The huge worldwide burden of maternal mortality was the focus of a special issue of The Lancet, published on October 12th to coincide with the 20th anniversary of the Safe Motherhood Initiative launched by the WHO. In a series of themed articles, experts emphasized that maternal mortality rates have remained largely unchanged over the last 15 years. An estimated 536,000 women still die as a result of pregnancy and childbirth each year, the majority in the developing world.
Millennium Development Goal 5 aimed to reduce maternal mortality by 75% from 1990 levels by 2015. However, 20 years on, the extent of the problem is still apparent, with tens of thousands of women in developing countries dying as a result of pregnancy complications, unsafe abortions, lack of access to clinics or owing to bans on abortions and contraception.
In a study published in The Lancet, Professor Ken Hill and colleagues, on behalf of the Maternal Mortality Working Group, assessed the available data on maternal mortality between 1990 and 2005. Recent calculations from the Harvard Center for Population and Development Studies (MA, USA) suggest that the maternal mortality ratio has dropped from 425 to 402 per 100,000 pregnancies over the 15-year period. However, Hill fears that this may be a best estimate, given the lack of data available from the countries with the worst death tolls.
“A 0.4% [annual drop in mortality rate] unfortunately I think is the more realistic figure for the globe as a whole,” said Hill. “The proportion of sub-Saharan African births is going up and maternal mortality is not going down.”
The Lancet special issue also coincided with ‘Women Deliver’, a landmark global conference held in London on October 18-20th, which focused on creating political will to save lives and improve the health of women, mothers and newborn babies worldwide. Several United Nations agencies, international nongovernmental organizations and bilateral organizations were involved in the conference.
“In this 21st Century no woman should die giving life,” said Thoraya Ahmed Obaid, Executive Director of the United Nations Population Fund, who also wrote an editorial for The Lancet. “It is unacceptable that one woman dies every minute during pregnancy and childbirth when proven interventions exist. Millions of lives are at stake, and we must act now.”
Source: The Lancet: www.thelancet.com
Pregnancy weight gain may not be advantageous in obese women
It may not be advantageous for obese women to gain weight during pregnancy, according to results published in the October issue of Obstetrics and Gynecology. Contrary to current Institute of Medicine guidelines, this study suggests that limited or no weight gain may result in favorable pregnancy outcomes in obese women.
The researchers carried out a population-based cohort study of 120,251 obese pregnant women who delivered full-term, live-born, singleton infants, and investigated the risk of preeclampsia, cesarean delivery, small for gestational age births and large for gestational age births by obesity class and total gestational weight gain.
Gestational weight gain less than the currently recommended 15 lb was associated with a significantly decreased risk of preeclampsia, cesarean delivery and large for gestational age births. Small for gestational age births were significantly increased.
“The fear has been that not gaining weight would have a deleterious effect on the fetus,” said Dr R Artal, study author and chairman of the Department of Obstetrics, Gynecology and Women’s Health at Saint Louis University School of Medicine (MO, USA).
“Not only were there no deleterious effects, but there are benefits. Women, by not gaining weight in pregnancy, reduce their risk of hypertensive disorder, have less cesarean sections and have babies of normal weight.”
“The guidelines are outdated and we have to change them,” he added.
Source: Kiel DW, Dodson EA, Artal R, Boehmer TK, Leet TL. Gestational weight gain and pregnancy outcomes in obese women: how much is enough? Obstet. Gynecol. 110(4), 752–758 (2007).
Routine thyroid screening for pregnant women not recommended
The American College of Obstetricians and Gynecologists (ACOG) has released a Committee Opinion recommending against routine screening for subclinical hypothyroid disease in pregnant women. ACOG says there is no evidence that screening and treating pregnant women who have subclinical hypothyroidism improves either maternal or infant outcomes.
“The issue has been whether thyroid screening should be a routine test during prenatal care,” said Sarah J Kilpatrick, MD, PhD, Chair of ACOG’s Committee on Obstetric Practice, which released the statement. “Some groups argue that identifying and treating asymptomatic (subclinical) hypothyroidism will improve outcomes for pregnant women and their infants. With the information we have at this time, there isn’t any proven health benefit.”
