Strategies to prevent eclampsia in a developing country: I. Reorganization of maternity services.

OBJECTIVE: To determine whether changes in primary and secondary care service delivery could prevent antenatal eclampsia. METHOD: One intervention (St. Catherine) and two control (St. Ann, Manchester) parishes were chosen. The health system in St. Catherine was restructured. Primary antenatal clinics had clear instructions for referring patients to a high-risk antenatal clinic or to hospital. Guidelines were provided to high-risk clinics and the antenatal ward for appropriate treatment of hypertension and preeclampsia when induction of labor should occur. Antenatal eclampsia incidence was monitored before and during the intervention and compared with control parishes (no intervention). Each eclampsia case was investigated to identify inadequacies in the system. RESULTS: The process resulted in better identification of women at risk. Antenatal eclampsia incidence dropped dramatically as care improved. Compared with control areas, by completion of the study, the rate was significantly lower than at the start: OR 0.19 (95% CI: 0.13-0.27; p<0.001 trend). Antenatal admissions for hypertensive disorders declined significantly, and the number of bed days halved. CONCLUSION: Reorganization of maternal care can have major public health benefits and cost savings; however, women need to be alerted to recognise and act upon signs of impending eclampsia.

Strategies to prevent eclampsia in a developing country: II. Use of a maternal pictorial card.

OBJECTIVE: To assess the efficacy and acceptability of a patient-held pictorial card aimed at raising awareness and appropriate health seeking behavior in response to prodromal symptoms of imminent eclampsia. METHOD: Pictorial cards (and posters) were issued to antenatal clinics and used to focus instruction and advice to pregnant women. Mothers were surveyed before and after the cards were introduced to assess maternal likelihood of seeking care if edema was seen, and of attending hospital if so advised. We monitored the eclampsia rate. Health workers were interviewed 6 months after cards and posters were issued to determine the acceptability of using the cards as part of routine antenatal care. RESULTS: The card was seen as widely acceptable by health professionals, and increased their own awareness of the prodromal symptoms of eclampsia and their discussion of these symptoms with antenatal mothers. Mothers' awareness and response to symptoms improved significantly and there was a marked drop in eclampsia incidence. Suggested improvements to the card were made by mothers and health workers. CONCLUSION: The cost of providing a card for every pregnant mother is likely to be offset by health service delivery savings.

Access to care and maternal mortality in Jamaican hospitals: 1993-1995.

BACKGROUND: As part of the reproductive health quality assurance programme, the Ministry of Health sought to review maternal deaths in public hospitals. These hospitals attend 95% of institutional births and 82% of all births. METHODS: Deaths among females 10-50 years in public hospitals during 1993-1995 were reviewed to identify pregnancy-related deaths. Cause of death and access to care were compared with previous studies (1981-1983 and 1986-1987 [12 months]). RESULTS: The maternal mortality ratio of 106.2 per 100 000 live births, was no different than the 119.7 observed in 1986-1987 and 118.6 for 1981-1983. The leading causes of death remained pre-eclampsia/eclampsia and haemorrhage. The only significant cause-specific decline occurred among deaths due to ruptured ectopic pregnancy (P = 0.012). While in 1986-1987 access to care was associated with risk of death from gestational hypertension (P = 0.02), these differences are no longer significant. Differences persist, however, for haemorrhage and all other causes, which were less likely to occur at the more skilled institutions. The region with the least obstetricians had the highest mortality ratio but the one with the most did not have the lowest ratio, indicating that quality is more important than quantity. CONCLUSIONS: Regional differences indicate the capacity to reduce maternal mortality by at least 50% with re-allocation of skilled personnel and improved quality. All hospitals must be able to manage haemorrhage cases as patients are unlikely to survive referral.

Preeclampsia in twin pregnancies: incidence and outcome.

