Elina Naydenova

Maternal Nutrition - Who Pulls the Strings of Maternal Mortality

This is the second part of 'Why sometimes less is more in maternal mortality'. You can read the first part, about the safe childbirth checklist, 

The story of food is really the story of human kind. Many facets of the human experience have forged the development of food through the ages. For example, socio-political history: after the Second World War, Western governments vowed to end hunger, increase production and reduce the cost of food. Inevitably, science plays a deep role - fertilizers changed the landscape completely, doubling agricultural production between 1947 and 1979 [1]. Then there is fashion - take Julia Child, who singlehandedly introduced a generation of Americans to French cuisine. And let's not forget the influences of climate change, cultural differences, or the food corporate battles dictating the market. But this is not a blog post about how we shaped food. Rather, it is about how food subliminally shapes us, our health and our well-being.

The big performers on the maternal mortality stage

800 women die every day due to often avoidable complications related to pregnancy or childbirth

99% of these cases occur in developing countries

 [2]. Why does this still happen in today's day and age? In 2006, the World Health Organisation (WHO) published a strategic analysis of leading maternal death causes, accounting for regional differences (Figure 1) [3]. Which are the big players? Haemorrhage is the leading cause of deaths in Africa and Asia. Hypertensive disorders claim most maternal lives in Latin America.

Accessible and affordable interventions to counteract causes of maternal death exist. They vary in nature, cost-effectiveness and universality:

: from women's empowerment and education programmes to community groups for family planning

: from the construction and improvement of appropriate maternal health facilities to training schemes for midwives and healthcare workers

: from screening programs for preeclampsia and hypertensive disorders to management tools and programmes for sepsis and obstructed labour.

What do these two stories - the story of food and the story of childbirth - have in common?

As cost-effective as most of the interventions mentioned above are, some of them are only scratching the surface. There appears to be a more deeply rooted cause, a 

 as an example: on its own, it is a relatively minor cause of maternal deaths (1% - 13%). However, it can be 

indirectly associated with as many as 50% of maternal deaths

 worldwide, by aggravating haemorrhage cases [4, 5]. This effect is particularly horrifying when one considers the overwhelming prevalence of iron deficiency (anaemia) which affects 30-60% of pregnant women in developing countries [6,7]. How do we fight this hidden enemy? Daily 

 during pregnancy has been shown to reduce anaemia by as much as 70% [8,9]. Similarly, 

 during pregnancy has been shown to reduce incidence of hypertensive disorders: preeclampsia (a hypertensive disorder originating in pregnancy) by 55% and gestational hypertension by 35% [10, 11]. Additionally, low-dose weekly supplementation of 

, was seen to reduce mortality due to infection during labour by 44% [12, 13-14].

Does it really work in practice? Randomized trials have delivered compelling evidence that 

nutrition interventions are essential for the prevention of maternal as well as neonatal deaths

 [12]. Existing analysis of the cost-effectiveness of such programmes has indicated their comparable and often superior performance to other standard approaches [12, 15].

But exactly how far does the impact of malnutrition stretch? Much further than we thought...

In the last two decades, multiple studies have demonstrated the indisputable link between maternal health & nutrition and the well being of the child [16-19]. This link originates in pregnancy, where nutritional deficiencies adversely affect foetal development, resulting in low-birth weight or overweight infants and increased risk of complications during labour. But this link extends further than just these first years of life - both low-birth weight and overweight infants have been shown to be more prone to diabetes and cardiovascular disease later in life [20-21]. Nutritional interventions can improve the health of children and adults born to well-nourished mothers; they have also proven to be remarkably cost-effective in ensuring dramatic and sustained impact for little up-front investment [15,22].

Nutrition pulls the health strings of more than one generation - its effects run from maternal health, to the health of her child, and on to the adult they will become. This trans-generational passage of risk constitutes a curse as well as an opportunity - with one cost-effective intervention we can deliver multi-dimensional benefit. Nutrition is the hidden force against maternal and neonatal mortality.

, one of our recommended charities, provides nutritional solutions to communities worldwide in a cost-effective and population-contextualised way. If you would like to empower the hidden force of nutrition, fight maternal mortality and improve the health of future generations, supporting Project Healthy Children is one way to do this effectively. You can learn more about Project Healthy Children 

Somers, M. The Story of our food, Next Nature, 

http://www.nextnature.net/2011/08/the-story-behind-our-food/

http://www.who.int/mediacentre/factsheets/fs348/en/index.html

Khan, K. S. et al. WHO analysis of causes of maternal death: a systematic review 2006.

Gillespie, S. et al. Controlling iron deficiency. United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition, State-of-the-Art Series Nutrition Policy Discussion, 1991 WHO.

Galloway, R. et al., Women's perceptions of iron deficiency and anaemia prevention and control in eight developing countries, Social Science & Medicine 55 (2002) 529 - 544.

Fifth report on the world nutrition situation: nutrition for improved development outcomes, United Nations, ACC/SCN, 2004.

