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Improving Birth Outcomes: Meeting the Challenge in the Developing World Glossary1 Abortion: Abortion is termination of pregnancy (expulsion or extraction of embryo/fetus) before 22 weeks of gestation or below 500 grams. Abruptio placentae: Premature detachment of the placenta, often accompanied by shock, oliguria, and fibrinogenopenia. Anencephaly: Congenital absence of the cranial vault with cerebral hemispheres missing or reduced to small masses attached to the base of the skull. Anemia in pregnancy: Anemia in pregnancy is defined as a hemoglobin concentration of less than 110 g/L. The degree of anemia is classified as moderate (70-109 g/L), severe (40-69 g/L) and very severe (<40 g/L). The corresponding hematocrit values are 24-37 percent, 13-23 percent, and <13 percent respectively. Antepartum fetal deaths: Fetal deaths that occur before labor. Antepartum hemorrhage: Bleeding from the genital tract occurring after the 20th week of pregnancy but before the delivery of the baby. Basic essential obstetric care: The ability of a health institution to perform manual removal of retained placental pieces; assisted vaginal delivery (i.e., 1 Several definitions have been adapted from WHO definitions.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World vacuum extraction), as well as the ability to administer antibiotics, sedatives (Valium, magnesium sulfate) and oxytocics (Ergometrine, Pitocin) IM or IV and IV fluids. It is recommended that there should be four basic obstetric care facilities per 500,000 people. Basic essential obstetrical care facility: Such a facility should manage major obstetric complications (e.g., eclampsia, severe anemia, and diabetes mellitus); monitor labor using a partograph; provide surgical procedures such as assisted delivery, removal of placenta, repair of perineal tears, manual vacuum aspiration; and manage other indirect complications associated with high rates of fetal mortality, including the need to resuscitate an asphyxiated baby. Behavioral change: Characterized as proceeding through four stages—precontemplation, contemplation, action, and maintenance of a behavior—usually toward a healthy behavior. Bilirubin: A breakdown product of heme that normally circulates in plasma as a complex with albumin. It is taken up by the liver cells and conjugated to form bilirubin diglucuronide, which is excreted in bile. Birth asphyxia: Birth asphyxia is characterized by absent or depressed breathing at birth. Birth defect: Any structural or functional abnormality determined by factors operating largely before conception or during gestation. Birth prevalence: The number of individuals who have an attribute or disease at the time of birth divided by the population at risk of having the attribute or disease at the time of birth. Birth weight: The first weight of the baby after birth. The mean birth weight is 3.2 kg. Capacity building: Increasing the ability of a local institution to provide high-quality services appropriate to the local setting, which involves performance assessment and targeted strategies to improve staff competency, logistics, and other determinants of quality of care. Case report and case series: This report or series of reports describe an intervention provided to an individual or a small group and the outcome or outcomes experienced by a by the subject(s).
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Improving Birth Outcomes: Meeting the Challenge in the Developing World Cerclage: A stitch that encircles and holds the incompetent cervix uteri. Cesarean delivery: Abdominal delivery of the baby by laparotomy and section of uterus. Clean delivery: A clean delivery is one that is attended by health staff in a medical institution or by a trained birth attendant at home observing principles of cleanliness (clean hands, clean surfaces, clean cutting of the cord). Comprehensive emergency obstetric care: The ability of a health institution to perform all the basic obstetric care functions, as well as the ability to perform surgery under general anesthesia, remove retained placental pieces, and provide blood replacement. It is recommended that there should be one comprehensive obstetric care facility per 500,000 people. Comprehensive essential obstetrical care facility: The facility should, in addition to providing basic obstetric care services, provide for surgical obstetrics including anesthesia (e.g. cesarean delivery, removal of ectopic pregnancy, laparotomy, repairs of cervical or high vaginal tears), and blood transfusion. Confounder: A characteristic of the study population which is associated with both the risk factor and the outcome. Controlled and uncontrolled observational studies: In a controlled study the researcher observes groups of persons who are exposed or are not exposed to the intervention of interest and compares the occurrence of one or more outcomes in these two groups. An uncontrolled study includes population-based survey, hospital-based studies, demonstration projects, and program reports. Cost-effectiveness analysis: A systematic methodology for the comparison of the overall costs and health benefits of public health interventions. Disability adjusted life years (DALY): An indicator that combines losses from premature death (the difference between the actual age at death and life expectancy in a low mortality population) and loss of healthy life resulting from disability. Developing countries: See Appendix B. Eclampsia: Convulsions and coma occurring in pregnant or puerperal