OBJECTIVES: To confirm the increased incidence of preeclampsia in twin pregnancy and to determine the relationship to zygosity and placentation; to consider the perinatal outcome of twin pregnancies in this condition. METHODS: Retrospective study of all twin pregnancies (n = 2473) identified from the Aberdeen Maternity and Neonatal Databank to women resident in the Grampian Region of Scotland for the period 1950-1995. RESULTS: The increased relative risk for gestational hypertension, preeclampsia, and eclampsia in twin pregnancies compared to singleton pregnancies has been confirmed as significant both in primiparas and multiparas with little variation in rates over the time period under review. Neither the sex of the offspring nor zygosity influences the incidence of hypertensive disease, whereas preeclampsia is more common in association with monochorionic placentation. As the birth weight was lower and placental weight greater in MzMc twins compared to either MzDc or DzDc, there was a higher placental index in such cases. No difference in the birth weights of individual twins, the difference in birth weights between the twins, placental weight, or placental index were found in relation to hypertensive disease. Gestation at delivery was earlier in normotensive twin pregnancies than in those women who developed a hypertensive problem. This leads to a higher perinatal death rate and lower survival rate for the babies in normotensive women with a twin pregnancy. CONCLUSION: Although gestational hypertension, preeclampsia, and eclampsia all occur more commonly in twin pregnancy, this does not lead to significant growth retardation nor discordant fetal growth and a poor outcome for the twins. Although the incidence of preeclampsia is higher in twin pregnancies with monochorionic placentation, this does not seem to be mediated by deficiencies in placental development as assessed in this study.

The changing pattern of cerebral palsy in Avon.

The overall rate of cerebral palsy excluding post-neonatal cases, has remained relatively constant, varying between 1.93 and 2.27 per 1000 births over the 20-year period between 1969 and 1988 in Avon. The rate of the subgroup of spastic cerebral palsy varied from 1.40 to 1.78 per 1000 births over the same time period. In singletons the corresponding figures were 1.80-2.17 per 1000 births and 1.28-1.67 per 1000 births, and in multiple births the figures were 7.12-8.80 per 1000 births and 7.12-8.44 per 1000 births. Although the overall rates have remained fairly constant there was an increase in incidence in the later years among children with low birthweight and short gestation.

Does labetalol influence the development of proteinuria in pregnancy hypertension? A randomised controlled study.

It is the development of proteinuria in pregnancy-induced hypertension which is associated with an increased perinatal mortality. There is some evidence to suggest that labetalol may diminish the amount of proteinuria in patients who have already developed proteinuric pre-eclampsia. A randomised controlled study design was used to investigate whether labetalol treatment, started when a persistent diastolic blood pressure greater than 90 mmHg was observed, influenced the subsequent development of proteinuria. One hundred and fourteen women with singleton pregnancies and hypertension in the absence of proteinuria were randomised to receive either labetalol or no antihypertensive therapy. At recruitment maternal age, blood pressure and gestation were similar in both the labetalol and control groups. There was no difference in the frequency, quantity or timing of subsequent proteinuria between treatment and control groups. Overall 34% of primigravidae and 10% of parous women developed proteinuria. Labetalol did, however, control the blood pressure in 45 of the 51 treated women (88%) within 24 h. This effect was often shortlived requiring dose escalation after 3 to 5 days in the majority of cases. Labetalol was well tolerated and no significant maternal toxicity was noted.

Experience with sperm counts following vasectomy.

The records of Aberdeen men requesting vasectomy between 1978 and 1981 were studied and a sample of men were interviewed about 3 years after the operation; 85% completed the standard requirements for seminal analysis and were given the "all clear"; two-thirds were cleared after sending 2 samples and usually within 20 weeks after vasectomy; 10% of men sent at least 1 sample but were never cleared and the remaining 5% ignored the requirements. Information from 70 men (63 interviews, 7 questionnaires) gave some indication of reasons, often multiple, for incomplete or non-compliance; these included embarrassment, ambiguous feelings about having more children, inadequate understanding of reproductive physiology and blind faith in the surgeon.

