Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process

Objective

To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.

Design

Modified Delphi process.

Setting

Participants from 34 countries.

Population

Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.

Methods

We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.

Main outcome measure

Consensus on bundle items.

Results

Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.

Conclusion

A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.

Tweetable abstract

A maternal sepsis bundle for low resource settings has been developed by international consensus.

A maternal sepsis bundle for low resource settings has been developed by international consensus.

Randomised trial of vitamin A supplementation in pregnant women in rural Malawi found to be anaemic on screening by HemoCue

OBJECTIVE

To assess the effects of vitamin A supplementation in women with anaemia during pregnancy.

DESIGN

Single-centre randomised controlled trial.

SETTING

Rural community in southern Malawi, central Africa.

POPULATION

Seven hundred women with singleton pregnancies at 12-24 weeks measured by ultrasound scan and with haemoglobin <11.0 g/dl by HemoCue screening method. Analysis was by intention to treat. All received iron and folate, and sulphadoxine/pyrimethamine for antimalarial prophylaxis.

METHODS

Women were randomised to receive oral supplementation with daily 5000 or 10,000 iu vitamin A, or placebo.

MAIN OUTCOME MEASURES

Anaemia, as assessed by Coulter counter, severe anaemia, iron status and indices of infection.

RESULTS

Vitamin A deficiency was, in this rural population, less common than predicted. Vitamin A supplementation had no significant impact on anaemia, severe anaemia, iron status and indices of infection. Vitamin A stores were less likely to be depleted at the end of pregnancy in supplemented groups.

CONCLUSIONS

Vitamin A supplementation programmes to reduce anaemia should not be implemented in similar antenatal populations in rural sub-Saharan Africa unless evidence emerges of positive benefit on substantive clinical outcomes. Introducing public health interventions of unknown benefit and with unclear biological mechanisms can divert scarce resources from clinical and social interventions more likely to impact maternal mortality.

Intermittent sulfadoxine-pyrimethamine in pregnancy: effectiveness against malaria morbidity in Blantyre, Malawi, in 1997-99

Plasmodium falciparum malaria in pregnancy predisposes to maternal and foetal morbidity. In 1993 Malawi adopted intermittent presumptive therapy with sulfadoxine-pyrimethamine (SP) as malaria prophylaxis for all pregnant women. To assess operational effectiveness of SP, we examined (in 1997-99) the relationship between number of doses of SP prescribed in antenatal clinic and indicators of malaria infection and morbidity at delivery, including peripheral and placental parasitaemia, maternal and neonatal anaemia, and birthweight. Among Malawian women delivering in a large urban hospital, SP prescription was associated with a decrease in placental malaria prevalence (from 31.9% with no SP prescription to 22.8% with > or = 2 doses SP) and density, decreased prevalence of low birthweight (from 23% in women not receiving SP to 10.3% in women given > or = 2 doses), and higher maternal haemoglobin concentrations. These effects were most marked in first and second pregnancies, in which malaria prevalence was highest. Maternal and cord blood malaria prevalence and mean cord blood haemoglobin concentrations did not differ with SP usage. Implementation of the SP administration policy was incomplete: 24% of women were not prescribed any SP, and only 30% were prescribed at least 2 doses as recommended. Intermittent presumptive treatment with SP is having a positive impact on some, but not all indicators of malaria infection and morbidity in Malawi. Improved implementation and continued surveillance are essential.

Plasmodium falciparum isolates from infected pregnant women and children are associated with distinct adhesive and antigenic properties

Plasmodium falciparum malaria during pregnancy is an important cause of maternal and infant morbidity and mortality. Accumulation of large numbers of P. falciparum-infected erythrocytes in the maternal blood spaces of the placenta may be mediated by adhesion of infected erythrocytes to molecules presented on the syncytiotrophoblast surface. In this study, isolates from placentas and peripheral blood of infected pregnant women and from children were tested for binding to purified receptors and for agglutination with adult sera. Results suggest that adhesion to chondroitin sulfate A may be involved in placental parasite sequestration in most cases, but other factors are also likely to be important. Agglutination assay results suggest that parasites infecting pregnant women are antigenically distinct from those common in childhood disease. The prevalence of agglutinating antibodies to pregnancy isolates was generally low, but it was highest in multigravidae who are likely to have had the greatest exposure.

Reproductive mortality in Lusaka, Zambia, 1982-1983

In this study, age- and parity-specific birth data were used to estimate maternal mortality rates for 1982-83 at University Teaching Hospital in Lusaka, Zambia. Overall, 60 maternal deaths occurred during pregnancy or within 42 days after pregnancy termination, and four pregnancy-related deaths occurred more than 42 days after pregnancy termination. Nine of the 60 maternal deaths were caused by induced abortion, one by spontaneous abortion, twelve by hypertensive disease of pregnancy, ten by hemorrhage, nine by puerperal sepsis, and four by ectopic pregnancy. Of the 12 women who died from nonobstetric causes, one committed suicide because of an unwanted pregnancy. Women aged 35 years and older or who had had four previous pregnancies had a higher risk of dying than other women, especially by hemorrhage. The chief risk factors included not using an effective method of contraception, using an unsafe means to terminate unintended pregnancies, lack of prenatal care, refusing a blood transfusion (for religious reasons), and inadequately treating hypertensive disease of pregnancy. Overall, 31 of 60 women who died lacked adequate or appropriate medical care and 19 failed to obtain available health care. Medical management problems appeared to occur more frequently during the night-time medical shift.

Women refused second-trimester abortion: correlates of pregnancy outcome

Little is known of the outcome of pregnancy in women denied abortions in the United States. To address this question, we studied the pregnancy outcomes in 316 low-income women who were denied second-trimester abortion at a large, metropolitan teaching hospital in the Southeast between August, 1978, and July, 1979. Follow-up information was available on 82%. One in five women denied an abortion managed to obtain one elsewhere. Earlier gestational age at the initial abortion request, higher education level, and higher income were the best predictors of whether a woman subsequently obtained an abortion. For the women who continued their pregnancies, neither the rate of serious maternal complications nor the neonatal death rate was increased when compared with that of the rest of the hospital's population.