Pregnancy and Early Neonatal Period Essay
The role of the Australian father is chiefly economy-oriented. He is of the view that his wife needs to be a housewife until the baby attains the age of 4 years when he can be sent to a kinder garden. He focuses mainly on the financial impact in the upbringing of the child as the cost of child care in Australia is high and supposes that any income earned by his wife’s early employment would be forced to be paid in the costly child care alone. Partly this view of him is justified because in addition to the fiscal issue early employment of the mother would enforce avoidable physical separation of the infant from parents.
The mother’s intention to go to work at the child’s age of 1 or 1.5 does not imply any diminished care orientation. However, the pragmatic inconveniences in bringing up the child at this stage are not foreseen by her. The assistance rendered by her mother during the birth time would not be quite available nor be accessed easily after one or two years. Pregnancy and Early Neonatal Period Essay. This should have been given weight in assessing future modalities. Hence the father’s wish of his wife going for a job at the schooling age of the child is acceptable, although he too does not foresee the types of inconveniences that may arise in due course of bringing up of the baby. Services of the grandparents (father side) of the baby can be harnessed by the mother of the baby to the extent possible, as there exist in some lingual communication delay. The actual requirement of the baby at a particular time need be expressed to her mother-in-law or father-in-law, for which the mother’s communication skill in the Australian language accent may be a hurdle. Moreover, the father’s side grandparents’ ability to understand Chinese or Chinese accent in her English can be considered too wanting. In this view, the mother’s wish to go away for a job can be considered right as she may gain some more knowledge and language of the soil at an early stage.
The greatest risk of childhood death occurs during the neonatal period, which extends from birth through the first month of life. About 60 percent of all deaths to children under age 5 and nearly two-thirds of infant deaths (birth to 12 months) occur during the neonatal period (Rutstein, 2000). About two-thirds of all neonatal deaths occur during the first week of life. Current estimates place the annual neonatal death toll at 4 million (Save the Children, 2001).
Approximately 98 percent of neonatal deaths occur in the developing world (World Health Organization, 1996b). The highest annual neonatal rates are in South Asia, where an estimated 51 deaths occur for every 1,000 live births. Each year in South Asia alone, 2 million children die within a month of their birth. By comparison, the rates per 1,000 live births are 42 in Africa, 25 in Latin America, and fewer than 10 in Europe and North America (World Health Organization, 1996b). Pregnancy and Early Neonatal Period Essay. The burden of neonatal morbidity in developing countries is unknown; however, a recent study of neonatal morbidity in rural India revealed that nearly half of the 763 infants observed developed high-risk morbidities (those with a case fatality greater than 10 percent), and nearly three-quarters suffered low-risk morbidities, some in addition to high-risk conditions (Bang et al., 2001).
Most neonatal deaths occur at home, following unsupervised deliveries; thus little accurate information is available as to their causes (Stoll, 1997). Limited epidemiological research indicates that the principal direct causes of neonatal death are infectious diseases, birth asphyxia, birth injuries, and the sequelae of preterm birth and birth defects (Figure 3-1). During the early neonatal period (0-7 days), the major causes of death are asphyxia, infection, complications of prematurity, and birth defects; infections cause most late neonatal deaths (8-28 days) (Lawn et al., 2001).
This chapter addresses neonatal infections, birth asphyxia, birth injury, hypothermia, and hyperbilirubinemia. Strategies to reduce mortality and morbidity associated with low birth weight are discussed in Chapter 6; those associated with birth defects, in Chapter 7; and those associated with perinatal transmission of HIV, in Chapter 8.
Infections are the major cause of mortality and morbidity in infants under 3 months of age in developing countries (Stoll, 1997). As noted in Chapter 1, more than 20 percent of children born in developing countries acquire an infection during the neonatal period, leading to an estimated 30 to 40 percent of all neonatal deaths (Stoll, 1997; Stoll, 2000). Pregnancy and Early Neonatal Period Essay.Most of these deaths are caused by acute respiratory infections, bacterial sepsis and/or meningitis, neonatal tetanus, and diarrhea (Table 3-1). Maternal infections, including sexually transmitted diseases (STDs) such as HIV (the topic of Chapter 8) and syphilis, can be transmitted to the fetus or newborn in utero, through contact during labor and delivery, and in some cases, through breastfeeding.
In many countries, bacterial sepsis accounts for a substantial burden of disease and has a 40% case fatality rate (Stoll, 2000). Early-onset neonatal sepsis (48-72 hours) usually results from organisms acquired from the maternal genital tract during birth and often is associated with maternal complications; late-onset neonatal sepsis (7-28 days) is more likely to be caused by organisms acquired from the environment (Korbage de Araujo et al., 1999; Martius et al., 1999; Moreno et al., 1994; Kuruvilla et al., 1998; Schuchat et al., 2000; Stoll et al., 2002a,b).
Estimates of the incidence of neonatal sepsis are based largely on cases that reach the hospital, which undoubtedly underestimates the incidence in the community. In pooled data from hospital-based case series, the incidence was 6 cases per 1000 live births (Stoll, 2000); other studies suggest that rates may be even higher (Kuruvilla et al., 1998; Asindi et al., 1999). Among patients enrolled in the WHO Young Infants Study—a study of infants under 3 months of age with serious infections conducted at four sites (Ethiopia, the Gambia, Papua New Guinea, and the Philippines)— 30 percent of infants with a positive blood culture died (WHO Young Infants Study Group, 1999a). In 47 hospital-based studies, case fatality rates were as high as 69 percent (Stoll, 2000). Left untreated, bloodstream infections can spread to the meninges, resulting in meningitis. Estimates of neonatal meningitis incidence range from 0.3 to 2.8 per 1,000 live births (average 1/1000 live births), and reported case fatality rates range from 13 to 59 percent (Stoll, 2000).
Omphalitis (umbilical infection) continues to be a problem in developing countries (Cushing, 1985). Births in the home, nonsterile cutting of the cord, and unhygienic cord care after birth all increase the risk of omphalitis. Pregnancy and Early Neonatal Period Essay. Because localized umbilical infection is not prevented and may be inadequately treated in developing-country settings, it may be associated with the subsequent development of necrotizing fasciitis and/or neonatal sepsis (Faridi et al., 1993; Weber et al., 2001). Moreover, omphalitis in patients with neonatal tetanus (discussed below) is associated with an increased risk of bacterial sepsis (Egri-Okwaji, 1998).
