Maternal & Neonatal Health: A Global

Overview Of Contributing Factors

Professor Hora Soltani

Professor of Maternal and Infant Health
Sheffield Hallam University

Newton Fund Researcher Links Workshop:

Maternal and Infant Health and Nutrition in Indonesia
Padang-Indonesia 28th Aug-1st Sept 2016
 Objectives
• To provide an overview of
Sustainable/Millennium Development
Goals in relation to maternal and neonatal
health
• To discuss major factors contributing to
maternal & infant health globally
• To discuss how research and innovation
can impact on reducing health inequalities
for mothers and their families
Background

17 points were set to

achieve from 2015 to
2030

In 2000, agreed 8
goals to achieve
between 1990-2015
Women and Children correspond to all SDGs, particularly to 3 & 5
Available at: www.everywomaneverychild.org.
Millennium Development Goals
(MDG: 1990-2015) Reduce75%MMR by
Eradicate extreme Improve maternal
poverty and hunger health

Achieve universal Combat HIV/AIDS,

primary education malaria

Promote gender Ensure

equality and environmental
empower women Reduce Under 5 sustainability
mortality by 70%
Develop and global
Reduce child
partnership for
mortality
development
 Did you know….
• 800 women die every day from
preventable causes related to pregnancy
and childbirth globally

• More than 16,000 children under 5 die per

day! ~70% of these are under 1 and ~50%
are within the first 28 days!
Maternal mortality
576,000 in 1990

245,000 in 2012
 Causes of maternal mortality
30
25
20
%

15
10 Develped regions (%)
5
Developing regions (%)
0
ge
ion s is io n
s m e s es
a e rt li us aus
rr h tens Sp bo bo a
m
o er A E m ct c ct c
ae Hyp di re
d ire
H r In
e
th
O

Direct causes
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A, Daniels J, Gülmezoglu AM,T Temmerman M and
Alke L. (2014) Global causes of maternal death: a WHO systematic analysis. The Lancet Global
Health DOI: 10.1016/S2214-109X(14)70227-X
 Haemorrhage
Developed regions Developing regions

29%
Antepartum 24%

49% Intrapartum 73% 3%

Postpartum

21%
 3rd stage of labour

The time from the birth of the baby to

the expulsion of the placenta and fetal
membranes
 Postpartum Haemorrhage

"PPH is commonly defined as a blood loss

of 500 ml or more within 24 hours after
birth." (WHO 2012)
 Third stage of labour care

1. Expectant management:
• no medication
• no cord clamping
• placenta is delivered with
the aid of gravity and/or
maternal effort
 Third stage of labour care
2. Active management:
• administration of uterotonic
drugs
• cord clamping and cutting
• controlled cord traction
• uterine massage
 Overview
Whole Package: Active Vs Expectant
(Begley 2010)
1.Adm.of 2.Cord 3.Controlled Cord 4.Uterine
Uterotonics/drugs management Traction massage

Cord clamping Cord

Type/Route Timing
timing drainage

McDonald Peña-Martí
6 reviews Soltani 2010 Soltani 2011 Hofmeyr 2008
2013 2010

Baby's position Umblical vein Chinese

at birth (14) injection medicine

Others
Soltani H. Royal College of Obstetrics and Gynaecology 2011 -London
(invited lecture)
 c t ant
v e Expe
A c t i
PPH

5 studies: 6486 women Begley 2010 UK(3), Ireland, Abu Dhabi

Active: 1. prophylactic uterotonics, 2. early cord clamping, 3. CCT

• Risk of PPH BUT

• Reduced infant BW (due to
reduced placental
transfusion)

Recommended:
1. Further evaluation of active care components
2. In low income countries & alternative settings (Doctorate student)
 2.1.Timing of Cord Clamping
Early CC Deferred CC
PPH
11 studies: 2989 women Australia, Canada, UK, USA (2), India(2),
McDonald 2013 Libya, Mexico, Zambia & Argentina,

• No significant differences in the risk of PPH

• Lower Hb levels in babies who had early cord clamping (ECC)

Vs those in the deferred cord clamping (DCC)

• (Mild) Jaundice (non-pathologic) requiring phototherapy was

higher in DCC Vs ECC
 Iatrogenic effect of
"Early cord clamping"

"Just a cold baby"

 1.2. Timing of Uterotonics
U before Placental U after placental
delivery delivery

3 studies: 1671 women X2 used Oxytocin IV infusion

Soltani 2008
Philippine(1) & US(2)

• No significant differences in • More investigation is

the incidence of PPH required due to limited data

• No data on neonatal
outcome was reported

Implications: uterotonics after placental delivery can

potentially reduce risk of over-perfusion of the baby (following
deferred cord clamping)
 Declining global maternal
mortality is due to
• Reduced fertility
• Improved maternal education
• Improved income per head
• Improved healthcare & access to facilities
• Increased skilled birth attendance (e.g.
midwives)
• Nutrition

Soltani H, Fair F and Hakimi S (2015).

