Accomplishments of the GNPRH
In the ten years of its existence, the Network has developed an administrative structure, showed its ability to perform demographic and observational studies, and evaluate various types of diagnostic technologies. Below, four selected GNPRH initiatives are described. These initiatives have been identified as priority areas by the investigators and considered essential for the future development of intervention projects that have impact on the populations served by the GNPRH.
Assessment of Neonatal Mortality Rates and the Use of Effective Perinatal Clinical Practices:
GNPRH sites were surveyed to assess birth-weight and gestational age specific neonatal mortality rates. Results indicate that sites use discrepant criteria for recording neonatal deaths with the most pronounced differences occurring between developed and developing centers.
Inconsistent neonatal death reporting has implications for across site evaluation of interventions designed to reduce neonatal mortality. Therefore, the GNPRH is working to implement consistent guidelines for accurate collection of neonatal death information and will use the web based information exchange system to be developed through this proposal, to achieve this goal. Incomplete and inconsistent data collection procedures also complicates accurate evaluation of factors contributing to the high perinatal mortality rates, and underscored the need for improvement in the area of data quality.
As part of this initiative, participating sites were also surveyed to assess the rate of use of various clinical interventions shown to reduce neonatal mortality. Results of this survey demonstrated that the use of perinatal clinical procedures also varied widely across sites.
For example, in developing countries the gestational age at which cesarean section is performed to enhance fetal survival (i.e.,not for maternal indications) ranges from 26 to 37 weeks (In developed countries the gestational age at which cesarean section is targeted at improving fetal outcomes is 24 weeks.) Only five out of nine centers used antibiotics to prolong latency of pregnancy after rupture of membranes, a practice shown to improve neonatal outcomes (Mercer BM, et al, JAMA, 1997) Most centers routinely used corticosteroids for preterm infants, and all centers employed repeat weekly steroid dosing if undelivered, a practice recently not recommended.
A manuscript has been published "Birthweight-Specific Neonatal Mortality in Developing Countries: Relation to Obstetric Practices", Int J Gyn & Obst 2003: 80(1) 71-78
Evaluation of the use of Peri-Operative Antibiotic Prophylaxis During Cesarean Section.
Endometritis and wound infection are common, potentially life-threatening complications of cesarean section (Cunningham FG, 1997). Evidence indicates that the use of antibiotic prophylaxis during cesarean section can reduce the rate of post c-section endometritis and wound infection (Smaill F, Hofmeyr GJ The Cochrane Library, 2001).
In collaboration with the International Hospital Infection Prevention and Quality Assessment Program at Children's Hospital and Harvard Medical School in Boston, GNPRH conducted a study to evaluate if antibiotic prophylaxis during cesarean section was being consistently practiced at member sites. Fifty consecutive cesarean sections performed in eight centers in five countries (The Philippines, Thailand, India, Myanmar and the United States) were surveyed. Data from each center were compared to a regimen recommended by the Cochrane Collaboration.
Results indicated large variations in the use of antibiotic prophylaxis across centers, and only four centers administered antibiotic prophylaxis to all women. Inappropriate multidrug regimens were used commonly. Only two centers reliably administered the antibiotic at the appropriate time. This study identified a significant opportunity for improvement in the care of women through enhancing the consistency of antibiotic use at all centers. A program to develop interventions specific to each center to improve this practice is being designed.
A manuscript has been published: "An International Survey of Practice Variation in the use of Antibiotic Prophylaxis in Cesarean Section"; Int J Gynecol Obstet; 73(2001) 141-45.
Case management of Reproductive Tract Infections in India:
An analysis of clinical protocols and costs Reproductive tract infections (RTI's) are among the most common reasons why adults seek health care in low-income countries, and hence they carry a large resource burden for both health systems and individual sufferers. Adequate management of these infections has been shown to significantly decrease the risk of HIV transmission and acquisition. Untreated or mismanaged RTI's carry serious long-term sequelae including chronic pain, ectopic pregnancy, male and female infertility, and adverse outcomes of pregnancy including fetal loss, and higher rates of neonatal morbidity and mortality.
Effective case management strategies for the most appropriate and effective management of the RTI's depends to a large degree on the local epidemiological profile (prevalence and aetiology) of the infections most commonly seen. In many cases, however, such an epidemiological picture may not have been outlined locally, and practitioners may instead use standardized procedures designed elsewhere. The appropriateness of such a response has not been validated to any large extent in India and other regions of the world.
This project aims to review existing guidelines for RTI management in four sites in India and to validate the effectiveness of these guidelines in terms of clinical management and costs. This will include evaluating the guidelines with respect to their levels of undertreatment and/or overtreatment of common infections. The results will be used to develop protocols for management which can be used in a variety of epidemiological and socio-cultural settings which may be expected to be found in India. In addition, we aim to incorporate an evaluation of rapid diagnostic tests for the most common sexually transmitted infections.
(Manuscript submitted for publication)
Use of Pesticides and Their Effect on Reproductive Health
A project to study the effect of exposure to pesticides and herbicides used in the flower industry, on the reproductive health of women, men and children, is on-going in Colombia. It been developed together with the Department of Environmental and Occupational Health at Emory University, the Colombian Association of Flower Exporters and the Colombian National Institutes of Health. Field work was completed to determine the types of pesticides used, how they are used and which are the opportunities for human exposure. A cost-effectiveness analysis of the current biological markers used to monitor workers exposure will be done, as well as a study of the attitudes and beliefs of the workers with respect to the utilization of safety equipment and recommended safe practices to reduce exposures. In a follow-up project biological markers for exposure will be developed and a cohort of women, men and children will be followed to determine if there are associations between exposure and adverse reproductive health outcomes, including those during pregnancy.
We accept the definition of Reproductive Health as outlined by the World Health Organization:
?Within the framework of WHO?s definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions and systems at all stages of life.
Reproductive health, therefore, implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide, if, when, and how often to do so.
Implicit in this last condition are the right of men and women to be informed of, and to have access to, safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate healthcare services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.?
In summary, the GNPRH has already demonstrated its ability to design, implement and successfully complete descriptive studies and randomized controlled trials. Our research has had a direct and important impact on the populations served by the network.
The GNPRH also has the potential to rapidly develop and disseminate culturally and clinical significant interventions in reproductive health. Therefore our network is poised to accept the challenge posed by the World Health Organization to rapidly develop innovative interventions that are sustainable in resource-poor countries. Over time, we envision that these activities will become the sustainable core activities of the GNPRH, through additional grant funding from international agencies such as the WHO, UN, NIH, CDC, and through national and local in-country funding mechanisms.