Because the majority of developing-country studies that present data on the bacterial etiology of neonatal sepsis and meningitis are hospital-based, they may not reflect what is happening at the community level. While group B streptococcus (GBS) remains an important cause of early neonatal sepsis in industrialized countries (Schuchat, 1998), it appears to be a much less important pathogen in developing countries (WHO Young Infants Study Group, 1999a; Stoll, 2000). The most frequent organisms reported from case series in developing countries are gram-negative organisms (especially Escherichia coli and Klebsiella) and Staphylococcus aureus (Stoll, 2000; Mulholland, 1998). The organisms responsible for neonatal sepsis and meningitis are similar, change over time, and vary by geographic region. Therefore, prospective microbiological surveillance is key for prevention and appropriate treatment of these diseases.
The emergence of antibiotic-resistant pathogens is a particularly alarming problem in developing countries. Hospital-based studies of the bacterial etiology of neonatal sepsis and reports of nosocomial outbreaks from a variety of countries demonstrate that the problem of antibiotic resistance is of global concern (Banerjee et al., 1993; Reish et al., 1993; Haddad et al., 1993; Bhutta, 1996; Ako-Nai et al., 1999; Musoke, 1997; Musoke and Revathi, 2000). The widespread availability of antibiotics and their indiscriminate and inappropriate use contribute to this problem, along with poor infection-control practices in hospitals.
Surveillance capacity and the transfer of surveillance information must be developed to determine both the global and local impact of resistant microorganisms and to identify interventions that can address this threat (Williams, 2001). Strategies are needed to reduce the risk of infection, as well as to encourage the judicious prescription and appropriate use of antibiotics in the community and in hospital (Levy, 2001; Boyce, 2001; Perchère, 2001; Bell, 2001; de Man et al., 2000). Some epidemiologists caution, however, that the prudent use of antibiotics is unlikely to reverse resistance trends and that the true clinical impact of antibiotic resistance has not yet been measured (Phillips, 2001). Pregnancy and Early Neonatal Period Essay.
Pneumonia and other acute respiratory infections (ARIs) account for up to a quarter (Pan American Health Organization, 1999) or perhaps more of all mortality in children under 5, but it is difficult to determine the incidence of neonatal ARI in developing countries because many sick neonates are not referred for medical care. The risk of death due to ARI is highest in young neonates and decreases with age (Garenne et al., 1992).
Most ARI deaths are due to pneumonia, which annually kills more than 3 million children under the age of 5 in developing countries (Garenne et al., 1992). Like sepsis, neonatal pneumonia may have an early onset if acquired from the maternal genital tract or a late onset due to infection from the hospital or home environment. Bacterial pneumonia is the most common; streptococcus pneumoniae is the most frequent cause. Low birth weight is associated with higher mortality (Misra et al., 1991). The risk of pneumonia increases in infants who are of low birth weight and/or malnourished, and in those who are not breastfed (Victora et al., 1999).
In preterm neonates of low birth weight, respiratory distress syndrome, due to surfactant deficiency, is a major risk for early death (Mlay and Manji, 2000). Information on the prevalence of this disorder in developing countries is especially difficult to obtain because most infants of very low birth weight (those weighing less than 1500 grams, who are at greatest risk) die soon after birth. In these cases, causes of death other than prematurity are poorly recognized (Bhutta et al., 1999).
A leading infectious disease, tuberculosis (TB) kills more than 2 million people worldwide each year, including 250,000 children, despite the availability of cost-effective prevention and treatment (United Nations Children’s Fund, 2000). The vast majority of these deaths occur in developing countries; approximately 70 percent of all TB cases occur in Asia (United Nations Children’s Fund, 2000). TB is a particular risk in areas where HIV is prevalent, as approximately 40 percent of people whose immune systems have been weakened by HIV develop TB (United Nations Children’s Fund, 2000; Thillagavathie, 2000). Pregnancy and Early Neonatal Period Essay. The reportedly higher TB prevalence in men than in women appears to be an artifact of gender differences in notification rates (Thorson and Diwan, 2001).
In pregnant women, TB has been shown to increase the risk of fetal loss, preterm delivery, and low birth weight (Starke, 1997; Jana et al., 1994). Although rare, transplacental congenital infection may occur (Connelly Smith, 2002; Starke, 1997); infection with HIV increases a woman’s risk for placental or genital TB. The most common route of mother-to-child transmission is postnatal from an untreated infected mother to her newborn. Infected newborns are at high risk for severe disseminated TB and death (Starke, 1997; Adhikari et al., 1997).
Several community-based studies suggest that diarrhea is responsible for approximately 3 percent of all neonatal deaths (Stoll, 2000). Diarrheal episodes tend to occur with greatest frequency among children aged 6 months to 2 years; in many developing countries, initial episodes frequently occur in the first 6 months of life (Bern et al., 1992; Snyder and Merson, 1982; Jacobson, 1999). Some factors common to developing countries— home delivery; relative segregation of newborn infants for a period of time after birth; and the high prevalence of early, exclusive breastfeeding—protect against neonatal diarrhea. Among hospitalized newborns in developing countries, nosocomial diarrhea is an important problem (Aye et al., 1991; Yankauer, 1991; Tessema, 1994). Pregnancy and Early Neonatal Period Essay.
Rotavirus is an important cause of diarrhea among infants and children worldwide, occurring most commonly in those aged 3 months to 2 years. However, several studies from developing countries report rotavirus infections in newborns (Haffejee, 1995; Parashar et al., 1998b; Cicirello et al., 1994; Espinoza et al., 1997; Gomwalk et al., 1990).