Reduction in global maternal mortality rate 1990–2012 : Iran as a case example.
Midwifery, 31 (2), 271-273
 Infant/Neonatal Mortality
• Neonatal period
• Mainly due to: prematurity,
pneumonia, labour and
Killer factors birth complications,
diarrhoea, sepsis, and
malaria

• Poverty
Socioeconomic/Nutrition • Malnutrition
status • Education

• Skilled birth attendance

Health coverage • Universal access

Available from: https://www.womenandchildrenfirst.org.uk/impact/key-issues/infant-mortality-newborn-health

 Why we are here?!
Local
Priorities
evaluation/ Gaps in
Monitoring Knowledge
Maternal and
Infant Health &
Nutrition
Evidence
Implementation
Generation

Share Lessons/Good Primary research-Locally

Practice sensitive effective interventions
Systematic evidence
synthesis
Maternal Mortality-Indonesia
Perinatal Mortality-Indonesia
(deaths/1000 pregnancies)
Perinatal Mortality by region-
Indonesia
 History of collaboration with
Andalas University
• Maternal weight and health
project-Indonesia 2010 (HS&IL)
• British Council fund-Project follow
up visit-2012 (HS &IL)
• BC Socio-cultural & economic
aspects of maternal nutrition (SB,
HS & IL)
• BC (SB&HS&IL) Newton Fund
workshop (SB, HS, IL & SK)
Maternal and Infant Health-SHU
 Characteristics of our local
research
• Interdisciplinary Research: health
psychology, technology, maternity,
nutrition,...
• Woman centred
• Developed in collaboration with women
• High Impact/In line with local, national and
global priorities
Examples of local research
• Funded: EFL, CLAHRC, Bupa
• ACES: Dearden, D&S: Arden, Furness &
MOMTech Doncaster: Garland, Williams, MIHRG: Alex

1. Taxonomy • D&S, Queen Mary University

2. Obesity & of London
Breastfeeding • Cochrane review- Fair F

• CLAHRC, Doncaster NHS

Talking Health • D&S, Doncaster (Hampshaw,
Wardle)

• Medical Research Council-PHND

Adolescent • CLAHRC,Tommy's
pregnancy & • SBS (Rachel Rundle, Cecile Morris)
Nutrition Manchester, London, Doncaster (Ricky
Hurley)
• PhD students (4 projects)
International developments
• CLAHRC:
Midwife
led care • World Health Organisation

Third • WHO funded survey in Iran

stage • Neonatal guideline
manage
ment development/cord clamping

• Indonesia-Andalas
University-Maternal
Maternal weight and Health
mortality/ • British Council funded
morbidity workshop in Indonesia
(Aug 2016)
 PhD students

• Born in Bradford (BIB) Data: Teenage:

Pregnancy & Nutrition
• Physical activity in Pregnancy
• Third stage of labour management
• Overweight during pregnancy
 Conclusion
This is a step towards
• developing international partnerships
• to address top priority research gaps
• in reducing health inequalities for mothers
and babies, in line with the SDGs
• and in collaboration with researchers,
practitioners, policy makers and
operational organisations!
 THANK YOU
Acknowledgement:
Maternal and Infant Health Research Group (MIHRG)

Template Provided By

www.animationfactory.com
Developing countries: Indonesia
– With its economical growth has been through
a remarkable transition
– Change in diet and lifestyle
– 19.6% underweight Vs 27.2% OW&OB
pregnant women