PIP: To better understand why some men do not comply with the requirement for 2 seminal analyses after vasectomy, 84 men from a random sample of Aberdeen residents who requested vasectomy between 1978 and 1982 were studied. Interviews and follow up were conducted on 70 men 3 years later. The sample was similar to all men requesting vasectomy by age, occupation, duration of marriage, and family size. The procedure for seminal analysis involved sending a specimen kit 3 and 4 months after the operation date. The doctor was informed when there was no response. If both sperm counts were negative, the all clear sign was given, but when spermatozoa were present, consultants recommended further action. The results showed that 4.8% sent no samples, 4.8% sent 1 sample, 66.3% sent 2 samples, and the remaining 20 cases sent 2 samples. 86% men complied fully and were given the all clear. Compliance time varied from 17 weeks to 40 weeks with a mode of 18 weeks. In the 3-year follow up survey of 70 men, 58 had given the all clear after 2 samples, 8 provided at least 1 sample and had never been cleared, and 4 sent no samples. Of the 8 men not completing the requirements, responses varied with the number of samples. It is concluded that the reasons for noncompliance can be grouped in embarrassment, ambiguous or uncertain feelings about having more children, absolute trust in the surgeon, and inadequate understanding of reproductive physiology. Few were told to engage in intercourse as soon and as often as possible to get rid of the bank of sperm. More and better information is needed and wives should by given the option of attending the consultations.

Some factors in the choice of male or female sterilisation in Aberdeen.

In a random sample of 84 men and 167 women, medical considerations, an intransigent attitude of one partner or a fear of adverse effects, were related to the decision on which partner should seek sterilisation. Only 19% of couples felt that they had a real choice between male and female sterilisation.

PIP: Researchers conducted a prospective study of men and women asking for sterilization in the Aberdeen City District in Scotland from 1978-1981. They randomly chose and interviewed 84 men and their wives and 167 women and 123 of their husbands to determine what factors played a role in their decision for sterilization. About 50% of all couples had sisters who had experienced sterilization and 20% had brothers who did. Therefore sibling experience played a significant role in the couples' choice between male and female sterilization (p.05). Spouses of only 19% of all couples were both willing to be sterilized. 66% of the wives in the vasectomy sample and 50% of those in female sample wanted to stop using oral contraception. 46% of the couples in the vasectomy group reported that both spouses were willing to be sterilized. In fact, 48.7% carefully considered their decision after becoming well informed of their options and going to the physician together. 46.1% of the husbands volunteered for a vasectomy because of the shorter waiting list (p.001). The remaining couples chose vasectomy because the wives had done their share and/or concern for the wives' health, the wives did not want to be sterilized (time for husbands to assume the responsibility), or female sterilization was contraindicated. The leading reason for female sterilization was that husbands (49%) did not want a vasectomy, mainly because they would lose their manhood or it would affect their sec life. The next reason was women (23%) wanted optimal personal security against pregnancy. The remaining reasons for female sterilization included vasectomy was unnatural and medical considerations (e.g., repeated cesarean section). 5% of the couples who wanted female sterilization switched to vasectomy because of the long waiting list.

Social differences in low birthweight and preterm deliveries in twins.

The relationship between low social class and low birthweight or preterm deliveries is well established in singletons but not in twins. We present a study using all twin deliveries registered in Belgium in 1983 and in Aberdeen between 1951 and 1983. No significant relationship was found between social class and low birthweight, very low birthweight or preterm deliveries in the Belgian sample. In Aberdeen, we found significantly higher rates of low birthweight twins in low social classes. This increase of low birthweight twins in low social classes occurred in Aberdeen during the period 1951-1968, but not in the more recent data.

Comparison of prevalence of depression in mothers of twins and mothers of singletons.

OBJECTIVE: To determine whether the apparent additional and exceptional stresses associated with bearing and parenting twins affect the emotional wellbeing of mothers. SETTING: Great Britain, 1970-5. DESIGN: Cohort study of 13,135 children born between 4 April and 11 April 1970. Mothers of all children, both singletons and twins, were interviewed by health visitors (providing demographic data) and completed a self report measure of emotional well-being (the Rutter malaise inventory) when the child was 5 years of age. The malaise scores of mothers of twins were compared with those of all mothers of singletons and then with those of mothers categorised by the age spacing of their children (only one child, widely spaced, or closely spaced), taking account of maternal age, social class, and whether the study child had a disability, by using logistic regression. SUBJECTS: 139 mothers of twins--122 pairs of twins and 17 twins whose cotwin had died--and 12,573 controls, who were mothers of singletons. RESULTS: A significantly higher proportion of mothers of twins at 5 years had malaise scores indicative of depression than mothers of singletons at the same age. Mothers who had borne twins, one of whom had subsequently died, had the highest malaise scores and were three times more likely than mothers of singletons to experience depression. Both mothers of twin pairs and mothers of singletons closely spaced in age were at significantly higher risk of experiencing depression than mothers of children widely spaced in age or mothers of only one child (p less than 0.0001). Odds ratios indicated that the risk of depression in mothers of twins was higher than that in mothers of closely spaced singletons. CONCLUSION: Mothers of twins are more likely to experience depression. This suggests a relation between the additional and exceptional stresses that twins present and the mother's emotional wellbeing.

