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Full pregnancy history - recommendations from Newborn Indicators Technical Working Group [message #1764] Wed, 02 April 2014 13:37
dsitrin is currently offline  dsitrin
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Registered: March 2014
Location: Washington, DC
Newborn deaths now account for 44% of deaths among children under the age of five (UNICEF 2013), and reductions in newborn deaths lag behind reductions in maternal, infant and child deaths. The estimated number of worldwide stillbirths in the third trimester for 2009 was 2.64 million (Cousens 2011), yet the problem of stillbirth has remained an almost invisible global health issue. The current use of birth history alone is widely believed to underestimate stillbirths and early neonatal deaths and doesn't capture other important pregnancy outcomes (such as miscarriage and abortion); this deficit has been identified as a major data gap, impeding actions towards improving maternal and newborn health.

The recommendations below are made on behalf of members of an inter-agency Newborn Indicators Technical Working Group (TWG) established in 2008 to improve the capture and measurement of newborn care. The TWG includes representatives from United Nations agencies, nongovernmental organizations and national institutes of health, research and academic institutions, and donors.


1. What is the information needed?
We propose further pretesting a complete pregnancy history (in place of a birth history alone) in the DHS woman's questionnaire. Complete pregnancy history has been collected by DHS in several countries and testing this method in more settings would be a step towards improving capture of pregnancy loss data, capitalizing on the progress made in the last few decades on collecting data from birth histories. Pregnancy loss data are vital to improve information on stillbirths, miscarriages, and terminations of pregnancy and could improve capture of early neonatal deaths.

2. What questions will elicit this information?
Questions can be taken from previous DHS that included a full pregnancy history, such as Nepal 2011. Additional examples from Eastern Europe and Central Asia could also be used, such as Ukraine 2007, Armenia 2010, Kyrgyz Republic 2012 and Tajikistan 2012.

In addition, existing questions can be improved, whether used in a full pregnancy history or as part of the existing birth history:
Q206: Any baby who cried or showed signs of life, but did not survive?
Could be amended to:
Any baby who cried or showed ANY signs of life, but did not survive?

Q230: Have you ever had a pregnancy that miscarried, was aborted or ended in a stillbirth?
Where women report that this happened at 7 months gestation or later, the question could be followed by:
When that baby was born, was there ever any movement, sound or effort to breathe?

3. How will the resulting information be used?
Improved understanding of all pregnancy outcomes and maternal conditions associated with stillbirth and neonatal death could provide a firmer foundation for prioritizing interventions in order to benefit the mother and infant. Further pretesting approaches to collecting full pregnancy history would be a step towards improving misclassifications of stillbirths and early neonatal deaths. Failure to accurately count stillbirths and early neonatal deaths ignores their impact on women and families. Furthermore, it leads to systematic undervaluation of the potential benefits of both antenatal care and care at the time of birth. Because standardized tracking systems that are comparable between countries, such as DHS, don't currently collect information on all pregnancy outcomes, it is more difficult to achieve universal coverage of maternal and newborn care interventions that could prevent up to half of maternal deaths, nearly three quarters of newborn deaths, and over a third of stillbirths.

The data can feed directly into the Every Newborn Action Plan (ENAP), which has reduction targets for both stillbirth and neonatal mortality rates. ENAP is closely linked to A Promise Renewed and is supported by more than 60 partners, co-chaired by UNICEF and other key partners including USAID, WHO, the Bill and Melinda Gates Foundation and Save the Children. ENAP will focus attention on newborn health and identify priority actions for improving survival, health and development. However, it relies on regular data on pregnancy outcomes in order to design, implement, cost and monitor strategies to end preventable newborn deaths.

4. What is the priority of suggested additions compared with what is already in the questionnaires?
The proposed addition involves replacing the birth history section of the core women's questionnaire with a complete pregnancy history. Q211-224 would be replaced with a pregnancy history, such as Nepal DHS 2011. The Nepal example also replaces the summary history question (Q201-Q210) and the questions immediately following (Q225-240).

5. If suggesting more than one addition, what is the priority among the suggested additions?
Not applicable

6. Should the additional data be collected in all countries, or only in selected types of countries?
Ultimately, the goal would be to improve the capture of pregnancy and birth history for all countries in order to allow for consistency in calculation of stillbirth rates, comparability of data across countries, tracking of all pregnancy outcomes and tracking of stillbirths as a core indicator alongside neonatal mortality rates. The format used in Nepal differs from that used in other countries. At this stage, we propose testing approaches to collecting the pregnancy history. Potentially, a split sample in the DHS pretest could be used as a methodological exploration of the measurement issues that may arise from the different approaches. Measurement issues that need to be considered are: the extra time taken to collect the information, the accuracy and validity of the approaches, and whether a forwards (as in Nepal example) or backwards (as in Ukraine example) more accurately captures the desired information on all pregnancies.

1. UNICEF (2013). Committing to Child Survival: A Promise Renewed.
2. Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, Creanga A A, Tuncalp O, Balsara Z P, Gupta S, Say L and Lawn J E (2011). National, regional, and worldwide estimates of stillbirth rates with trends since 1995: a systematic analysis. The Lancet Stillborn Series. 6736(11)60098-6
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