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Improving Birth Outcomes: Meeting the Challenge in the Developing World women, which are associated with pre-eclampsia. (See hypertensive disorders of pregnancy.) Effective treatment: The effect of a treatment as observed in the controlled circumstances of a clinical trial. Efficacious treatment: The effect of a treatment that can be expected in real clinical practice. Emergency obstetric care: The basic intervention capacity needed to appropriately manage obstetrical complications. This includes surgical obstetrics, cesarean sections, treatment of laceration, laparotomy; anesthesia; medical treatment of shock, eclampsia, and anemia; blood replacement; manual procedures; and assisted delivery. Emergency preparedness: An approach to promote early recognition of complications for mother and baby at any time during pregnancy, delivery, or after delivery and to maximize the likelihood of timely referral and management. This involves preparedness in the community and in the formal health care system. Encephalocele: A protrusion of the brain and its covering membranes through the skull. Epidemiology: The study of the distribution and determinants of health-related states and events in populations and the application of this study to control health problems. Essential newborn care: Basic preventive care for all newborns, especially warmth, cleanliness, breastfeeding, cord and eye care, and immunizations. Essential obstetric and neonatal care: A set of minimal health care elements which should be made available to all pregnant women and that includes both preventive and curative health measures. Essential obstetric care includes both life-saving and emergency measures (e.g., cesarean section, manual removal of the placenta) as well as nonemergency measures (e.g., partograph, maternity waiting homes, intravenous oxytocics). It must have the basic intervention capacity to promote fertility regulation, prepregnancy care including nutrition, postabortion care, refocused antenatal care, essential obstetric care, essential newborn care, and postpartum care. Evidence-based medicine/health care: In evidence-based health care, the policies and practices used for prevention are based on principles that have
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Improving Birth Outcomes: Meeting the Challenge in the Developing World been proven through appropriate scientific methods. As well as proving the clinical effectiveness of a procedure, this involves evidence of use and provider satisfaction and demonstrations of the feasibility and cost-effectiveness of the procedure in different settings. Feticide: Intentional destruction of a human fetus. Gestational age: The number of completed weeks since the last menstrual period of the mother. This can be assessed by obstetric ultrasound or clinical assessment. Incidence: The number of new cases of a disease or condition in a particular population in a specified time interval. Hospital: A health facility performing all essential obstetric functions. Also described as first referral level, or a district or subdistrict hospital. Hyperbilirubinemia: An excess of bilirubin in the blood. Hyptertensive disorders of pregnancy: A diagnosis of hypertension in a pregnant woman is made when the blood pressure is 140/90 mm Hg or greater, or there has been an increase of 30 mm Hg systolic or a 15 mm Hg diastolic rise over baseline values on at least two occasions, 6 or more hours apart. Pregnancy-induced hypertension (which occurs without a previous history of hypertension) is differentiated from preexisting hypertension. Infant mortality rate (IMR): Number of deaths among infants under one year of age per 1,000 live births. Infanticide: The intentional killing of an infant. Intrapartum fetal deaths: Fresh stillbirths that occur during labor. Intrauterine growth restriction (IUGR): A baby less than 10 percent of the expected weight for gestational age and gender, born after ≥37 weeks gestation. Formerly interuterine growth retardation, this term is used synonymously with small for gestational age (SGA), (although not all SGA infants are affected by IUGR; some are simply at the lower tail of the “normal” fetal growth distribution). Kangaroo care: A neonate wearing only a diaper is placed between the mother’s breasts and both are covered. The uninterrupted body heat through