The thyroid gland produces hormones that control key body functions. However, in hyper- or hypothyroidism, too much or too little thyroid hormone is released. If untreated, symptomatic hypothyroidism can result in preterm birth, low birth weight and impaired mental ability in infants. Furthermore, affected pregnant women can suffer from preeclampsia or placental abruption.
Thyroid hormones, and particularly the predominant form, thyroxine, are essential for normal fetal brain development. During the first trimester, the fetus is entirely dependent upon maternal thyroid hormone, and if a woman is clinically hypothyroid throughout pregnancy, the negative effects on fetal brain development can be dramatic.
Approximately 2–5% of women are estimated to have subclinical hypothyroidism, which is asymptomatic. Here, while one test of thyroid function is mildly abnormal, the level of thyroxine itself is normal. Studies have suggested a link between subclinical hypothyroidism and preterm birth and impaired brain development in children, which has led to some groups to call for routine screening in pregnant women. However, the benefits of screening to either the mother or fetus remain unproven.
The US Preventative Services Task Force insists that there must be a demonstrated improvement in the health outcomes of those individuals identified through screening before routine screening of asymptomatic people can be recommended.
“There just isn’t any data that supports the routine screening of millions of pregnant women for subclinical hypothyroidism every year because the long-term effects are not certain and there is no evidence that any treatment would make a difference in the long run,” said Kilpatrick.
ACOG says that thyroid screening is not part of routine prenatal care and, as such, should be limited to women with symptoms or a history of thyroid disease and those with associated medical conditions, such as diabetes.
Sources: ACOG Committee Opinion No. 381: Subclinical hypothyroidism in pregnancy. Obstet. Gynecol. 110(4), 959–960 (2007).
American College of Obstetricians and Gynecologists: www.acog.com
Study highlights risk factors for uterine rupture
A new study has found that the risk of uterine rupture during childbirth is markedly increased in women who have a history of cesarean delivery, and calls for prudent management of these women. Uterine rupture was also associated with other factors, including labor induction, high birth weight and high maternal age.
The study used population-based registers to obtain information about 300,200 Swedish women who delivered two consecutive single births between 1983 and 2001. The researchers, from the Department of Epidemiology at Emory University, Atlanta (GA, USA) and the Department of Medical Epidemiology and Biostatistics at the Karolinska Institute, Stockholm (Sweden), gathered information on demographics, pregnancy and birth characteristics, and neonatal outcomes, and analyzed potential risk factors for uterine rupture and associated neonatal mortality.
Of the women studied, 24,876 had attempted a vaginal delivery after a previous cesarean section. The rate of uterine rupture was 9.00 per 1000 among women with a history of cesarean delivery, compared with 0.18 per 1000 among those without. A total of 24.7% of women who had had a previous cesarean required an emergency cesarean during the second birth, compared with 2.2% of women who had delivered their first baby vaginally.
Lead author Melissa Kaczmarczyk from Emory University commented, “Our study is one of the largest population-based cohort studies to examine the risk factors for uterine rupture in all women regardless of history of cesarean delivery.
We found that previous cesarean, induction of labor, and high maternal age significantly increased the risk of uterine rupture. This is of particular concern due to a rise in the presence of these factors within the pregnant population.
Patient counseling and prudent management of labor among patients considered to be at higher risk is needed to prevent this catastrophic event and associated neonatal morbidity and mortality.”
Professor Philip Steer, Editor in Chief of BJOG: An International Journal of Obstetrics and Gynecology, said “The rate of cesarean deliveries continues to increase in the developed world which means that a growing percentage of women will experience birth following a previous cesarean section.
Although uterine rupture is a relatively rare occurrence, the consequences can be devastating. The link between a prior cesarean section and uterine rupture during subsequent delivery warrants very careful management of pregnancy and labor so that early signs of difficulty can be speedily detected and ensuring that women are fully informed of their options regarding mode of delivery.”