Assessment and management of hypertensive disorders in pregnancy by health professionals in the Avon district.

A questionnaire based survey was carried out in the Avon health districts to investigate the assessment and management of hypertensive disorders in the third trimester of pregnancy by health professionals. A total of 673 responses were analysed from 310 general practitioners, 48 hospital doctors, 214 hospital midwives, 81 community midwives and 120 student midwives. The study revealed a wide variation in the criteria used for the diagnosis of a hypertensive disorder in pregnancy and some outmoded recommendations for management. The importance of continuing education is stressed, in order to ensure that current research and the consensus of expert opinion is being relayed to the personnel involved in antenatal care.

Classification of perinatal death.

Three paediatric pathologists, one perinatal paediatrician, one obstetrician, and one epidemiologist separately used information collected on 239 babies in an attempt to validate the Wigglesworth classification of perinatal deaths. This was first done using clinical data only, then using the combination of clinical and gross necropsy findings and finally using clinical, gross necropsy, histological and any other information (for example, chromosome analyses, microbiological investigations). Only 14 (6%) of deaths changed groups within the Wigglesworth classification when gross necropsy findings were considered as well as clinical findings, and altogether only 21 (9%) changed classification when complete investigations were available. There was an unacceptable amount (15%) of disagreement between the classifiers, largely the result of failure to comply with the rules laid down for classification. We set out amendments to Wigglesworth's original definitions to clarify certain ambiguities.

Does fetal heart rate predict subsequent heart rate in childhood?

An investigation to determine whether there is any relationship between extremes of fetal heart rate during labour and subsequent heart rate at the age of 10 was carried out using data from the 1970 cohort of British Births. In 11,000 nationally representative children it was found that low fetal heart rate (below 120 beats/min) was associated with a heart rate at age 10 which was significantly lower than in those children whose fetal heart rate had remained between 120 and 160 beats/min (P less than 0.01). This relationship could not be explained by fetal asphyxiation, maternal antenatal hypotension or the method of pain relief during labour. There was no equivalent relationship with high fetal heart rate during labour. This could imply that some fetuses with low heart rates are not exhibiting fetal distress but have an inherent tendency to relatively slow heart rates.

Maternal mortality and morbidity in Belgium.

The Belgian maternal mortality rate was 8.6/100,000 births in 1984 but it is probable that underreporting occurred. Data on morbidity from one Belgian hospital are presented. Gestational hypertension occurred in 9% of the women who delivered between 1982 and 1987. Gestational diabetes was observed in 2% of the cases during the same period. Data on antepartum haemorrhage are also discussed.

The classification and definition of the hypertensive disorders of pregnancy.

Hypertension and proteinuria in pregnancy may be the result of a number of different disorders with different etiologies and pathologic characteristics. As the causes of hypertension and proteinuria in pregnancy are largely unknown, a new clinical classification of the hypertensive disorders is proposed and is based solely on the physical signs of hypertension and proteinuria. The classification is intended to define meaningful clinical categories by which all cases of hypertension and proteinuria occurring in pregnancy, labor, or the puerperium may be classified. New definitions of hypertension and proteinuria are also proposed; they are based on standardized methods of measurement and simple criteria of abnormality. It is hoped that this clinical classification and associated definitions will find general acceptance so that the incidence and outcome of the hypertensive disorders of pregnancy and the results of research in different centers may be compared and mutual understanding achieved.

Placenta praevia and sex ratio at birth.

The ratio of male to female sex among infants born to 391 women with and 114 079 without placenta praevia was analysed by parity. In the women without placenta praevia the sex ratio decreased significantly with increasing parity, whereas in the women with placenta praevia it increased. Overall, the sex ratio was increased among the women with placenta praevia, particularly multiparas. An increase in the sex ratio at birth is associated with insemination early or late in the menstrual cycle, which may result in delayed development and implantation of the blastocyst; this may be a predisposing factor in placenta praevia.