Improving Maternal, Newborn, and Child Health and Reducing Maternal Morbidity

Afghan Safe Birth Project

In response to the DHHS Afghanistan Health Initiative, CDC has worked with other agencies in the U.S. Department of Health and Human Services to establish, as part of U.S. reconstruction efforts in Afghanistan, a training program in Obstetrics and Gynecology at Rabia-Balkhi Hospital (Kabul) as a center of excellence. This work was performed in collaboration with the Department of State, the Department of Defense, the Afghanistan Ministry of Public Health, the International Medical Corp , and CARE. CDC’s Division of Reproductive Health (DRH) activities in Afghanistan ended in 2011 due to budget cuts.

CDC activities focused on—

• Developing health care surveillance systems for maternal and child health.
• Helping clinical staff obtain skills to provide quality care to women and newborns.
• Promoting the use of infection control measures.
• Developing neonatal assessment and triage.

• Introducing quality assurance principles into the hospital system.
• Developing targeted occupational safety and health services for health care workers.
• Fostering the development of midwifery services.
• Supporting the informatics function of the project.
• Improving hospital management. 

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Global Tobacco Use in Pregnancy

DRH is funding a 4-year project to evaluate the adaptation and implementation of a brief smoking cessation counseling intervention (5A’s) with nurse midwives and system reminders in prenatal clinics in Buenos Aires, Argentina, and Montevideo, Uruguay. Prenatal smoking rates in these countries are among the highest in the world, 15% and 20%, respectively; however, pregnancy-specific smoking cessation interventions are not systematically integrated into prenatal clinics. The project objectives are to increase the frequency of women receiving the “5 A’s,” decrease the frequency of women who smoke at the end of pregnancy, and increase the frequency of positive attitudes and readiness to provide smoking cessation counseling.

Research is being led by Tulane University in collaboration with the Institute for Clinical Effectiveness and Health Policy and Montevideo Clinical and Epidemiological Research Unit. The intervention will be delivered in spring 2012 with baseline and follow-up data collection. If found to have an effect on outcomes, the intervention will be disseminated for use in similar settings. In addition, DRH recently analyzed the patterns and predictors of cigarette smoking among reproductive age women in Ecuador, El Salvador, Guatemala, and Honduras. We found that smoking prevalence ranged from 2.6% in Guatemala to 13.1% in Ecuador, and that smoking prevalence was highest in women who lived in urban areas, were previously married, or had high socioeconomic status.

The UN Millennium Development Goals 4 and 5 call on all nations to take action to improve maternal and child health, and tobacco use is known to negatively influence maternal and child health outcomes. There are effective interventions to help pregnant women quit smoking. While published guidelines on the treatment of tobacco dependence during pregnancy are available for some countries, guidelines that transcend national borders are needed for low and middle income countries. DRH, in collaboration with CDC’s Office on Smoking and Health, will support the development of World Health Organization (WHO) guidelines for the treatment of tobacco dependence during pregnancy. This project will build upon the recommendations and experiences accumulated in other relevant programs of WHO dealing with maternal and reproductive health and making pregnancy safer, and departments dealing with substance abuse (including alcohol). The process will include conducting systematic reviews/meta-analyses and consultation with a technical panel. The expected outcome will be a WHO document to provide guidance and support to Member States for the treatment of tobacco dependence during pregnancy. This project started in October 2011 and will last approximately 2 years.

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Obstetric Fistula

Prolonged labor without adequate medical care can result not only in the death of the infant but also in permanent injury to the mother (if she survives) when the long pressure from the fetal head creates necrosis and breakage in the wall of the vagina, urethra, bladder, or rectum. This condition, which particularly affects young mothers whose pelvises are not fully grown, is known as obstetric fistula. Fistula formation results in uncontrollable leaking of urine and, less frequently, feces, through the vagina, which often leads to rejection and ostracism of the young women by family and society.

An important step in tackling this problem is collecting and disseminating accurate information on the extent of fistula formation and its risk factors, prevention and treatment approaches; and the assistance needed for women living with fistula. This information can be used to convince decision makers of the gravity of the situation and of the need for urgent and effective action. DRH leads the Data, Indicators, and Research Committee, one of the three components of the International Obstetric Fistula Working Group, a global alliance to end fistula. The group is currently improving the monitoring and evaluation of existing programs that aim to eliminate fistula occurrence and its consequences and help design ways to research the burden that the condition places on individuals and communities.

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Prospective Tracking of Maternal and Infant Health Outcomes (Kisumu, Kenya, and Ifakara, Tanzania)

Rates of illness and death among mothers and infants are still regrettably high in much of Sub-Saharan Africa. In an effort to assess the use of emergency obstetric care and other services, including the unmet need for such services, DRH is engaged in prospective pregnancy tracking in Demographic Surveillance Sites in Kenya and in Tanzania. Data were collected through postpartum interviews with the mothers; these interviews complemented the current practices of demographic surveillance programs to track a variety of health indicators. CDC's Division of Reproductive Health is analyzing these data to see how and where care and services can be improved and will provide this information to the district- and national-level government health services. Results will be used to develop more effective programs and services to improve health and reduce death rates. The lessons learned in these study may be more broadly applicable in other areas of Africa.

Technical Assistance

• DRH provides subject matter expertise to support CDC's Tanzania’s monitoring and evaluation of a task shifting project to provide emergency obstetric services in 4 areas. 
• DRH provides technical support to the UN Health 4 group (WHO, UNICEF, UNFPA, World Bank) in using science to improve maternal and neonatal outcomes in a pilot project in Malawi.  

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