Soltani et al 2015. Patterns of pre-pregnancy BMI and gestational weight gain in

West Sumatra, Indonesia and their effects on pregnancy and labour outcomes. in
progress.
 Conclusion
• High quality maternity care with particular
attention to reducing PPH is essential
• Access to midwives/skilled birth
attendance is crucial in enhancing
maternal and neonatal health
• Improving maternal nutrition can have long
lasting effects benefiting future
generations
•
References
Wyer PC, Silver SA. Where is the wisdom? I—a conceptual history of evidence-based medicine. J Eval Clin Pract.
2009;15(6);891-898.
• Tonelli MR. The philosophical limits of evidence-based medicine. Acad Med. 1998;73(12):1235.
• Buetow S, Kenealy T. Evidence-based medicine: the need for a new definition. J Eval Clin Pract. 2000;6(2):85-92.
• *Soltani H, Poulose TA, Hutchon DR. Placental cord drainage after vaginal delivery as part of the management of
the third stage of labour. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD004665. DOI:
10.1002/14651858.CD004665.pub3
• *Soltani H, Hutchon DR, Poulose TAAcademic Journal. (2010). Timing of prophylactic uterotonics for the third
stage of labour after vaginal birth. Cochrane Database of Systematic Reviews 2 2010, Issue 8. Art. No.:
CD006173. DOI: 10.1002/14651858.CD006173.pub2.
• Soltani H. 2008 Global implications of evidence biased practice; management of the third stage of labour.
Midwifery 24(2):138-142.[Special report]
• Soltani H. Uterine massage for preventing postpartum haemorrhage: RHL commentary (last revised: 1 April
2010). The WHO Reproductive Health Library; Geneva: World Health Organization
• Sandall J, Soltani H, Gates S, Shennan A, Devane D.; Midwife-led continuity models versus other models of care
for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004667. DOI:
10.1002/14651858.CD004667.pub3. URL upon publication:
http://doi.wiley.com/10.1002/14651858.CD004667.pub3
• Afshari P, Medforth J, Aarabi M, Abedi P, Soltani H. Management of third stage labour following vaginal birth in
Iran: A survey of current policies. Midwifery(2013), http://dx.doi.org/10.1016/j.midw.2013.02.002.
• Davenport MH and Rodriguez Cabrero M. Maternal nutritional history predicts obesity in adult offspring
independent of postnatal diet J Physiol 587.14 (2009) pp 3423–3424 3423
• Tonelli MR. The philosophical limits of evidence-based medicine. Acad Med. 1998;73(12):1235.
• Mid led care review was cited in the WHO OptimizeMNH (taskshifting) guideline (
http://www.optimizemnh.org/intervention.php) which will be the reference points for the health system questions in
the preterm birth guideline.
• Symonds, M.E., Mendez, M.A., Meltzer, H.M., Koletzko, B., Godfrey, K., Forsyth, S. and van der Beek, E.M.
(2013)
Early life nutritional programming of obesity: mother-child cohort studies. Annals of Nutrition & Metabolism, 62, (2)
, 137-145.
 Complexity of evidence based
practice
• "Population statistics" dictate clinical decision
making (Tonelli 1998)
• Individuality of each case should be
remembered [benefits Vs potential harms]
(Soltani 2008)
Soltani H. (2008) Global implications of evidence biased practice; management of the
third stage of labour. Midwifery 24(2):138-142.[Special report]
Long term effects of obesity in
pregnancy

Soltani-K H & RB Fraser. A longitudinal study of maternal anthropometric

changes in normal-weight, over-weight, and obese women during
pregnancy and postpartum. British Journal of Nutrition (2000), 84:95-101.
 Public health implications
• Obesity and excessive
gestational weight gain are
associated with Increased risk
of obesity
– in the mothers (1)
– in their offspring (2)

1. Institute of Medicine. (2009) Weight gain during pregnancy: reexamining the

guidelines. Report brief. See: www.iom.edu/ CMS/3788/48191/68004.aspx
2. Gale CR, Javaid MK, Robinson SM, Godfrey KM & Cooper C (2007). Maternal size in
pregnancy and body composition in children. J Clin Endocrinol Metab 92, 3904–3911.
 Complications
• OB pregnancies are associated with an
increased risk of
• macrosomia, anomalies, fetal loss
• gestational diabetes
• raised BP
• infection
• induction, caesarean, instrumental
birth
• longer PN stay
• resource & cost implications for NHS
(x5 greater)
 Fetal programming
• Epigenetic studies have shown links
between mothers' diet and degree of
obesity in their children at 6 and 9 years of
age!
• To prevent childhood obesity we need to
start improving mothers nutrition during
pregnancy!

Symonds, M.E., Mendez, M.A., Meltzer, H.M., Koletzko, B., Godfrey, K., Forsyth,
S. and van der Beek, E.M. (2013)
Early life nutritional programming of obesity: mother-child cohort studies. Annals o
f Nutrition & Metabolism, 62, (2), 137-145. (
doi:10.1159/000345598). (PMID:23392264).
 GUIDING PRINCIPLES
• Country-led • Community-owned
• Universal • Accountable
• Sustainable • Aligned with
• Human rights-based development,
• Gender-responsive effectiveness and
• Evidence-informed humanitarian norms
• Partnership-driven
• People-centred