Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial.

OBJECTIVES: Community-based maternal and newborn intervention packages have been shown to reduce neonatal mortality in resource-constrained settings. This analysis uses data from a large community-based cluster-randomized trial to assess the impact of a community-based package on cause-specific neonatal mortality and draws programmatic and policy implications. In addition, the study shows that cause-specific mortality estimates vary substantially based on the hierarchy used in assigning cause of death, which also has important implications for program planning. Therefore, understanding the methods of assigning causes of deaths is important, as is the development of new methodologies that account for multiple causes of death. The objective of this study was to estimate the effect of two service delivery strategies (home care and community care) for a community-based package of maternal and neonatal health interventions on cause-specific neonatal mortality rates in a rural district of Bangladesh. STUDY DESIGN: Within the general community of the Sylhet district in rural northeast Bangladesh. Pregnancy histories were collected from a sample of women in the study area during the year preceding the study (2002) and from all women who reported a pregnancy outcome during the intervention in years 2004 to 2005. All families that reported a neonatal death during these time periods were asked to complete a verbal autopsy interview. Expert algorithms with two different hierarchies were used to assign causes of neonatal death, varying in placement of the preterm/low birth weight category within the hierarchy (either third or last). The main outcome measure was cause-specific neonatal mortality. RESULT: Deaths because of serious infections in the home-care arm declined from 13.6 deaths per 1000 live births during the baseline period to 7.2 during the intervention period according to the first hierarchy (preterm placed third) and from 23.6 to 10.6 according to the second hierarchy (preterm placed last). CONCLUSION: This study confirms the high burden of neonatal deaths because of infection in low resource rural settings like Bangladesh, where most births occur at home in the absence of skilled birth attendance and care seeking for newborn illnesses is low. The study demonstrates that a package of community-based neonatal health interventions, focusing primarily on infection prevention and management, can substantially reduce infection-related neonatal mortality.

Preterm birth and neonatal mortality in a rural Bangladeshi cohort: implications for health programs.

OBJECTIVE: To estimate the burden of prematurity, determine gestational age (GA)-specific neonatal mortality rates and provide recommendations for country programs. STUDY DESIGN: Prospective data on pregnancy, childbirth, GA and newborn mortality collected by trained community health workers from 10 585 mother-newborn pairs in a community-based study. RESULT: A total of 19.4% of newborn infants were preterm; 13.5% were late preterm (born between 34 and 36 weeks of gestation), 3.3% were moderate preterm (born at 32 to 33 weeks) and 2.6% were extremely preterm (born at 28 to 31 weeks of gestation). Preterm babies experienced 46% of all neonatal deaths; 40% of preterm deaths were in late preterm, 20% in moderate preterm and 40% in very preterm infants. The population attributable fraction of neonatal mortality in premature babies was 0.16 for very preterm, 0.07 for moderately preterm and 0.10 for late preterm. CONCLUSION: In settings where the majority of births and newborn deaths occur at home and successful referral is a challenge, moderate and late preterm babies may be an important target group for home-based or first-level facility-based management.

Childhood risks from the ferret.

The ferret is becoming an increasingly popular pet, yet the dangers of ferret ownership remain unrecognized by physicians and the general public. Reported are three incidents of ferret attacks in a 3-month period of time. The risk of attack is greatest in infants and small children. Wounds caused by ferret attacks must be evaluated for injury, infection, and rabies prophylaxis. Such attacks should be reported to animal control authorities. Physicians need to recognize the ferret as a risk to children.

Practice variations between family physicians and obstetricians in the management of low-risk pregnancies.

BACKGROUND: Studies suggest that family physicians and other generalist physicians practice differently than specialists. This study was performed to determine whether practice patterns and outcomes differ for women with low-risk pregnancies who obtain maternity care from family physicians as compared with those who are cared for by obstetricians. METHODS: A retrospective chart review was performed at five sites across the United States. Women who presented for elective repeat cesarean section or who had any one of 14 high-risk conditions were excluded from the analysis. The final sample analyzed included 4865 women. Family physicians managed the labor of 2000 of these women, and obstetricians managed 2865. RESULTS: During intrapartum care, women managed by family physicians were less likely to have their labor induced (8.6% vs 10.4%, P = .03), receive oxytocin augmentation (14.9% vs 17.8%, P = .006), or receive epidural anesthesia (5.4% vs 17.0%, P < .001) as compared with those managed by obstetricians. Delivery outcomes showed that patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001) and a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians. CONCLUSIONS: Women obtaining maternity care from family physicians were less likely to receive epidural anesthesia during labor or an episiotomy after vaginal births, and had a lower rate of cesarean section delivery rates, primarily because of a decreased frequency in the diagnosis of cephalopelvic disproportion. Differences between outcomes persisted after adjustment for potential confounders such as parity, previous cesarean delivery, and use of epidural anesthesia during labor. No differences between the two physician groups with respect to neonatal outcomes were found.

Cesarean section rate: a comparison between family physicians and obstetricians.

This retrospective study compared the cesarean section rates of family physicians and obstetricians for low-risk pregnancies. The study populations (n = 492) were demographically similar. The overall cesarean section rate for the study was 7.5%. Chi-square analysis revealed a statistically significant higher rate of cesarean section for obstetricians compared to family physicians. Obstetricians were overall three times more likely to deliver by cesarean section than were family physicians (11.3% compared to 3.8%). This pattern persisted for normal-length Stage I and Stage II labors. Equal cesarean section rates were noted in prolonged labor patterns. The rate of fetal distress, meconium, or other complications was equal between family physicians and obstetricians; equivalent fetal outcomes and Apgar scores were noted. None of the studied patient factors explained the difference in cesarean section rates between family physicians and obstetricians.