Current Women's Health Reviews - Volume 2, Issue 4, 2006

An article in this issue extensively shows how much research have been done and how little have been achieved in the prevention and management of preterm birth. Preterm birth is one of the most important problems that obstetrics is facing both in developing and developed countries. Developed countries are solving such problems through a major improvement in the care of newborns, which implies not only a high survival rate but also an increase in the number of children surviving with handicaps. This signifies a high increase in the cost of care. Such an approach is not possible in developing countries, where scarce resources need to be fairly distributed and the extremely high costs of care for preterm births and handicapped individuals are well out of their scope. In developing countries, major efforts should be made to improve maternal conditions and care, and pioneering interventions are greatly needed. Another article in this issue reviews an innovative and feasible intervention, maternity waiting homes, which can be applied in the rural areas of developing countries to improve pregnancy outcomes. Feasible and innovative interventions are much needed at the global level, where one relevant scope should be on how to scale-up well-known beneficial interventions. As an example, one of the most powerful perinatal interventions to reduce neonatal mortality is the administration of antenatal corticosteroids to pregnant women at high risk of preterm birth. It is assumed that 80% is the maximum rate of use of the intervention in preterm babies below 34 weeks of gestational age (1-3). However, it is estimated that in the 42 countries with 90% of the worldwide childhood deaths in 2000, only 5% of appropriate candidates received antenatal corticosteroids (4). Another study based on data from 75 countries estimated that 10% of appropriate candidates received corticosteroids (1). How can research aid in testing and providing interventions that could achieve an acceptable rate of use of beneficial interventions in a diversity of settings, particularly in developing societies? Research capacity building in developing countries is mandatory, therefore these countries could look for feasible interventions to improve the alarming health situations in their population. Ninety-five percent of funds for research in the world are focused on 5% of the world's population, which is located in the developed countries. To attain an improvement on global health situations, this pattern needs to change both quantitatively and qualitatively. We need strong research structures in developing countries, with support to conduct appropriate research to improve the health situations of their populations. Global health research support should change for a more equitable distribution of funds to benefit those with major needs. Two articles in this issue focused on the subject of assisted fertilization. While this technique is a solution to the problem that some couples face, it is also responsible for an increase in multiple pregnancies, and, consequently, in preterm births in developed countries. It requires selective and careful use, and critical reviews about the technique are required to improve its outcome and diminish its deleterious consequences. REFERENCES [1] Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, for the Lancet Neonatal Survival Steering Team. Neonatal Survival 2: Evidence-based, cost-effective interventions: how many newborn babies can we save. Lancet 2005; 365: 977-88. [2] Gortner L, Wauer RR, Hammer H, Stock GJ, Heitmann F, Reiter HL, Kuhl PG, Moller JC, Friedrich HJ, Reiss I, Hentschel R, Jorch G, Hieronimi G, Kuhls E. Early versus late surfactant treatment in preterm infants of 27 to 32 weeks' gestational age: a multicenter controlled clinical trial. Pediatrics 1998; 102(5): 1153-60. [3] Horbar JD, Badger GJ, Carpenter JH, Fanaroff AA, Kilpatrick S, LaCorte M, Phibbs R, Soll RF; Members of the Vermont Oxford Network. Trends in mortality and morbidity for very low birth weight infants, 1991-1999. Pediatrics 2002; 110(1 Pt 1): 143-51. [4] Jones G, Steketee R, Black RE, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003; 362: 65-71.

Utilisation of maternal health services is low and pregnancy outcome poor in many rural, poor districts in sub- Saharan Africa. Long distances, poor transport facilities and inadequate distribution of health care facilities are responsible for low utilisation of health care services. In addition, a range of social, economic, and cultural factors also contribute to women's poor health during pregnancy and childbirth. Provision of a maternity waiting home (MWH), a residential facility, located near a medical facility providing comprehensive emergency obstetric care, where women can await birth, is a possible intervention. A systematic literature review of effectiveness of MWHs is presented. MWHs have proven to be effective in several studies. Pitfalls, however, are to be anticipated. The accessibility of the MWH itself, the risk identification process, the quality of community education and antenatal care and the quality of service delivery at the District Hospital are factors to be considered.

Since the birth of the first test-tube baby in 1978, assisted fertilization techniques have been performed all over the world to alleviate human infertility. Later on, with the advent of the intra-cytoplasmic sperm injection (ICSI) technique, severe male infertility cases have been successfully solved. ICSI revolutionized most of the biological knowledge on the mechanism of fertilization, giving rise to a serious debate about its long-term safety. Actually, either conventional in vitro fertilization (IVF) or ICSI are considered commonplace in the clinical practice and chosen on the basis of the specific advantages that they offer in improving the live birth rate. Nevertheless, it remains an open question if these procedures increase the risk for woman health, birth defects and congenital anomalies of the children. In this regard, many meta-analysis are actually reporting the follow-up studies of the IVF-conceived babies. In this review we describe: i) the general biological mechanism of the fertilization in order to compare advantage and disadvantages of IVF vs ICSI; ii) the biological risks associated to different assisted fertilization techniques; and iii) a summary of the extensive literature dealing with pregnancy complications and outcome, congenital malformations, tumors and specific syndromes increase in the children conceived by IVF/ICSI. Results show that the major risks for mother and babies health are associated with multiple gestations and their following complications. On the contrary, although a few exceptions, the majority of the studies do not support an absolute increased health risk for the babies conceived by IVF and ICSI.

The rate of multiple gestations has increased dramatically over the past three decades. Most of the excess multiple pregnancies are due to the widespread use of ART. Nowadays, IVF is responsible for most of the twins, while ovarian stimulation is responsible for most of the higher-order multiples. A multiple gestation, even a twin gestation, is associated with significant maternal and fetal risks. The extra expenses place a burden on the health care system. Many attempts were made to identify patient, stimulation and laboratory characteristics that are associated with better implantation potential. Improvements in laboratory technology (preimplantation genetic screening, extended embryo culture) have also helped to limit the number of embryos transferred. The best approach to reduce the risk of multiple gestations is to limit the number of embryos transferred. Elective single embryo transfer essentially eliminates multiple gestations but is associated with lower pregnancy rates in an unselected group of patients. It is currently recommended to a minority of couples with excellent prognosis. Future research should try to identify other markers (e.g.: embryonic products from culture medium) that could be used to identify those embryos that have the best chance for successful implantation. This review will summarize the efforts made so far to reduce the incidence of multiple gestations.

Preterm birth at less than 37 weeks gestation is a substantial burden to the community, representing a major source of infant death, severe handicap, and suffering for both victims and their families. Despite considerable research, little progress has been made in its prevention, partly because preterm birth is the endpoint of a silent multifactorial syndrome which begins long before labour starts. Infectious inflammation often plays a central role, but maternal susceptibility is probably also critical. Although progestogen treatment is preventive in some women with a prior history of preterm birth this will have little impact on the overall preterm birth rate unless effective treatment can be used in a much larger population of at risk women. An accurate screening test to identify such women is needed. The discovery of a screening test and of novel treatments requires a better understanding of the underlying biomolecular events. This paper gives an overview of the physiology and molecular biology of normal and abnormal pregnancy and parturition, the causes and consequences of preterm birth, and the difficulties of predicting and preventing preterm birth.