Worldwide, about a quarter-million infants die from tetanus each year (Table 3-1). Risk factors for neonatal tetanus occur in the antenatal, perinatal, and neonatal periods: failure to immunize the mother against tetanus; unhygienic delivery and cutting of the umbilical cord at birth; and unsterile handling of the cord in the early days of life. Cultural practices prevalent in specific areas, such as the application of ghee (Pakistan and India) and other unclean substances to the cord after birth increase risk (Traverso et al., 1991). Diagnosis of neonatal tetanus is relatively straightforward: the newborn can suck at birth and for the first few days of life, then loses this ability between 3 and 10 days of age, then develops spasms, stiffness, convulsions, and death. For decades, community surveys have determined the burden of disease and mortality rates for tetanus (Galazka and Stroh, 1986). Routine national surveillance, however, may still underestimate the true occurrence of the disease (Singh et al., 1997). In some of the least-developed countries, neonatal tetanus remains a major cause of neonatal death, particularly among infants delivered at home and without skilled assistance (Gasse, 1995; Gupta and Keyl, 1998; Gurkan et al., 1999; Davies-Adetugbo et al., 1998).
Between 1990 and 2000, deaths caused by neonatal tetanus declined by half through a combination of maternal immunization and clean delivery practices (United Nations Children’s Fund, 2002). Substantial reductions in neonatal mortality due to tetanus occurred in China, Indonesia, Bangladesh, India, and Pakistan. Nevertheless, approximately 250,000 neonates died of tetanus during 1997; the majority of these deaths occurred in Africa and Southeast Asia, with nearly 20 percent in India (World Health Organization, 1999a). Pregnancy and Early Neonatal Period Essay.
More than 333 million cases of the four major curable STDs—syphilis, gonorrhea, chlamydia, and trichomoniasis—were estimated to occur in 1995, the vast majority in developing countries (Gerbase et al., 1998). Collectively, STDs rank among the leading causes of morbidity worldwide, a burden borne disproportionately by women of reproductive age. STDs among pregnant women often receive delayed treatment or none at all, largely because they are asymptomatic or unrecognized (Sturm et al., 1998). Most STDs are readily transmitted from mother to child during pregnancy and/or childbirth (Moodley and Sturm, 2000). The extent of neonatal infections with these agents in developing countries is difficult to estimate. Adverse pregnancy outcomes associated with STDs range from miscarriage and preterm birth (see Chapter 7) to congenital infections to maternal, fetal, and neonatal mortality (Carroli et al., 2001a; Moodley and Sturm, 2000). Neonatal HIV is discussed in detail in Chapter 8.
Among women worldwide, there are approximately 7 million new cases of syphilis each year (Gerbase et al., 1998). Rates of congenital syphilis parallel those of syphilis in women of reproductive age. Many developing-country studies have found seroprevalence rates of syphilis among pregnant women of 5 to 15 percent, or up to two orders of magnitude higher than typical rates in developed countries (Carroli et al., 2001a); in South Africa, rates of infection in pregnant women have been reported to range from 6 to 19 percent (Rotchford et al., 2000). Untreated syphilis during pregnancy increases the risk of late fetal death, low birth weight, preterm birth, and severe neonatal disease (Lumbiganon et al., 2002). Data from a demonstration project in Zambia determined that syphilis was the most significant cause of adverse pregnancy outcome among women attending antenatal clinics (Hira et al., 1990); a more recent prospective study of congenital syphilis in a Papua New Guinea hospital found that the infection was responsible for 6 percent of admissions and 22 percent of all neonatal deaths (Frank and Duke, 2000). Pregnancy and Early Neonatal Period Essay.
Syphilis is transmitted from an infected mother to the fetus largely via transplacental infection, and rarely via contact with an infectious genital lesion during delivery. Active infection with syphilis in pregnant women is estimated to result in fetal or infant death or disability for 50 to 80 percent of affected pregnancies (Gloyd et al., 2001). The majority of infants born to mothers with untreated syphilis are asymptomatic at birth, but if left untreated may develop clinical manifestations of disease months to years after birth (Dorfman and Glaser, 1990; Sanchez et al., 1991). Symptoms of early congenital syphilis include intrauterine growth restriction, anemia, thrombocytopenia, jaundice, and hepatosplenomegaly (Stoll et al., 1993). The most devastating complications of untreated or late congenital syphilis are neurological manifestations that include mental retardation, hydrocephalus, cranial nerve palsies, and seizures (Stoll, 1994). With adequate treatment of infected mothers, syphilis is a preventable cause of neonatal morbidity and mortality.
Neonates delivered vaginally to mothers with untreated gonorrhea are at great risk of developing gonococcal conjunctivitis, which, if left untreated, can lead to blindness. Rarely, neonates develop disseminated gonococcal infection (Desenclos et al., 1992; Rawstron et al., 1993). Similarly, chlamydia infections occur in approximately two-thirds of infants born by vaginal delivery to infected mothers (Moodley and Sturm, 2000). Chlamydia can cause conjunctivitis and/or pneumonia, which may not be evident until the infant is several weeks old.
Neonatal infection with herpes simplex usually occurs during delivery, via an infected birth canal or an ascending infection following the rupture of membranes to women with primary genital herpes at the time of delivery (Prober et al., 1988; Brown et al., 1996; Brown et al., 1987). The infection can spread to the central nervous system and beyond, and has both a high mortality rate and a high likelihood of neurodevelopmental sequelae among survivors (Tookey and Peckham, 1996; Brkic and Jovanovic, 1998; Jacobs, 1998; Whitley et al., 1991).
Infections of the urinary tract, particularly asymptomatic bacteriuria, occur in an estimated 4 to 7 percent of all women (Carroli et al., 2001a; Dempsey et al., 1992;). Unless the infection is treated with antibiotics, an estimated 20 to 40 percent of pregnant women with asymptomatic bacteriuria will develop pyelonephronitis (Smaill, 2003); of those who do, 20 to 50 percent will experience preterm deliveries (Carroli et al., 2001a).Pregnancy and Early Neonatal Period Essay. Antibiotic treatment is associated with reductions in preterm delivery and low birth weight (Smaill, 2003).
Malaria in pregnancy has serious health consequences for both mother and newborn. Because it causes significant maternal morbidity, its prevention and treatment are discussed in Chapter 2. The primary malaria-associated risk for neonates is reduced birth weight, which is discussed in Chapter 6. In highly endemic settings, malaria has been estimated to account for 13 percent of low birth weight (LBW) due to intrauterine growth restriction (IUGR) (Steketee et al., 1996).
