV.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World ceive antiretroviral prophylaxis to prevent mother-to-child transmission of the virus, along with appropriate counseling on infant feeding options (Chapter 8). Improving Birth Outcomes in the Future Recommendation 5. Each country should develop a strategy to reduce maternal, neonatal, and fetal mortality, a framework of activities by which this can be accomplished, and the commitment of health leaders to accomplish these goals (Chapter 5). Recommendation 6. To determine the true burden of disease associated with adverse birth outcomes and measure the effectiveness of interventions to address these problems, basic epidemiological and surveillance data must be collected, analyzed, interpreted, and acted upon. Each country should, as resources permit, incrementally develop complete national demographic data and ongoing surveillance of maternal, neonatal, and fetal mortality and morbidity (Chapter 5). Recommendation 7. Each country should strengthen its public health capacity for recognizing and implementing interventions that have proven effective in reducing maternal, neonatal and fetal mortality in similar populations. This also involves monitoring and tuning interventions for clinical- and cost-effectiveness in the local setting (Chapter 5).
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