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Improving Birth Outcomes: Meeting the Challenge in the Developing World skin to skin can maintain the newborn’s body temperature and facilitate early breastfeeding. Kernicterus: A condition with severe neural symptoms, associated with high levels of bilirubin in the blood. Late fetal deaths: Fetal deaths that occur between 22 or 28 weeks (varies with organizations and countries) of gestation and birth. Synonymous with stillbirth. Lay providers: Delivery by unskilled persons such as traditional birth attendants, relatives, or on one’s own, is a norm in many developing countries. Live birth: A baby born with any signs of life, independent of weight or gestation. Low-birth-weight (LBW): Birth weight less than 2,500 grams. Management: A process by which one plans, implements, and evaluates an organized response to a health problem. Maternal mortality: A maternal death is the death of a woman while pregnant or within 42 days of termination of the pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Maternal mortality rate (MMR): The maternal mortality rate is the number of maternal deaths per 1,000 women of reproductive age. Maternal mortality ratio: The maternal mortality ratio is the number of maternal deaths per 100,000 live births. Meta-analysis: Meta-analysis is the statistical method used to integrate results from more than one study to produce a summary estimate of the treatment effect across studies (typical relative risk). Midwife: A midwife has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. She must be able to give the necessary supervision, care, and advice to women during pregnancy, labor, and the postpartum period; to conduct deliveries on her own responsibility; and to care for the mother and infant. This care includes
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Improving Birth Outcomes: Meeting the Challenge in the Developing World preventive measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help. She provides health counseling and education for women, families, and the community on preparation for parenthood, health risks during pregnancy, family planning, and child care. She may practice in hospitals, clinics, health units, or homes. Miscarriage: Spontaneous early fetal loss. Morbidity: Any departure from a state of physiological or psychological well-being. Neonatal death: A death of a liveborn infant during the period between birth and 28 completed days after birth. Early neonatal deaths occur during the first 7 days of life, and late neonatal deaths occur after the seventh day but before 28 completed days of life. Neonatal mortality rate (NMR): Number of deaths among live births during the first 28 completed days of life per 1,000 live births. Neonatal period: The first 28 days of life. Divided into early neonatal period (first 7 days) and late neonatal period (days 8-28). Newborn/neonate: Baby from birth until 28 completed days of life (the neonatal period). Obstructed labor: A labor in which progress is arrested by mechanical factors. Delivery often requires cesarean section. Parity: Number of of full-term children previously born by a woman, excluding miscarriages and abortions in early pregnancy but including stillbirths. Partograph: A written record charting the progress of labor and delivery and showing the key observations to monitor the women, the fetus, and labor progress. Perinatal mortality rate (PMR): The perinatal mortality rate is the number of deaths of fetuses weighing at least 500 g (or, when birth weight is unavailable, after 22 completed weeks of gestation), plus the number of early neonatal deaths, per 1,000 total births (livebirths and stillbirths). Because of the different denominators in each component, this is not necessarily equal to the sum of the fetal death rate and the early neonatal mortal-
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Improving Birth Outcomes: Meeting the Challenge in the Developing World ity rate. There is considerable confusion regarding PMR as countries use definitions that vary in minimal gestation and numerical weight. WHO encourages countries to report (internationally) the PMR for babies over 1,000 g or 28 weeks of gestation. Perinatal period: As defined by WHO, this period begins at 28 completed weeks of gestation (the time when birth weight has normally reached 1,000 grams), and ends seven completed days after birth. It includes: late fetal deaths (weight above 1kg = 28 weeks gestation) and early neonatal deaths (birth to 7 days). WHO prefers weight to gestation, as gestation is often unknown in developing countries. Many industrialized and some transitional countries use 22 weeks gestation as cutoff. Postpartum care: Care from the delivery until the sixth completed week after delivery, including care both at home and in the formal health care system. Postpartum hemorrhage (PPH): Excessive loss (usually of 500 milliliters or more) of blood from the genital tract within 24 hours of delivery. If uncontrolled, hemorrhage can quickly lead to shock and death, which generally occurs within 7 days of childbirth. Because of the difficulty of measuring blood loss, a more practical definition of PPH is any blood loss that causes a physiological change, such as low blood pressure, that threatens a woman’s life. Postterm birth: Baby born after 42 completed weeks of gestation. Pre-eclampsia: A condition in pregnancy manifested by hypertension, edema, and/or proteinuria. Premature rupture of membranes (at term or preterm): Rupture of the membranes before onset of labor. Preterm birth delivery or prematurity: Live birth before 37 completed weeks of gestation. Prevalence: The number of instances of a given disease or other condition in a particular population at a specified time. Prolonged labor: Active labor with regular uterine contractions for more than 12 hours. Prolonged pregnancy: A pregnancy beyond 42 weeks gestation.