Of the estimated 4 to 7 million neonates born each year worldwide that require some form of resuscitation immediately after birth, approximately 1 million die and another million suffer serious sequelae (Saugstad et al., 1998). Epidemiological data provide only rough estimates of the global burden of perinatal asphyxia, in part because of the imprecision of diagnosis. Numerous definitions of perinatal asphyxia, all of which correspond to the failure to initiate and sustain normal breathing, have been used in studies from developing countries. These include apnea or gasping with a slow heart rate (<80) at birth, absent or poor respiratory effort at 1 minute, gasping at 1 minute, low Apgar scores (variously defined), and the need for assisted ventilation for more than 1 minute (Paul et al., 1997; Chandra et al., 1997; Daga et al., 1990; Saugstad et al., 1998; Kinoti, 1993). In addition, data on perinatal asphyxia are largely hospital-based and therefore may either underestimate or overestimate the true magnitude of the problem, as seen in many studies (Paul et al., 1997; Chandra et al., 1997; Daga et al., 1990; Kinoti, 1993; Chaturvedi and Shah, 1991; Boo and Lye, 1991; Nathoo et al., 1990; Ellis et al., 2000). Pregnancy and Early Neonatal Period Essay.
The incidence of perinatal asphyxia is thought to be higher in developing than developed countries because of the higher prevalence of risk factors for the disorder, as well as the lack of appropriate interventions (Deorari et al., 2000). Mortality is greater among preterm than term infants, and decreases with increasing birth weight. However, asphyxia also has an important effect on mortality among normal-weight term infants, who otherwise have a good chance for survival (Paul et al., 1997). The contribution of perinatal asphyxia to long-term neurodevelopmental disability in developing countries is unclear (Ellis et al., 1999).
Conditions that increase the risk of asphyxia include antepartum hemorrhage, prolonged labor and/or prolonged rupture of membranes, drugs given to the mother that may depress respiration (e.g., magnesium sulfate, narcotics), cord accidents, vaginal breech deliveries, multiple gestation, pregnancy-induced hypertension, congenital anomalies, and IUGR with placental dysfunction (Chandra et al., 1997; Daga et al., 1990; Chaturvedi and Shah, 1991; Boo and Lye, 1991; Nathoo et al., 1990). In most resource-poor countries, where the vast majority of births take place at home, asphyxia is difficult to anticipate. The passage of meconium in the amniotic fluid and an abnormal fetal heart rate (bradycardia or persistent tachycardia) are the only simple ways to predict asphyxia prior to delivery in most developing countries; only about half of all cases can be detected this way (Chaturvedi and Shah, 1991).
Birth injury is a nonspecific term that includes potentially preventable and unavoidable injuries—mechanical or hypoxic-ischemic—suffered by the neonate during labor and delivery. Specific injuries include intracranial hemorrhage; blunt trauma to the liver, spleen, or other internal organs; injury to the spinal cord or peripheral nerves (the most devastating is cord transection; the most common is brachial plexus injury); and fractures to the clavicles or extremities.
Although WHO has estimated that birth injuries are responsible for 11 percent of neonatal deaths worldwide (World Health Organization, 1996c), the incidence of specific injuries in most developing countries is unknown. Pregnancy and Early Neonatal Period Essay. Birth injuries can result in transient neonatal problems, long-term morbidity, and death. Predisposing factors include macrosomia, cephalopelvic disproportion, dystocia, prolonged or obstructed labor, breech presentation, and prematurity. Although injury may occur despite skilled care at delivery, some injuries result from inadequate medical knowledge or suboptimal care during labor and delivery and are therefore potentially preventable. A specific diagnosis is preferable to the use of the nonspecific term “birth injury,” especially when considering prevention strategies.
Hypothermia, defined as a body temperature below 36.5°C, is frequent in newborns, especially those of low birth weight. Several studies have shown that without adequate care, many newborns will experience severe hypothermia, reaching core temperatures lower than 32°C (Ellis et al., 1996). Neonatal hypothermia has been reported to increase the risk of infection, coagulation abnormalities, acidosis, complications of preterm birth, and death (Dragovich et al., 1997; Dagan and Gorodischer, 1984; Manzar, 1999).
Dragovitch et al. (1997) evaluated the knowledge and practices of health professionals on thermal control of newborns in seven countries: Brazil, India, Indonesia, Kazakhstan, Mozambique, Nepal, and Zimbabwe. They found that thermal control practices were frequently lacking in the following areas: ensuring a warm environment at the time of delivery, initiation of breastfeeding and contact with the mother, bathing, checking the baby’s temperature, thermal protection of low-birth-weight neonates, and care during transport. The study also demonstrated that health professionals involved in newborn care underestimate the impact of hypothermia on neonatal morbidity and mortality. A recent survey of health professionals involved in newborn care in an Indian hospital revealed similarly weak knowledge of hypothermia diagnosis and care; for example, fewer than one-fifth of the respondents knew the correct method of measuring the body temperature of a newborn (Choudhary et al., 2000). Pregnancy and Early Neonatal Period Essay.
Since most births occur at home, the magnitude of this problem is unknown. Although a relatively rare cause of death in neonates, untreated extreme bilirubinemia can cause devastating neurologic injury, long-term disability or death. With adequate vigilance, detection, and treatment such infrequent but severe damage can be prevented. The major risk of untreated hyperbilirubinemia is bilirubin encephalopathy or kernicterus (Dennery et al., 2001; Alpay et al., 2000). In the first week of life, visible jaundice occurs in approximately 15 percent of newborns (Cashore, 1994). However, many more with elevated bilirubin below 7 to 8 mg/dL do not develop jaundice and the bilirubin elevation remains undetected. However, mild elevation, though common, need not cause harm to the baby. Causes of hyperbilirubinemia include prematurity, blood group incompatibility, and peripartum infection. Most often, elevated levels of bilirubin in the baby’s blood come about from breakdown of hemoglobin in old or hemolyzed red blood cells (Dennery et al., 2001). There are many causes of indirect hyperbilirubinemia, including increased production of bilirubin, impaired conjugation, and increased enterohepatic circulation. The reason for racial differences in hyperbilirubinemia has some genetic basis but is not completely understood (Setia et al., 2002; Dennery et al., 2001; Akaba et al., 1998). The risk of Rh hemolytic disease has been markedly reduced in industrialized countries by the use of Rh immune globulin (Rhogam) (Queenan, 2002). However, Rh disease remains a problem in developing countries, where most women deliver at home, blood type is unknown, and Rhogam is not available.
