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National Academies Press
Improving Birth Outcomes:: Meeting the Challenge in the Developing World

Improving Birth Outcomes:: Meeting the Challenge in the Developing World


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Product Details

ISBN-13: 9780309086141
Publisher: National Academies Press
Publication date: 11/04/2003
Edition description: New Edition
Pages: 372
Product dimensions: 6.00(w) x 9.00(h) x 0.93(d)

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Copyright © 2003 National Academy of Sciences
All right reserved.

ISBN: 978-0-309-08614-1

Chapter One

Executive Summary

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, where the vast majority of the 515,000 maternal deaths, 4 million late fetal deaths (beyond 22 weeks' gestation), and 4 million neonatal deaths are conservatively estimated to occur each year. In Eastern Africa, 1 in 11 women dies of pregnancy-related causes, a lifetime risk of maternal death 500 times greater than that faced by women in some industrialized countries. Most maternal, neonatal, and fetal deaths occur between late pregnancy and the end of the first month of the child's life and many are preventable. Yet this important period has received inadequate attention in the health care programs of most countries. This report reviews the evidence on key interventions that could greatly improve birth outcomes in developing countries.


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 inthe 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 was:

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. The study will:

1) review statistics on low birth weight, premature infants, and birth defects;

2) review current knowledge and practices;

3) identify cost-effective opportunities for improving birth outcomes, reducing maternal, infant, and fetal mortality, and supporting families with an infant handicapped by birth problems; and

4) 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 of Child Health and Human Development of the National Institutes of Health, 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.

Initial discussions 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 extended from addressing neonatal outcomes to including maternal and fetal outcomes in developing countries. In addition, the discussion of perinatal transmission of HIV/AIDS was expanded to a full chapter. The committee also wrote a companion report, Reducing the Impact of Birth Defects: Meeting the Challenge in the Developing World.

To conduct the current study, the Institute of Medicine assembled a 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 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 delivery 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 judgement as well as scientific research. The committee's research recommendations emphasize the importance of 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

While recognizing the profound influence of social, cultural, and economic factors on birth outcomes and supporting efforts to counteract their negative effects, this study focuses on interventions and health care services that can rapidly reduce maternal, neonatal, and fetal mortality. However, it is clear that to be successful, such interventions must not only be clinically effective, but must take into account the following major influences on birth outcomes.


At the individual and the population level, poverty tends to reduce the availability of all types of health services. Populations with high infant mortality generally have low GDP per capita and significant inequalities in income. Women in poverty face higher rates of infectious disease, including malaria, rubella, and HIV/AIDS, that also pose risks to the fetus and neonate. Unhygienic conditions, frequently associated with poverty, increase the risk of maternal and neonatal sepsis. Malnourished mothers are at increased risk for complications and death during pregnancy and childbirth and their infants are more likely to have low birth weight, fail to grow at a normal rate, and have higher rates of disease and death.

Women's education and socioeconomic status

Maternal education, literacy, and overall socioeconomic status are powerful influences on the health of both mother and newborn. Where women's social or economic status is low, maternal mortality tends to be higher. The educational level of women relative to men in a society both determines and is determined by the degree of autonomy and power held by women. Women's educational and socioeconomic status also influence age at marriage and first pregnancy, use of family planning, and the prevalence of domestic violence. Female literacy has been found to be a strong predictor of family size and birth spacing, which in turn strongly affect birth outcome. Female literacy also appears to influence the proportion of physicians and nurses in a population.

Unintended pregnancy

Worldwide estimates indicate that between 100 and 150 million married women want to postpone or stop childbearing, but lack access to family planning services. Other barriers to women's control of their own reproduction include poverty, lack of education, and low social status. A major consequence of the unmet need for family planning is maternal mortality and morbidity-including infertility-due to unsafe abortion. The 20 million unsafe abortions estimated to occur each year, 90 percent in developing countries, result in more than 70,000 maternal deaths. Most of these women live in countries where abortion is illegal.

