Using standard primipara method to compare the quality of maternity care in Cairo and London.

SUMMARY: There is no universally agreed definition of quality of care (QoC). However, we assumed that the QoC in a London teaching hospital is high and could be used as a benchmark QoC with which to compare the practice in Cairo. We aim to highlight differences in the frequency of adverse outcomes attributable to differences in the QoC between two maternity teaching hospitals in Cairo and London, in low risk, standard primiparae (SP) delivered in 1999. In Ain Shams Maternity Hospital in Cairo and St Mary's Maternity Hospital in London, the caesarean section rate was 9.1% and 22.5%, respectively (OR = 0.34, p < 0.0001); the instrumental delivery rate was 4.1% and 26.8%, respectively (OR = 0.12, p < 0.0001), and the induction of labour (IOL) rate was 1.1% and 16.7%, respectively (OR = 0.06, p < 0.0001). Third degree perineal tears occurred in 0.3% and 8.2%, of the vaginal deliveries (OR = 0.14, p = 0.002) and the still birth rate was 0.78% and 0.1%, (OR = 7.96, p < 0.01) in the Cairo and London hospitals, respectively. This is the first time the SP method has been used to compare similar institutions in developed and developing countries. Intervention rates were significantly higher at St Mary's and so was the improved fetal outcome. A trade-off of improved fetal outcomes for more interventions is difficult to establish. Residual differences in case mix and patient preferences may explain some of the results.

Vitamin A and causes of maternal mortality: association and biological plausibility.

OBJECTIVE: To review the association between major causes of maternal mortality and vitamin A, trying to determine if these associations are causal in nature, and to highlight possible biological pathways that may explain vitamin A effects. DESIGN: Literature review, observational studies and clinical trials. The strength of association was determined by applying Bradford Hill criteria of causality. RESULTS: In a vitamin A deficient population, vitamin A is essential for adequate treatment of anaemia. While vitamin A does not seem to be capable of preventing uterine atony, obstetric or surgical trauma, which are important causes of haemorrhage, it might be capable of preventing or decreasing coagulopathy. Possible effects on the placenta as regards implantation, site and size are not clear. As regards pregnancy-related infections, vitamin A supplementation can improve wound healing by decreasing fibrosis and increasing transforming growth factor-beta (TFG-beta). It can increase resistance to infection by increasing mucosal integrity, increasing surface immunoglobulin A (sIgA) and enhancing adequate neutrophil function. If infection occurs, vitamin A can act as an immune enhancer, increasing the adequacy of natural killer (NK) cells and increasing antibody production. beta-carotene in its provitamin form can act as an antioxidant by decreasing endothelial cell damage (the pathognomonic feature of pre-eclampsia) and promote the vasodilator effect of nitric oxide that might bring about a better outcome of toxaemia in pregnancy. It is unlikely that vitamin A or beta-carotene has an effect on obstructed labour. CONCLUSIONS: Plausible biomedical pathways can only be constructed for obstetric haemorrhage, anaemia in pregnancy, hypertension in pregnancy and pregnancy-related infections. A 40% reduction in the maternal mortality ratio, as observed in Nepal, is unlikely to be solely explained through the aforementioned pathways.