Kernicterus or bilirubin encephalopathy results from deposition of unconjugated bilirubin in the basal ganglia. Kernicterus is rare in healthy term infants in the absence of hemolysis if the serum bilirubin level is under 25 mg/dL (Gourley, 1997; Hansen and Bratlid, 1986). The duration of exposure required for toxicity is unclear. Preterm infants are at greater risk for kernicterus, but the exact level at which toxicity occurs is unknown. The early signs of bilirubin encephalopathy are nonspecific (lethargy, poor feeding), but the infant may become critically ill with bulging fontanel, opisthotonus, shrill cry, spasms, and seizures. Late sequelae of kernicterus include extrapyramidal abnormalities, choreoathetosis, involuntary muscle spasms, and sensorineural deafness.
Reducing neonatal mortality and morbidity often involves established interventions or strategies along with the means to make them effective in each setting. For many conditions, improved education and behavioral change among women, families, and health care providers would have a major impact on birth outcomes. For direct impact, emphasis must be given to the delivery of care: getting appropriate services to those who need them and doing so in a timely manner. Interventions to reduce neonatal mortality and morbidity are discussed below, with emphasis on antenatal care, care during labor and delivery, and care during the early days and weeks of life.
Medical factors that may contribute to neonatal morbidity and mortality include several components that can be directly addressed by antenatal care: poor maternal health and nutrition, maternal infections, and lack of immunization against tetanus (Villar et al., 2001; Carroli et al., 2001a, 2001b; Bergsjo and Villar, 1997). Equally important, as described in the previous chapter, antenatal care can teach mothers to recognize signs during pregnancy, labor, and delivery and encourage them to plan clean and safe deliveries—preferably with trained assistance (Bloom et al., 1999). Appropriate antenatal care also includes explaining the benefits of breastfeeding, childhood immunization, and personal and domestic hygiene, and teaching parents to recognize danger signs that can occur in newborns. Pregnancy and Early Neonatal Period Essay.
As noted in the introduction to this report, maternal education has a significant and far-reaching impact on antenatal care (Bicego and Boerma, 1993; Victora et al., 1992; Terra de Souza et al., 2000; van Ginneken et al., 1996; Rao et al., 1996). Better formal and health education of girls leads them in later years to seek preventive services, increase food intake during pregnancy, reduce tobacco and alcohol use, understand the implications of danger signs during labor and delivery, and seek referral care for obstetric and/or newborn complications (World Bank, 1993; Ahmed et al., 2001).
The discussion in this chapter focuses on those antenatal interventions that are directed at preventing and treating maternal conditions that directly affect the neonate. Antenatal care directed at maternal morbidity and mortality is discussed in Chapter 2, at low birth weight in Chapter 6, at birth defects in Chapter 7, and at mother to infant transmission of HIV in Chapter 8. Findings from these chapters are assembled in a list of essential antenatal care interventions in the executive summary and the concluding chapter (9).
Timely diagnosis and treatment of maternal infections and other health problems during pregnancy can lead to significant improvement in fetal and neonatal outcomes, as well as prevention of maternal mortality and morbidity. These are discussed in Chapter 2. Conditions of particular concern to the neonate include the following:
Sexually transmitted diseases. Treatment of STDs is cost-effective (Mayaud et al., 1995), but clinical diagnosis is difficult because the symptoms are not specific, laboratory support is often unavailable (Bosu, 1999), and simple, inexpensive, sensitive tests exist only for syphilis (Moodley and Sturm, 2000). For these reasons, WHO has recommended a syndromic approach to diagnosing and treating STDs in low-resource settings (World Health Organization, 1994). However, the efficacy of syndromic treatment, especially among pregnant women, is unclear (Mayaud et al., 1995, 1998; Sturm et al., 1998). Several studies have documented that STDs facilitate HIV transmission (Fleming and Wasserheit 1999). A randomized, controlled trial in the Mwanza region of Tanzania concluded that STD treatment significantly reduced the incidence of HIV infection (Grosskurth et al., 1995) and was highly cost-effective (Gilson et al., 1997). Pregnancy and Early Neonatal Period Essay. A community-based, randomized trial of STD control in the Rakai district of Uganda (where the HIV infection rate is higher) demonstrated that reduction of STDs improved pregnancy outcome (reduced the rate of low birth weight, infant ophthalmia, and early neonatal mortality), but did not reduce transmission of HIV to mother, fetus, or neonate (Gray et al., 2001). All women were treated for syphilis if their serological test was positive. Other STDs were treated presumptively in randomized fashion using antibiotics effective against a wide range of pathogens. Further research is needed to determine the optimal strategy to reduce the neonatal impact of STDs in developing countries. Two possibilities are presumptive therapy for all pregnant women and development of cost-effective diagnostic tests for use in field settings to facilitate prompt maternal therapy.
Serologic screening of pregnant women for syphilis has been shown cost-effective even in areas where disease prevalence is low (Carroli et al., 2001a; Gloyd et al., 2001; Frank and Duke, 2000; Schmid, 1996). WHO recommends universal antenatal screening for syphilis; in areas of high prevalence of the disease, screening should be performed at the first antenatal visit and repeated early in the third trimester (Lumbiganon et al., 2002). Treatment in the last trimester of pregnancy may not ensure that the fetus/ newborn is uninfected at birth. If adequate maternal treatment cannot be documented, the infant should be treated for syphilis.
Rapid, inexpensive serological tests for syphilis increase the likelihood a woman will receive adequate treatment by allowing her to be screened and treated in the same clinic visit (Rotchford et al., 2000; Wilkinson and Sach, 1998). Routine screening is less effective as it involves follow-up of both the mother and her sexual partner(s). A “second-best” strategy in areas of low syphilis prevalence is the screening of high-risk groups, then examination of women with symptoms and those whose partners report symptoms (Carroli et al., 2001a).