Maternal age and parity

The following factors have been associated with an increased risk of infant death: a mother older than 35 years; a very young (early adolescent) mother; birth intervals of less than 2 years; and four or more older children. Traditions in many developing countries promote early marriage and frequent childbearing, and many women-due to cultural norms, lack of access to birth control, or both-continue to bear children until they reach menopause. Interpregnancy intervals of less than 6 months may be associated with increased risk of low birth weight. Advanced maternal age has consistently been associated with increased risk for fetal and neonatal deaths, primarily due to chromosomal abnormalities.

Cultural barriers to obstetric and neonatal care

Life-threatening complications for pregnancy and childbirth frequently go unrecognized in developing countries. Pregnancy is widely considered to be a time of well-being; complications may be viewed as fated due to a woman's misbehavior. Where such beliefs prevail, women and traditional birth attendants tend to perceive obstetric complications as supernatural and best treated through traditional means. When women recognize the need for obstetric care, the sometimes well-founded belief that care will be of poor quality may inhibit them from seeking that care. 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 limit her access to care.

The invisibility of many fetal and neonatal deaths that occur at home, along with the widespread acceptance of these deaths, poses major barriers to reducing fetal and neonatal mortality. In many cultures, a child's birth is not acknowledged until he or she has survived the first days or weeks of life. Until the critical period of survival has passed, mother and infant may be isolated, which can delay access to medical care if either becomes ill. Such delays are particularly dangerous for mothers and neonates with infections, as their survival often depends on receiving care within hours of the appearance of symptoms.

Adverse Birth Outcomes

Deaths of both mothers and infants are concentrated in the period spanning the onset of labor through the first 28 days postpartum. During those few weeks, most maternal deaths (except those due to unsafe abortion) and almost two-thirds of infant deaths occur. The intrapartum period is the most likely time for late fetuses to die. Labor is also particularly perilous for the fetus in rural areas, where few women receive skilled assistance at childbirth. Neonates are at greatest risk in the 48 hours after birth. For mothers, both periods are of high risk. Half of maternal, late fetal, or neonatal deaths occur in the intrapartum period and the next 48 hours.

Inadequate data on birth outcomes

The true magnitude of death, disease, and injury associated with poor birth outcomes in developing countries has not been established. Countries with the highest estimated maternal, neonatal, and fetal mortality rates also have the lowest registration of births and neonatal deaths; an even lower proportion of fetal deaths are recorded. Several factors contribute to this situation, including the absence of national systems for registration of vital statistics, failure to report deaths that occur in the home, the lack of consistent international definitions of neonatal mortality, and cultural practices that confer "personhood" on infants only after they have survived their first days or weeks. Inadequate data on late fetal deaths are partly responsible for their not being included in calculations of the global burden of disease.

Maternal mortality

Maternal death (death while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management) is a leading cause of death for women between the ages of 15 and 49. Ninety-nine percent of maternal deaths occur in the developing world, where one in four women suffers from an acute or chronic disability related to pregnancy. The five major causes of maternal mortality are hemorrhage, sepsis, unsafe abortion, eclampsia, and obstructed labor. Together these account for more than two-thirds of maternal mortality. Indirect causes of maternal death, which are responsible for approximately 20 percent of maternal mortality, include pre-existing conditions such as malaria and viral hepatitis that are exacerbated by pregnancy or its management.

Neonatal mortality

The greatest risk of childhood death occurs during the neonatal period. About 40 percent of all deaths to children under 5 years of age, and nearly two-thirds of all infant deaths (between birth and 12 months) occur during the neonatal period (the first month of life). Approximately 98 percent of the approximately 4 million neonates who die each year are born in the developing world. The major causes of neonatal death are asphyxia, infection, complications of preterm birth, and birth defects in the early neonatal period (0-6 days); infections cause the majority of late neonatal (7-27 days) deaths. Health services in the antenatal, labor and delivery, and postnatal periods can be refined to prevent or reduce neonatal mortality and severe morbidity, and can be made both accessible and workable in different developing country settings.