Sources: Kaczmarczyk M, Sparén P, Terry P, Cnattingius S. Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden. BJOG 114(10), 1208–1214 (2007).
Royal College of Obstetricians and Gynaecologists: www.rcog.org.uk
Royal Colleges issue recommendations for safe organization of care during birth
New information has been put forth to advise on standards for safely organizing care during childbirth. The recommendations, issued by the Royal Colleges of Anaesthetists, Midwives, Obstetricians and Gynaecologists and Paediatrics and Child Health, aim to provide clear guidelines on the roles and number of staff necessary to support women during childbirth.
The document is entitled ‘Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour’ and emphasizes the importance of good working relationships among the multidisciplinary care team. The report also stresses the importance of increasing staffing levels of midwives and obstetricians in order for an appropriate level of care to be attained.
The report established that women should receive individual attention from a midwife once in established labor. Increased obstetrician presence was also realized to be an important factor, as were visits and assessments from the anesthetist in cases where women required conduction or general anesthesia. In addition, the presence of a healthcare professional fully competent in neonatal basic life support was deemed to be essential for any birth.
Maggie Elliott, President of the Royal College of Midwives, explained that “women and their babies sit at the heart of these recommendations, which address many of the issues affecting the delivery of safe, quality care wherever women give birth,” and stressed the belief that the recommendations will be welcomed by midwives and result in improvements in women’s experiences of giving birth.
Source: Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour, Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, and Royal College of Paediatrics and Child Health; London; 2007.
New seafood recommendations for pregnant women
New recommendations for seafood consumption during pregnancy have been revealed by a maternal nutrition group. The group was made up of highly regarded professors of obstetrics and doctors of nutrition, in combination with the National Healthy Mothers, Healthy Babies Coalition (HMHB).
Recently, owing to concerns regarding mercury content in fish and a subsequent US FDA/Environmental Protection Agency (EPA) advisory, confusion has arisen among pregnant women, which has resulted in a reduction in their fish consumption. A consequence of this has been a diet with insufficient omega-3 fatty acids, with associated health risks to both mother and child. The National Health and Nutrition Examination Survey have released data reporting that as many as 90% of women are consuming inadequate amounts of fish according to FDA guidelines.
The new recommendations advise that women who want to become pregnant, are pregnant or are breastfeeding should consume at least 12 ounces of fish per week, such as salmon, tuna, sardines or mackerel, without safety concerns. They also note that fish is the richest dietary source of the long-chain omega-3 fatty acids docosahexaenoic acid and eicosapentaenoic acid.
In addition, the group noted the protective effects of selenium, an essential mineral that accumulates in some ocean fish, from the toxicity of the trace amounts of mercury that can be found.
Ashley Roman of the advisory group, New York University Medical Center (NY, USA) explained the findings. “The group reviewed recent scientific studies and found a link between ocean fish consumption and advanced cognitive and motor skill development in children. Some data also show a connection with reduced preterm labor and postpartum depression in mothers who ate ocean fish when pregnant.”
The HMHB are concerned with the reduction in women who are eating sufficient amounts of fish and are thus increasing their chances of nutritional deficiencies. Judy Meehan, Executive Director of HMHB, warns that “eating adequate amounts of fish during pregnancy is a nutritional and public health issue.” To overcome this she advises that, “patients and doctors alike must be better educated about the safety and importance of maternal food choices in optimizing pregnancy and childhood outcomes.”
A study conducted by William Goodnight et al. demonstrated that 56% of women reduced their fish intake unnecessarily, following the FDA/EPA advisory, to well below recommended levels in an attempt to reduce harm to their baby.
Roger Newman of the Maternal Nutrition Group, Medical University of South Carolina (SC, USA), is hopeful that the new guidelines will clear up some of the misconceptions regarding food consumption during pregnancy. “We know from our research that pregnant women are concerned about eating seafood and hope that our science-based recommendations will give women who are pregnant, nursing or planning to become pregnant the confidence that they are doing the right thing for their health – and the health of their children – by including fish in their diets,” he said.
Source: Healthy Mothers, Healthy Babies coalition: www.hmhb.org.