Routine screening for chlamydia during pregnancy has not proven cost-effective (Carroli et al., 2001a). WHO recommends that maternal screening and antibiotic treatment be considered in populations where chlamydia prevalence in pregnant women exceeds 10 percent and where some infants with chlamydial pneumonia are hospitalized at high cost. Sexual partners must also be treated to prevent reinfection during pregnancy (World Health Organization, 1996a). Pregnancy and Early Neonatal Period Essay.
In areas where HIV testing and counseling are readily available, WHO recommends that those services be offered to pregnant women, especially those at high risk for HIV infection (World Health Organization, 1996a). Chapter 8 examines the role of antenatal care in prevention of mother-to-infant transmission of HIV.
Urinary tract infection. Evidence from several randomized controlled trials indicates that antibiotic treatment of urinary tract infection and/or asymptomatic bacteriuria reduces the risk of low birth weight, but the mode of prevention is unclear. Screening for and treatment of asymtomatic bacteriuria during pregancy are recommended in order to prevent maternal pyelonephritis, as well as reduce risk to the neonate (Smaill, 2003).
Tuberculosis. Policies for screening pregnant women for TB, a leading cause of death in some parts of the world, may be adapted to local epidemiology and TB control programs (Ahmed et al., 1999). Some experts believe that only women with specific risk factors for tuberculosis infection or disease should receive a tuberculin skin test as part of antenatal care. Women coinfected with tuberculosis and HIV are at particularly high risk (Pillay et al., 2001). Women with positive skin tests require a chest radiograph to rule out active pulmonary disease and are referred for therapy if the radiograph is abnormal. Treatment of tuberculosis during pregnancy is essential (Pillay et al., 2001); the specific drugs provided depend on safety and efficacy in pregnancy (Starke, 1997), as well as local patterns of drug sensitivity (Davidson, 1995).
Malaria prevention and treatment in pregnant women is discussed in Chapter 2.
Rubella infection during pregnancy (especially the first trimester) can result in miscarriage, late fetal death, or congenital rubella syndrome. Congenital rubella syndrome and possibilities for prevention are discussed in Chapter 7. Immunization of school children and preconceptional women is recommended in countries as long as immunization reaches more than 80 percent of the population. Pregnancy and Early Neonatal Period Essay.
Fetuses, neonates, and young infants can be protected from a variety of infections through passively acquired transplacental and breast milk antibodies. For example, antenatal immunization against rubella provides low-cost, effective protection from congenital rubella syndrome. Because most IgG antibody is transported across the placenta in the last 4–6 weeks of pregnancy, maternal immunization to protect the infant is most promising for term babies. For preterm infants there is insufficient passage of maternal antibodies. However, boosting breast milk antibodies by immunizing mothers can protect both term and preterm infants.
Tetanus. Immunization of pregnant women with tetanus toxoid, which has dramatically reduced cases of neonatal tetanus, is an important, low-cost antenatal intervention (Gupta and Keyl, 1998; Jeena et al., 1997; Bergsjo and Villar, 1997. Moreover, maternal tetanus immunization has been associated not only with lower neonatal mortality but also with lower early childhood mortality (Luther, 1998). In a study in Bolivia, traditional birth attendants employed single-use, prefilled injection devices to immunize more than 2,000 pregnant women against tetanus during routine antenatal visits. Because tetanus toxoid is relatively heat-stable, the prefilled devices could be stored for up to one month without refrigeration (Quiroga et al., 1998). A study in Bangladesh showed that tetanus toxoid immunization rates were positively associated with proximity to outreach clinics and the presence of a health worker in community and home visits. The effects were greatest in poorer households (Jamil et al., 1999).
Pneumonia. Maternal vaccines have been developed to protect neonates and infants against Streptococcus pneumoniae, Haemophilus influenzae type B, and Group B streptococcal infections (Child Health Research Project Special Report, 1999; Glezen and Alpers, 1999; Mulholland et al., 1996; Mulholland, 1998; Monto and Lehman, 1998). Studies in Bangladesh and Papua New Guinea showed that maternal immunization with pneumococcal polysaccharide vaccines produced an increase in type-specific serum IgG antibody level in both mother and newborn (Shahid et al., 1995; Lehmann et al., 2002). Combination vaccines would be especially useful for populations with limited access to health services (Monto and Lehman, 1998).
H. influenzae type B. In developed countries, invasive disease resulting from H. influenzae type B (HiB) has been almost eliminated by the use of HiB conjugate vaccines (Bisgard et al., 1998). In many countries, however, HiB remains an important cause of life-threatening infections in infancy, particularly pneumonia and meningitis. Pregnancy and Early Neonatal Period Essay. Maternal immunization with HiB polysaccharide-tetanus protein conjugate vaccine has been shown to increase both maternal and neonatal antibody concentrations: at 2 months of age, 60 percent of the infants of vaccinated mothers had protective levels of antibody (Mulholland et al., 1996).
Before routine maternal immunization with these vaccines can be recommended, further studies are needed to determine each vaccine’s short-and long-term safety for the fetus and newborn, and its efficacy in preventing neonatal disease. Moreover, the delivery of vaccines to those who need them in poor countries is a massive task that will necessitate novel public-private partnerships (Smith, 2000).
In developing countries, anemia has several possible causes, including iron or other micronutrient deficiencies, malaria, and hookworm (van den Broek and Letsky, 2000). Antenatal iron supplementation and prevention and treatment of the salient infections are discussed in Chapters 2 and 6.
Late in pregnancy, abdominal examination can reveal a fetus in breech presentation, a significant risk factor for obstructed labor. To reduce the attendant risk to the fetus and newborn of intrapartum or postpartum asphyxia or birth injuries, external cephalic version may be attempted after 37 weeks’ gestation (Villar and Bergsjo, 1997).
Evidence from several randomized trials indicates that similar maternal and neonatal outcomes could be obtained from antenatal care in as few as five visits (on average) by focusing on interventions known to be effective in reducing morbidity and mortality (Villar et al., 2001; Carroli et al., 2001b): counseling on birth preparedness and emergency readiness; provision of folic acid; tetanus immunization; prophylaxis and intermittent preventive treatment for malaria and hookworm as needed; and early detection and timely management of certain diseases or complications (severe anemia at the end of pregnancy, hypertension and proteinuria, asymptomatic bacteriuria and urinary tract infection, syphilis, HIV, and other sexually transmitted diseases prevalent in the local population, and concurrent conditions such as hepatitis, malaria, and tuberculosis); and fetal malpresentation after the 37th week. Pregnancy and Early Neonatal Period Essay. A multicenter randomized, controlled trial conducted in more than 50 clinics in Argentina, Cuba, Saudi Arabia, and Thailand concluded that women assigned to the new model of essential antenatal care that called for an average of five visits per pregnancy had similar rates of low birth weight, postpartum anemia, urinary tract infection, and several secondary outcomes to those of women enrolled in a standard antenatal care program with an average of eight visits (Villar et al., 2001). This finding is further supported by a systematic review of seven randomized controlled trials that assessed the effectiveness of different antenatal care models in reducing adverse outcomes for mother and infant (Carroli et al., 2001b).
Complications of pregnancy and childbirth, a leading cause of death and disability among women of reproductive age (see Chapter 2), can also cause neonatal illness and death. Every pregnancy is at risk for complications, most of which can be managed successfully if recognized and addressed in a timely manner. However, the fact that the majority of births in developing countries occur outside hospitals and other health care facilities presents special challenges.
One such challenge is the use of poor aseptic techniques during labor and delivery, which lead to maternal and neonatal infections. The birth attendant can play a critical role in preventing infections of the mother and newborn by observing the need for clean hands, clean perineum, clean delivery surface, clean instruments, clean cord care, and use of an appropriate clean delivery kit.
The goal is for every delivery to be assisted by a skilled birth attendant such as a midwife, physician, or nurse (as described in Chapter 2). As well as providing a clean and safe delivery, a trained birth attendant recognizes complications such as preterm birth, preterm or prolonged rupture of membranes, and prolonged or obstructed labor and can promptly refer the patient to a health facility with essential obstetric and neonatal care. Skilled interventions are key for saving neonatal and maternal lives during labor, delivery, and the very early neonatal period. Pregnancy and Early Neonatal Period Essay.
Neonatal sepsis and pneumonia. Preterm or prolonged rupture of the membranes, maternal fever during labor, and chorioamnionitis are risk factors for early-onset neonatal sepsis and pneumonia. Because the risk of infection increases with the number of vaginal examinations performed during labor, the number of examinations should be minimized (Seaward et al., 1997). Induction of labor in pregnancies at term with prelabor rupture of membranes or chorioamnionitis can prevent infection of both mother and newborn (Tan and Hannah, 2001). In industrialized countries, intrapartum antibiotics are used to reduce both maternal and neonatal sepsis (Gibbs et al., 1988; Benitz et al., 1999): broad-spectrum antibiotics for women suspected to have chorioamnionitis to reduce maternal and neonatal infection (Gibbs et al., 1988); antibiotics for mothers with preterm rupture of membranes to reduce neonatal illness (Mercer et al., 1998); and intrapartum penicillin to prevent mother to neonate transmission of group B streptococcal infection (Schuchat, 1998). Some of these interventions may be adaptable to community-level use in developing countries.
When a mother develops a puerperal infection, the newborn requires special attention and should be treated for presumed sepsis. Ideally, infants at risk for sepsis who are born at home should be referred to the nearest health facility for observation and antibiotic treatment. Where this is not possible, ways to deliver care to the mother and newborn in the home need to be developed and evaluated (see Box 3-1 below).
Cord infections. Use of a sterile blade to cut the cord and a clean tie are essential. Clean cord care in the postnatal period includes washing hands before and after care and keeping the cord dry and exposed to air or loosely covered with clean cloths. The application of antimicrobial or antiseptic agents to the cord after birth reduces bacterial colonization of the cord and is a routine practice in many industrialized countries. In developing countries, where bacterial contamination of the cord is a higher risk, local antimicrobial agents might reduce infection. A small study in Papua New Guinea documented a decrease in neonatal sepsis following a simple cord care intervention: cutting the cord with a new razor blade and applying acriflavine spirit (Garner et al., 1994). Further studies are warranted.
Neonatal tetanus. Neonatal tetanus can be prevented by immunizing women before or during pregnancy and by ensuring a clean delivery, clean cutting of the umbilical cord, and proper care of the cord in the days following birth (Gupta and Keyl, 1998; Parashar et al., 1998a). Although tetanus toxoid is a highly effective immunogen (Gupta and Keyl, 1998; Koenig et al., 1998; McCarroll et al., 1962), cases of neonatal tetanus have been reported in infants born to fully immunized mothers (Hlady et al., 1992; Talukdar et al., 1994; de Moraes-Pinto et al., 1995; Davies-Adetigbo et al., 1998).Pregnancy and Early Neonatal Period Essay. These outcomes highlight the need for quality control of tetanus vaccine production and promotion of hygienic cord care practices. The protective efficacy of topical antimicrobials has been demonstrated by several case-control studies (Traverso et al., 1991; Bennett et al., 1997; Parashar et al., 1998a). The use of topical antimicrobials as a complement to maternal immunization warrants further study as part of the global effort to eliminate this disease.
Sexually transmitted diseases. Additional intrapartum or immediate postpartum interventions for infants born to mothers with confirmed or suspected STDs can prevent neonatal morbidity. WHO recommends that until syphilis screening and treatment in pregnancy have been fully and effectively implemented, all infants born to seroreactive mothers be treated for syphilis infection (World Health Organization, 2001). Prevention of mother-to-child transmission of HIV is discussed in Chapter 8.
Gonococcal ophthalmia neonatorum is prevented by antimicrobial eye prophylaxis immediately after birth. The cheapest and most widely available agent is silver nitrate (1 percent) eye drops; however, old, more concentrated solutions have been implicated in causing chemical conjunctivitis (Moodley and Sturm, 2000; World Health Organization, 1991). Topical erythromycin and tetracycline are more expensive but safer drugs for prevention of gonococcal ophthalmia (Laga et al., 1988); given increasing tetracycline resistance, erythromycin is the preferred choice (Moodley and Sturm, 2000).