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World Prolonged rupture of the membranes (regardless of labor status): Rupture of the membranes for more than 12 hours. Puerperal sepsis: Infection of the genital tract occurring at any time between the onset of rupture of membranes or labor and the 42nd day postpartum in which, apart from fever, one or more of the following are present: pelvic pain, abnormal discharge (e.g. presence of pus), abnormal smell/foul odor of discharge, delay in the rate of reduction of size of uterus (<2 cm/day during first 8 days). These can occur as a result of unhygienic practices during delivery, excessive examinations, and increasing rates of STDs and AIDS. Serious puerperal infections are more likely after prolonged or obstructed labor. Randomized controlled trials (RCT): Experiments in which investigators randomly allocate eligible people or health care units into groups to receive, or not to receive, the interventions(s) being compared. When sample size is adequate, randomization ensures baseline comparability of known and unknown prognostic variables. Outcomes are selected a priori in order to achieve unbiased assessment of the results. Relative risk: The ratio of the risk of disease or death among those exposed to the risk compared to the risk among the unexposed; this usage is synonymous with risk ratio. Safe delivery: A safe delivery is one where the birth attendant monitors progress to avoid prolonged labor and to detect obstructed labor that can lead to hemorrhage, infection, and shock in the mother and birth asphyxia and brain damage in the infant. Sector-wide approaches to health: These address all components of health services, including maternal and neonatal health. Sickle cell disease (SCD): Sickle cell disease results from the pairing of hemoglobin S (Hb S) with another abnormal hemoglobin; the most frequent and severe phenotypes are hemoglobin SS (Hb SS) and hemoglobin SC (Hb SC). The abnormal hemoglobins distort the shape of the red blood cells and damage and destroy them. Patients develop anemia and other serious complications. Skilled birth attendant: 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 pro-
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Improving Birth Outcomes: Meeting the Challenge in the Developing World longed labor, infection, and hemorrhage; and recognition and resuscitation of neonates who fail to initiate respiration at birth. Small for gestational age (SGA) (also called “small-for-dates”): Lower than 10 percent on a birth-weight-for-gestational-age, sex-specific, single/twins growth reference curve. Spina bifida: Incomplete closure of the spine through which the cord and meninges may or may not protrude. Stillbirth: The death of a fetus weighing at least 500 g (or when birth weight is unavailable, after 22 completed weeks of gestation, or with a crown-heel length of 25 cm or more) before the complete expulsion or extraction from its mother. Synonymous with late fetal death. Surveillance: The systematic collection and analysis of data in order to make management decisions. Term birth: Baby born between 37 and 42 completed weeks of gestation. Total births: All births, live and stillborn (late fetal deaths). Traditional birth attendants: Lay persons who assist women in many rural settings during labor and delivery. They have minimal formal education, minimal or no medical training, minimal or no medical oversight, and generally a low caseload. Unsafe abortion: Unsafe abortion is termination of an unwanted pregnancy by persons lacking the necessary skills or in an environment lacking minimal medical standards, or both. An abortion can be considered as unsafe when it is performed under circumstances in which there are risks of morbidity and mortality over and above those inherent in the procedure when performed under optimal conditions—that is, under conditions of asepsis and with appropriate skills and equipment. Very early neonatal period: First 24 hours of a newborn’s life. Very low birth weight (VLBW): Less than 1,500 grams. Vital registration: Identifying and recording every live birth and every death of a pregnant woman, late fetal death (22 or 28 weeks, depending on the jurisdiction), infant death (neonatal or postneonatal), and maternal death.
Representative terms from entire chapter: