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A new UNICEF report, The State of the World’sChildren 2005: “Childhood Under Threat,” shows that more than half the world's children are suffering extreme deprivations from poverty, war, and HIV/AIDS—conditions that effectively deny children a childhood and hinder the development of nations. “Too many governments are making informed, deliberate choices that actually hurt childhood,” said UNICEF Executive Director, Carol Bellamy, in launching the report at the London School of Economics. “Poverty doesn’t come from nowhere; war doesn’t emerge from nothing; AIDS doesn’t spread by choice of its own. These are our choices.” Among its health statistics the report lists basic indicators for all countries, including the most recent rates for infant mortality. In 2002, the rate increased in the United States to 7.0 infant deaths per 1,000 live births. By comparison, 30 countries have lower infant mortality rates, including Australia, Austria, Belgium, Brunei, Canada, Cuba, Cyprus, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Japan, Luxembourg, Malta, Netherlands, New Zealand, Norway, Portugal, San Marino, Singapore, Slovenia, Spain, Sweden, Switzerland, and the United Kingdom (UNICEF and World Health Organization 2002 statistics). The report is available at http://www.unicef.org/sowc05/english/index.html.

Three million of 4 million neonatal deaths could be saved each year by implementing low-technology and low-cost interventions, conclude authors of the landmark The Lancet Neonatal Survival Series, published online March 3, 2005. In a Comment, Richard Horton, Editor of The Lancet, noted “99% of deaths in the first month of life (the neonatal period) occur in developing countries—yet virtually all published research on neonatal health concerns the 1% of neonatal deaths in the developed world.” The series, comprising 4 articles, addresses a major gap in knowledge and provides new evidence detailing the causes of these deaths and the simple, effective interventions that are available to prevent them. “The deaths of 10,000 newborn children every day—largely ignored in global public-health policy—demands immediate and sustained action from international agencies, professional organizations, and national governments of both rich and poor countries alike,” observed Dr. Horton. The series of articles includes 3 additional studies on neonatal survival from Brazil, Bangladesh, and Nepal, and is available at http://www.thelancet.com/journal/vol365/iss9462/full/llan.365.9462.neonatal_survival_series.32489.1.

An estimated 40,000 pregnant women were among those left homeless as a result of the earthquake and tsunami in South Asia (WHO Press Release, Feb 10, 2005). As part of its emergency response, WHO dispatched medical professionals and essential supplies to the area affected for care of these women, and has been collaborating with respective national authorities and other international agencies to ensure pregnant women, particularly those who were displaced, have access to safe childbirth services. In most camps in the affected countries, the biggest problem for women is the lack of skilled attendants at birth. Dr. Samlee Plianbangchang, Regional Director for WHO's South-East Asia Region, cautioned that, “In a post-disaster situation where entire families and neighbourhoods have been lost, mothers, newborns and young children are the most vulnerable of the displaced persons and WHO is working with health ministries to ensure that they get the extra care they need and are not neglected.” According to Dr. Samlee, “Even under normal circumstances, maternal and child health is a matter of major concern in the region. Maternal deaths in this region account for one third of the total number of global deaths, and over 3 million children die below the age of 5 in this region annually, mostly from preventable causes. The tsunami has further added to the pressure.”

Preterm and low-birthweight rates both rose for 2003 in the United States, according to preliminary data from the National Center for Health Statistics (Natl Vital Stat Rep 2004;53(9):6). The preterm rate (percent of infants <37 completed weeks of gestation) increased from 12.1 to 12.3 between 2002 and 2003; the low-birthweight rate (percent of infants born at <2,500 g) rose from 7.8 to 7.9 percent. Preterm and low-birthweight levels rose slowly in recent years, up 16 and 13 percent, respectively, since 1990. The upswing in preterm and low-birthweight rates is related in part to growth in the multiple birth rate, but the rates also increased among singleton deliveries.

The cesarean delivery rate in Australia was 27.4 percent in 2002, the highest rate recorded, according to Australia's Mothers and Babies, 2002(AIHW National Perinatal Statistics Unit, Perinatal Statistics Series no. 15, Sydney, 2004). State and territory cesarean delivery rates ranged from 21.4 to 29.5 percent; rates were higher among older mothers and those admitted to private hospitals. Of all mothers giving birth in 2002, 12.8 percent had a previous cesarean section. Mothers with a history of cesarean section were likely to have a repeat cesarean section in 2002 (79.4%), whereas 16.6 percent had a spontaneous vaginal delivery, and 3.7 percent had an assisted vaginal delivery. In 2002, of all births in Australia, 7.9 percent were preterm, and 6.4 percent were low birthweight.

Aboriginal or Torres Strait Islander mothers comprised 3.6 percent of all mothers in Australia in 2002. Cesarean section deliveries occurred in 21.9 percent of these mothers, compared with 27.4 percent of other mothers. The proportion of Aboriginal or Torres Strait Islander mothers who had previously had a cesarean section was 14.4 percent, compared with 12.8 percent for other mothers. The proportion of low-birthweight babies of Aboriginal or Torres Strait Islander mothers was 12.9 percent, twice that of babies of other mothers.

The report contains a chapter titled, “Special Topic: Homebirths and Birth Centre Births.” In 2002, there were 637 planned homebirths and 5,379 confinements in birth centers (0.3% and 2.1% of all confinements, respectively). Liveborn babies born at home had a mean birthweight of 3,631 g, those born in birth centers had a mean birthweight of 3,564 g, and the average birthweight of all liveborn babies was 3,371 g. The percentage of low-birthweight babies born at home or in a birth center was 0.4 and 0.8 percent, respectively, and the percentage of preterm babies, 0.8 and 0.6 percent, respectively. The report is available at http://www.npsu.unsw.edu.au/AMB%202002.pdf.

HIV and Infant Feeding: A Compilation ofProgrammatic Evidence is a recently published report resulting from the collaboration of UNICEF, the Quality Assurance Project, World Health Organization agencies, and others involved in HIV and infant feeding programs. The United Nations-led process of updating the 1998 international guidelines related to infant feeding and the prevention of maternal-to-child-transmission of HIV called for a review of recent programmatic experience in addition to a review of the new scientific and medical evidence. This document represents an attempt to compile and synthesize reports on a wide variety of relevant programs conducted since the 1998 international guidelines were issued. It should also serve as a valuable resource to those involved in developing or improving related programs in the future. Key themes that emerged from the program synthesis included the major infant feeding modalities: exclusive breastfeeding, mixed feeding and its risks, and breastmilk feeding (wet nursing, breastmilk banks); desired characteristics of acceptability, feasibility, affordability, sustainability, and safety of infant-feeding modalities; counseling and informed choice, roles of partners, families, and communities; and behavior change and communication as a problem-solving strategy. Numerous controversial topics and constraints are also addressed in the report. It is available at http://www.dec.org/pdf_docs/PNADA872.pdf.

An increase in the birth of very small infants is the major reason behind the increase in United States infant mortality in 2002, according to a recent report by the Centers for Disease Control and Prevention, Explaining the 2001–02 Infant Mortality Increase(Natl Vital Stat Rep 2005;53(12)). The increase in infant mortality, from 6.8 infant deaths per 1,000 live births in 2001 to 7.0 in 2002, was the first increase in the infant mortality rate since 1958. Overall, 27,970 infant deaths occurred in 2002 compared with 27,523 infant deaths in 2001. Provisional data for 2003 suggest that the increase noted in 2002 may not be continuing. The number of extremely small babies (weighing <1 lb, 10.5 oz or 750 g at birth) increased by almost 500 births from 2001 to 2002. The increase occurred primarily among mothers in the peak childbearing ages of 20–34 years and occurred across most racial and ethnic groups. Multiple births may also contribute to the increase in low-birthweight infants. About 3 percent of births in the United States were multiple births, yet they made up about 25 percent of the overall increase in infant mortality. However, most of the rise was due to an increase for babies born in singleton deliveries.

Also potentially important are recent changes in the medical management of pregnancy, the report noted. In 2002, 57 percent of very low-birthweight infants were delivered by cesarean, up 3 percent from 2001. Substantial changes in technology have occurred over the past decade, including improvements in fetal imaging and diagnosis. More intensive monitoring of at-risk pregnancies may have resulted in an increased likelihood that a cesarean delivery will take place and a low-birthweight baby will be born. Detailed findings from this research are available at http://www.cdc.gov/nchs.

Report of a Structured Review of Birth CentreOutcomes December 2004 was published recently by the National Perinatal Epidemiology Unit in Oxford, United Kingdom. It is a review of evidence about clinical, psychosocial, and economic outcomes for women with straightforward pregnancies who plan to give birth in a midwife-led birth center, and outcomes for their babies. The authors sought to collect unpublished audit/survey information from National Health Service (NHS) Trusts. The primary aim was to highlight important gaps and make recommendations about priorities for research on these issues in the United Kingdom. In the absence of a standard definition of the term “birth center,” the authors agreed on a definition that included both centers that were freestanding and those alongside hospital obstetric units. No restriction was applied in terms of methodology or date of publication. Non-English language papers and those that described data from developing countries were excluded. In total, 297 papers were retrieved, 34 of which were included in the final report.