In areas where genital herpes is the predominant cause of genital ulcer disease, WHO recommends cesarean delivery when herpetic lesions are present in the genital tract at the time of membrane rupture or during labor, if the patient presents within 4-6 hours of labor’s onset, and if the risk for morbidity and mortality due to surgery or anesthesia are low. If genital herpes is a relatively minor cause of genital ulcer disease—that is, where chancroid and syphilis predominate—cesarean section is contraindicated since the predictive value of genital ulcers for HSV is low, and surgery-related morbidity may be high (Anonymous, 2000; Roberts et al., 1995). Pregnancy and Early Neonatal Period Essay.
Resuscitation. Skilled birth attendants should be proficient in neonatal resuscitation and ready to perform it at every birth, since asphyxia is usually unpredictable. The basic resuscitation procedure involves having appropriate equipment available (tube/mask or bag/mask); being prepared for and anticipating potential problems; using a warm, clean, flat surface; drying, stimulating, and assessing the newborn; clearing the airway, and ventilating a newborn who fails to initiate respiration. Complex interventions, such as endotracheal intubation, chest compression, and medications, are rarely needed. Use of a simple bag and mask to ventilate the newborn is the established practice in industrialized countries, and has been successfully adapted to low resource settings (Palme-Kilander, 1992; Deorari et al., 2000; Alisjahbana et al., 1999). Preliminary studies indicate that a simple mouth-to-mask (tube and mask) device is as effective as a bag and mask in the resuscitation of asphyxiated newborns (Milner et al., 1990; Massawe et al., 1996). Furthermore, a recent multinational trial demonstrated that neonates can be resuscitated with room air as efficiently as with oxygen (Saugstad et al., 1998). This is particularly important for home deliveries where supplemental oxygen is not available (Saugstad et al., 1998; Saugstad, 1998). The nearly 1 million births annually that are complicated by asphyxia could be improved through management of labor and childbirth that reduces the risk of asphyxia, and prompt resuscitation of newborns who fail to breathe at delivery.
Thermal control. Optimal thermal control of newborn infants in developing countries can be promoted by ensuring a warm environment for delivery in the home or hospital, drying the infant soon after birth, providing clean, dry clothing and blankets for mother and newborn, and keeping all newborns—including preterm infants—with the mother soon after birth. Maintaining skin-to-skin contact between mother and newborn efficiently stabilizes temperature in term infants and permits the early establishment of breastfeeding. Continuing skin-to-skin contact (Kangaroo care), proposed in 1978 by Rey and Martinez (Simkiss, 1999) is even more important for low-birth-weight and preterm infants. In the Kangaroo care method, a well low-birth-weight infant, wearing only a diaper, is placed between the mother’s breasts to provide uninterrupted adult body heat by means of skin-to-skin contact.Pregnancy and Early Neonatal Period Essay. Several studies have shown this method to be safe and effective for maintaining body temperature (Bergman and Jurisoo, 1994; Ludington-Hoe et al., 1999; Alisjahbana et al., 1998; Bosque et al., 1995).
Neonatal jaundice/hyperbilirubinemia. In developing countries, neonates with marked jaundice must be promptly referred for treatment to prevent the unconjugated bilirubin from reaching a level that is toxic to the brain. The treatment generally involves phototherapy but may involve exchange transfusion (Joseph and Kramer, 1998).
Corticosteroids have been found to reduce respiratory distress syndrome, reduce intraventricular hemorrhage, and improve the survival of preterm infants when administered to women in preterm labor in randomized, controlled trials and case-controlled studies (National Institutes of Health, 1994; Crowley, 1995). The benefits extend across a wide range of gestational ages (24–34 weeks) and are not affected by race or sex. In some developing countries, administration of corticosteroids to women in preterm labor has been recommended as a low-cost, low-technology intervention likely to reduce neonatal morbidity and mortality (Bhutta et al., 1999), especially among larger, more mature preterm infants, who are likely to survive if they do not develop respiratory distress syndrome.
Breastfeeding. Evidence indicates that frequent breastfeeding during the first hours of life can prevent hypoglycemia (Biancuzzo, 1999;Yamauchi and Yamanouchi, 1990). WHO recommends that infants be put to breast within an hour of birth (World Health Organization, 1994). Closeness between mother and infant during breastfeeding may also reduce the risk of hypothermia (Bosque et al., 1995). Pregnancy and Early Neonatal Period Essay.
Breastfeeding is particularly important where safe, affordable alternatives to breast milk are not available, hygiene is poor, and water is unsafe (Horton et al., 1996; Gupta and Khanna, 1999). The risk of transmitting HIV through breastfeeding is discussed in Chapter 8. Breast milk contains many anti-infective factors, including secretory immunoglobulin A antibodies, lysozyme, lactoferrin, zinc, and receptor analogs for certain epithelial structures that microorganisms need for attachment to host tissue and subsequent infection (Hanson et al., 1994, Hanson et al., 1982). The early initiation of breastfeeding is important because colostrum has higher levels of many anti-infective factors compared with mature milk, and because early feeding helps establish an adequate milk supply. Many studies have documented a reduction in infectious diseases, including sepsis, diarrhea, and pneumonia (Narayanan et al., 1984; Ashraf et al., 1991; Brown et al., 1989; Glezen, 1991), and in infection-related mortality (Betrán et al., 2001; Habicht et al., 1986; Srivastava et al., 1994; Victora et al., 1989, 1987; Daga and Daga, 1989; Sachdev et al., 1991) among infants who are breastfed.
WHO recommends that infants be breastfed exclusively for 6 months (Haider et al., 2000; World Health Organization, 1995). There appears to be no advantage to introducing complementary foods to infants before 4 months of age, and in many places, doing so introduces substantial risk that the infant will develop diarrhea (Cohen et al., 1994). While most women in developing countries breastfeed, many do not do so exclusively throughout this period (Betrán et al., 2001; World Health Organization Collaborative Study Team, 2000). Peer counseling of breastfeeding mothers has been found effective in encouraging exclusive and extended breastfeeding (Haider et al., 2000; Leite et al., 1998; Morrow et al., 1999; Sikorski and Renfrew, 2001). Breastfeeding (defined as exclusive breastfeeding in babies up to 4 months of age) has increased in 21 developing countries, aided by campaigns to publicize the benefits of the practice, prohibition of advertising and/or distribution of breast milk substitutes, and hospital-based breastfeeding assistance programs (United Nations Children’s Fund, 1999). Pregnancy and Early Neonatal Period Essay.