Hunt, J.M. Reversing Productivity Losses from Iron Deficiency: The Economic Case, Journal of Nutrition, 2002.

Pena-Rosas JP et al. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev 2012; 12: CD004736.

WHO. Guideline: daily iron and folic acid supplementation in pregnant women. Geneva: World Health Organization, 2012.

Hofmeyr GJ et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev 2010.

Imdad A et al. Effects of calcium supplementation during pregnancy on maternal, fetal and birth outcomes. Paediatr Perinat Epidemiol 2012; 26: 138–52.

Rouse, D.J., Potential Cost-effectiveness of nutrition interventions to prevent adverse pregnancy outcomes in the developing world, The Journal of Nutrition, 2003.

Sommer A,West KP Jr. Vitamin A deficiency: health, survival, and vision. New York: Oxford University Press, 1996.

Green HN et al. Diet as a prophylactic agent against puerperal sepsis. BMJ 1931;ii:595­8.

Baltussen, R. et al. Iron Fortification and Iron Supplementation Are Cost-Effective Interventions to Reduce Iron Deficiency in Four Subregions of the World, 2004, The Journal of Nutrition 134 (10): 2678–84.

Wijesuriya, M. et al. The Kathmandu Declaration: ‘Life Circle’ Approach to Prevention and Care of Diabetes Mellitus, 2010, Diabetes Research and Clinical Practice 87 (1): 20–26.

Kimani-Murage, E. W. et al. The Prevalence of Stunting, Overweight and Obesity, and Metabolic Disease Risk in Rural South African Children, 2010, BMC Public Health 10 (1): 158.

Whitaker, R. C. Predicting Preschooler Obesity at Birth: The Role of Maternal Obesity in Early Pregnancy. 2010, Pediatrics 114 (1): e29–e36.

Bhargava, S. K. et al. Relation of Serial Changes in Childhood Body-Mass Index to Impaired Glucose Tolerance in Young Adulthood, 2004 New England Journal of Medicine 350 (9): 865–75.

Haugen, G. et al. Fetal Liver-Sparing Cardiovascular Adaptations Linked to Mother’s Slimness and Diet. Circulation Research, 2005, 96 (1): 12–14.

Godfrey, K. M. et al. Fetal Liver Blood Flow Distribution: Role in Human Developmental Strategy to Prioritize Fat Deposition versus Brain Development, 2012, PLoS ONE 7 (8): e41759.

Rouse, Dwight J. Potential Cost-Effectiveness of Nutrition Interventions to Prevent Adverse Pregnancy Outcomes in the Developing World. The Journal of Nutrition 2003, 133 (5): 1640S–1644S.

The Promise of the Safe Childbirth Checklist

This post is the first part of an exploration of 'Why sometimes less is more in maternal health'.

The Checklist story - a minimalist's approach

We, the human race, are doing a pretty good job at understanding ourselves - how our bodies work and how they fail. Currently, there are about 14,000 different healthcare diagnoses known to apply to us. Consequently, doctors are armed with 6,000 drugs and 4,000 medical and surgical procedures, which they use in multiple combinations. So medical errors come as no surprise... Medical practice has become incredibly complex and it really takes a village of multi-disciplinary specialists, who each bring a piece of the puzzle, to deliver medical solutions. And as if this wasn't difficult enough, the changing demographic and socio-economic landscape means that there are more of us to treat and we all expect miracles.

Fortunately, human ingenuity might have found just the right solution - 

 (I am sorry to disappoint any artificial intelligence proponents). A 

cost-effective tool for streamlining the implementation of evidence-based medical practice

, the checklist has gained popularity over the last 15 years. The underlying logic is astonishingly simple: minor missteps in clinical practice can accumulate to BIG problems, meaning higher mortality and morbidity rates, as well as higher costs, which a checklist can help avoid by guiding evidence-based decisions.

For example, to address one typical such scenario, intravascular catheter-related infection, Dr. Peter Pronovost developed and implemented a simple checklist - the concept was then famously corroborated by Atul Gawane in his article 'The Checklist' [1].

The insertion of a line should be conducted in accordance with five steps (Figure 1) that reduce the chance of developing infection – at least one of those is commonly missed in hospital settings amounting to 80,000 line infections per year in the US [2]. Line infection prolongs the stay of patients in intensive care by at least a week, increasing costs; moreover, between 5% and 28% of line infections lead to death [2]. The implementation of the Pronovost checklist has demonstrated a swift decrease in infection rates (from 11% to 0% in the pilot study in ten days), substantial cost reduction, accompanied by (surprisingly) high staff compliance and a reported sense of empowerment [1].

Of course, the challenges in developing countries differ: even more people to treat, less resources, less highly trained professionals and less fancy medical gadgets. Nevertheless, the need for cost-effective, evidence-based interventions is overwhelming and standardising best practice might empower basically trained healthcare workers to deliver efficient medical solutions.

A Checklist to help combat maternal and neonatal mortality?