Overall, data were of poor quality, and derived mainly from small-scale observational studies, the authors found. Outcomes were inconsistently defined and reported with a high likelihood of bias. It was likely that there was disproportionate publication of positive or negative results. Given these limitations, the report concluded that birth center care can offer the possibility of accessible, appropriate, personal maternity care for women and their families. No reliable evidence about clear benefit or harm associated with birth center care compared with any other type of intrapartum care offered in the NHS was identified in this review. The report is available at http://www.npeu.ox.ac.uk/birthcentreview.

A steep rise in “no indicated risk” primary cesareans during the 1990s in the United States is reported in a new analysis of U.S. birth certificate data (BMJ 2005;330:71–72). The researchers, Eugene Declercq, Fay Menacker, and Marian MacDorman, studied data on approximately 4 million births per year between 1991 and 2001, and reported that first-time cesareans in women with “no indicated risk” rose 67 percent between 1991 and 2001, from approximately 3.3 to 5.5 percent. The increase was gradual until 1996 and rapid toward the end of the study period. Age was a major factor, especially among first-time mothers, the researchers found. Older primiparas over 40 years were 5.4 times more likely to have a cesarean than younger primiparas, aged 20 to 24 years. The researchers commented that “It would … be inappropriate to equate no indicated risk caesareans with ‘patient choice’ caesareans, as birth certificate data provide no record of the mother's intent.” They concluded that more research is needed “to elucidate whether the risks of a no indicated risk primary caesarean will be offset by associated benefits.”

The risks from vaginal delivery after a prior cesarean delivery (VBAC) are low, but slightly higher than for a repeat cesarean delivery, according to the findings from the largest, most comprehensive study of its kind ever conducted by the National Institute of Child Health and Human Development (NICHD)(NIH News Dec 14, 2004). The study was published in the New England Journal of Medicine(2004;351:2581–2589). “These findings provide women who have had a cesarean delivery—and their physicians—with reliable information to take into account when deciding whether to undergo labor or to have a repeat cesarean delivery,” said Duane Alexander, M.D., Director of the NICHD. The study women were all pregnant, and each had a previous cesarean delivery. In all, 17,898 women at 19 academic medical centers attempted a vaginal birth, and 15,801 underwent an elective repeat cesarean delivery. Among the complications the study found in women who attempted a VBAC were rupture of the uterus (0.7%, or 124 women), infection of the uterine lining (2.9%), lack of oxygen to the infant brain (0.08%), and 2 neonatal deaths. The study authors noted, however, that the risks of these complications were very low. Dr. Catherine Spong, one of the study authors, pointed out that risk for infection and other surgical complications appear to be greater in women undergoing repeat cesarean delivery compared with those who are successful with a VBAC, and having a repeat cesarean delivery may complicate future pregnancies. Citing figures compiled by the National Center for Health Statistics, the study authors noted that the rate of VBAC fell from 31 percent in 1998 to 10.6 percent in 2003. The U.S. Public Health Service, in its Healthy People 2010 Report, proposed a target VBAC rate of 37 percent. Dr. Spong said, because of the large number of women who took part in the study, and the careful, systematic way the researchers collected the data, it offers the most reliable estimate to date of the risks conveyed by attempting vaginal delivery after a previous cesarean delivery.

Later development of preeclampsia can be predicted by a substance in the urine of pregnant women, according to research from the National Institute of Child Health and Human Development (NICHD)(NIH News Jan 4, 2005). The study was published in the Journal of the American Medical Association(2005;293:77–85). “We may have reached a turning point in the extensive federal research investigation of this frequent, life-threatening complication of pregnancy,” said Duane Alexander, M.D., Director of the NICHD. “This finding sets the stage for the development of a test to screen women for high risk of preeclampsia. Once these women are identified through such a test, we can target studies to find effective ways to prevent its progression or to keep the most dangerous complications from occurring.” To conduct the study, the researchers analyzed stored urine samples of 120 women who developed preeclampsia and compared them with samples from 118 women who did not develop preeclampsia. Women were highly likely to develop preeclampsia if they had low levels of placental growth factor (PlGF) in their urine. PlGF works in combination with vascular endothelial growth factor (VEGF). Together, these two substances foster the growth of new blood vessels, and maintain the health of cells that line the inside of blood vessels, including those in the placenta that support the developing fetus. The researchers believe that the high blood pressure and other symptoms characteristic of preeclampsia result from low levels of PlGF and VEGF. Researchers are making plans to refine the finding into an accurate clinical test.