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Table of Contents

Part IMeeting the Challenge in the Developing World
Executive Summary3
Study Purpose and Approach18
The Social, Cultural, and Economic Context20
Women's Education and Socioeconomic Status22
Unintended Pregnancy23
Maternal Age and Parity24
Cultural Barriers to Obstetric and Neonatal Care26
Domestic Violence26
Natural Disasters and Political Conflicts26
Adverse Birth Outcomes27
Inadequate Data on Birth Outcomes27
Maternal, Fetal, and Neonatal Mortality28
Linking the Mother, Fetus, and Neonate29
Access to Care29
Three Additional Neonatal Challenges30
Child Survival and Safe Motherhood31
The Child31
The Mother32
The (Missing) Neonate and Fetus33
Organization of the Report34
Part IIAddressing Maternal, Neonatal, and Fetal Mortality and Morbidity
2Reducing Maternal Mortality and Morbidity43
Causes of Maternal Morbidity and Mortality44
Unsafe Abortion49
Hypertensive Disease of Pregnancy51
Obstructed Labor51
Interventions Involving Behavioral Change52
Antenatal Care54
Skilled Attendance at Childbirth58
Management of Childbirth65
Overused or Inappropriate Interventions76
Research Needs78
3Reducing Neonatal Mortality and Morbidity91
Causes of Neonatal Morbidity and Mortality91
Infectious Diseases92
Noninfectious Conditions99
Antenatal Care102
Care During Labor, Delivery, and the Very Early Neonatal Period107
Neonatal Care112
Research Needs117
4Reducing Fetal Mortality135
Factors Contributing to Late Fetal Deaths138
Intrapartum Fetal Deaths138
Antepartum Fetal Deaths141
Intrapartum Care149
Preconceptional and Antenatal Care150
Recognition of Fetal Deaths152
Research Needs153
Part IIIImproving Health Care Systems
5Improving Birth Outcomes within Health Care Systems165
The Evidence Base166
Primary Care and Referral166
Models of Care for Labor and Delivery168
Improving Access to Referral Care for Labor and Delivery176
Building Capacity for Reproductive Health Care178
Staff Development and Training179
The Role of the Private Sector180
Health Care Reforms183
Managing Health Care Systems184
Research Needs193
Part IVAdditional Causes of Neonatal Mortality and Morbidity
6The Problem of Low Birth Weight205
Patterns of Occurrence205
Causes of IUGR and Preterm Birth207
Consequences of IUGR and Preterm Birth212
Effects on Mortality212
Effects on Morbidity, Growth, and Development214
Interventions to Prevent Preterm Birth and IUGR217
Sources of Evidence217
Prepregnancy Energy/Protein Supplementation217
Energy/Protein Supplementation During Pregnancy218
Nutritional Advice218
Micronutrient Supplementation219
Treatment of Genitourinary Infection220
Smoking Cessation221
Malaria Prophylaxis and Treatment221
Other Interventions222
Research Needs224
7Reducing Mortality and Morbidity from Birth Defects237
Patterns of Occurrence238
Causes of Birth Defects238
Genetic Birth Defects240
Birth Defects of Environmental Origin242
Birth Defects of Complex and Unknown Origin245
Reducing the Impact of Birth Defects248
A Multistage Process248
Stage 1Low-Cost Preventive Strategies248
Stage 2Early Diagnosis and Treatment of Birth Defects250
Stage 3Screening for Genetic Disorders251
Research Needs254
8Preventing Perinatal Transmission of Hiv263
The HIV/AIDS Epidemic263
HIV in Women of Childbearing Age264
Perinatal Transmission of HIV266
Interventions to Prevent HIV Transmission267
Antiretroviral Strategies267
Nonantiretroviral Strategies277
Comparing Preventive Interventions278
Barriers to Implementing Antenatal Screening279
Guidelines for Antenatal HIV Screening283
Research Needs285
9Summing Up: The Way Forward293
The Skilled Birth Attendant294
Essential Obstetric and Neonatal Care295
AWorkshop Agenda301
BDefining Developing Countries305
CThe Essential Competencies of a Skilled Birth Attendant310
DCommittee Biographies314
EDissenting Note320

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