The absurdity of maternal mortality is that it takes the lives of 800 women every day and yet there are affordable interventions that can prevent most of these deaths [3,4,5]. A key strategy in tackling existing issues is moving the delivery room from the home to the hospital. Great progress has been achieved in this area, only to highlight that simply hospitalising births is not enough. What's missing is trained clinical staff and reliable medical facilities at these hospitals - the provision of good quality facility-based care remains a global challenge [6-10]. But this is where the checklist could make a difference! Why is it appropriate? Here are three great reasons [11,12]:

: the majority of deaths occur within 24 hours after birth

: the main causes of maternal and perinatal mortality are well documented and international guidelines for best practice exist

: proven interventions are affordable and consist of a multistage sequence of simple interventions.

In 2008, the World Health Organisation (WHO) developed the 

, a 29-item checklist designed to improve maternal care in a 

 way [13], originally in ten countries across Africa and Asia. The checklist contains reminders of 

 (haemorrhage, infection, obstructed labour and hypertensive disorders) as well as 

 during and after birth in resource-limited settings [14].

 The pilot study, in Karnataka, India, demonstrated 

 - 95% of the health workers adopted the use of the checklist. Furthermore, it was 

 - the delivery of essential practices increased from 10 to 25 out of 29 practices. Specific areas of improvement included: appropriate hand hygiene, adequate management of maternal infection and preeclampsia (a cardiovascular disease rooted in pregnancy), maternal blood loss assessment, cutting of the cord with a sterile blade, appropriate administration of oxytocin (medication used to induce labour and reduce bleeding), appropriate newborn thermal and resuscitation management.

 The Safe Childbirth Checklist can affect clinical outcome in three main ways: 

remind health workers of the crucial timing

identify gaps in existing clinical practice

Is it that simple - the realist's approach

 – e.g. the staff created a postpartum bay for observation of mothers and babies after birth, using an unused space; medical supplies were moved from remote storage into local stacks to better support labour ward workers. However, are these outcomes truly sustainable and scalable? The pilot studies were conducted in first-level referral centres in India with motivated local teams; plus behavioural changes could be driven by the awareness of being observed.

: a multi-centred randomized control trial in more than 100 hospitals has been set up to further evaluate the effectiveness and sustainability of the Safe Childbirth Checklist, with data collection conducted by Harvard School of Public Health between 2013 and 2016 [15]. And we are still to see a detailed quantitative analysis of its cost-effectiveness.

To play devil's advocate, the checklist excitement has been critically named a "Hitchcockian McGuffin", a false objectification of the problem that distracts from the true challenges of delivering safe care [16]. Checklists on their own could be equally unsafe if they are used to install a false sense of security, cloud judgement and consequently plant negligence - the very problem they were designed to tackle. Therefore, any checklist implementation programme should be designed around establishing a higher standard of baseline performance; it should empower clinical workers to improve their practice, minimise avoidable error but be careful not to drive complacency.

Gawande, A. The Checklist, The New Yorker, Annals of Medicine, 2010

Pronovost, P., Needham, D., Berenholtz, S. et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med, 2006, 355(26), pp. 2725-2732

Hogan, M. C., Foreman, K. J., Naghavi, M., et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5 2010

Rajaratnam, J. K., Marcus, J. R., Flaxman, A. D., et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress towards Millennium Development Goal 4 2010

Cousens, S., Blencowe, H., Stanton, C., et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: A systematic analysis 2011

Ekirapa-Kiracho, E., Waiswa, P., Rahman, M. H., et al. Increasing access to institutional deliveries using demand and supply side incentives: Early results from a quasi-experimental study 2011

Harvey, S. A., Blandón, Y. C. W., McCaw-Binns, A., et al. Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward 2007

Koblinsky, M., Matthews, Z., Hussein, J., et al. Going to scale with professional skilled care 2006

Friberg, I. K., Kinney, M. V., Lawn, J. E., et al. Sub-Saharan Africa's mothers, newborns, and children: How many lives could be saved with targeted health interventions? 2010

Van Den Broek, N. R., Graham, W. J. Quality of care for maternal and newborn health: The neglected agenda 2009

Tamburlini, G., Yadgarova, K., Kamilov, A. and Bacci, A. Improving the Quality of Maternal and Neonatal Care: The Role of Standard Based Participatory Assessments 2013

WHO, UNICEF, UNFPA. Trends in maternal mortality: 1990-2008 2010

Weiser, T. G., Haynes, A. B., Lashoher, A., et al. Perspectives in quality: Designing the WHO surgical safety checklist 2010

Spector, J. M., Agrawal, P., Kodkany, B., et al. Improving quality of care for maternal and newborn health: Prospective pilot study of the who safe childbirth checklist program 2012

Safe Childbirth Checklist Programme: an overview, World Health Organization, WHO/HIS/PSP/2013

Bosk, C.L., Dixon-Woods, M., Goeshel, C.A. and Pronovost, P.J., 2009. Reality check for checklists. Lancet, 374(9688), pp. 444-445

Elina Naydenova

Articles

Maternal Nutrition - Who Pulls the Strings of Maternal Mortality

The Promise of the Safe Childbirth Checklist