Biomedical subjects
J A Fortney
Publications and source records attributed to J A Fortney.
Puerperal sepsis and maternal mortality: what role can new technologies play?
OBJECTIVE: To identify new and underutilized technologies to reduce maternal mortality related to puerperal sepsis in developing countries. METHOD: Review of current medical literature. RESULT: The literature indicates that infection-control protocols and evidence-based procedures--including prophylactic antibiotics for cesarean section or preterm rupture of membranes, and updated antibiotic regimens--should be widely adopted. Devices such as hand rubs, needle-disposal systems, and rapid microbiological diagnostic tests can improve compliance and efficiency. Operational research on promising developments like vaginal cleansing with antiseptics, vitamin A supplementation, and prophylactic antibiotics in high-risk women is needed. CONCLUSION: Sepsis management continues to depend on good implementation of established technologies. Program-based approaches are required to improve uptake.
Editor's comment: The FIGO Save the Mothers Initiative.
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Estimates of the maternal mortality ratio in two districts of the Brong-Ahafo region, Ghana.
OBJECTIVE: To estimate the maternal mortality ratio (MMR) by the sisterhood method in two districts of the Brong-Ahafo region of Ghana, and to determine the impact of different assumptions and analytical decisions on these estimates. METHODS: Indirect estimates of the MMR were calculated from data collected in 1995 by Family Health International (FHI) on 5202 women aged 15-49 years, using a household screen of randomly selected areas in the two districts. Other data from the nationally representative 1994 Ghana Infant, Child and Maternal Mortality Survey (ICMMS) and from the 1997 Kassena-Nankana District study were also used for comparison. FINDINGS: Based on the FHI data, the MMR was estimated to be 269 maternal deaths per 100,000 live births for both districts combined, a figure higher than ICMMS estimates. Biases during data collection may account for this difference, including the fact that biases underestimating mortality are more common than those overestimating it. Biases introduced during data analysis were also considered, but only the total fertility rate used to calculate the MMR seemed to affect the estimates significantly. CONCLUSIONS: The results indicate that the sisterhood method is still being refined and the extent and impact of biases have only recently received attention. Users of this method should be aware of limitations when interpreting results. We recommend using confidence limits around estimates, both to dispel false impressions of precision and to reduce overinterpretation of data.
The impact of traditional birth attendant training on delivery complications in Ghana.
OBJECTIVES: In their efforts to reduce maternal and neonatal morbidity and mortality, many national and international agencies make considerable investments in training traditional birth attendants (TBAs). The value of TBA training is controversial, and plausible arguments are made both for and against. Numerous process evaluations are reported in the literature and the results are mixed, though generally positive. Outcome evaluations, however, are scarce. This article describes an outcome evaluation of TBA training conducted in two districts of Brong-Ahafo Region, Ghana, during 1996. DESIGN AND METHODS: Data from a random sample survey of 1961 clients of TBAs were subjected to logistic regression modelling to determine the effect of training on maternal outcomes, controlling for other independent variables. RESULTS: Of eight outcomes modelled, three were associated with training and five were not. Three additional outcomes were not modelled, primarily due to low prevalence. CONCLUSIONS: Despite some inherent design limitations, this study found that the evidence for a beneficial impact of TBA training was not compelling. Training sponsors should consider alternative health investments and, where TBA training remains the intervention of choice, be realistic about expectations of impact.
Selective screening for cervical neoplasia: an approach for resource-poor settings.
BACKGROUND: Cervical malignancies are the leading cause of cancer-related morbidity and mortality among women in developing countries. Although early detection programmes using cytological methods, followed by aggressive treatment of precursor lesions are accepted as the main disease control strategy, fiscal limitations make this strategy unfeasible in many countries. METHODS: To screen selectively, we developed two risk scores using data from a population-based case-control study in Jamaica with 202 cases and 363 controls. Independent risk factors for cervical neoplasia were determined using logistic regression. An unweighted risk score for each subject was developed by a simple count of risk factors present and a weighted risk score was calculated by summing regression coefficients for each risk factor. RESULTS: Four patient characteristics were independently predictive of cervical neoplasia, older age (OR = 3.4, 95% CI : 1.8-6.7), > or = 4 pregnancies (OR = 5.6, 95% CI : 1.2-18.7), poverty (OR = 2.1, 95% CI : 1.3-3.3) and cigarette smoking (OR = 1.9, 95% CI : 1.2-3.2). Using cut-off points of > or = 20 for the weighted scores and > 3 for unweighted scores, the sensitivity and specificity were 65% and 69% for the unweighted score and 75% and 61%, respectively, for the weighted score. Areas under the receiver operating characteristic (ROC) curves for the weighted versus the unweighted scores were similar, suggesting similar overall accuracy. CONCLUSION: Selective screening using risk assessment strategies is potentially useful, particularly in resource-poor settings. However, whether weighting factors is essential is dependent on prevalence of factors in a given setting. Although this approach needs validation in other populations, women at highest risk for cervical neoplasia can be identified using demographic factors available during a regular clinic visit.
Assessing recall and understanding of informed consent in a contraceptive clinical trial.
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Intrauterine devices. The optimal long-term contraceptive method?
OBJECTIVE: To review selected data on the effectiveness, safety, cost and technical ease of intrauterine device (IUD) use compared with Norplant and surgical sterilization. STUDY DESIGN: Literature review. RESULTS: IUDs are highly effective, safe and relatively inexpensive methods of contraception that may offer advantages for some women over other long-term methods, such as sterilization and Norplant. IUDs provide protection against pregnancy comparable to that provided by female sterilization, and they may be more effective than Norplant. IUDs have a long duration of effectiveness: the copper T 380A (TCu380A) is effective for at least 10 years, and the levonorgestrel (LNg) IUD appears to be effective for at least 7. Norplant is effective for only five years. Both types of IUD can disrupt menstrual bleeding patterns, although the patterns of bleeding are different. Copper IUDs often increase blood loss, whereas the LNg IUD, like Norplant, substantially reduces menstrual bleeding. The most important adverse outcome associated with IUD use is higher rates of pelvic inflammatory disease; careful attention to proper insertion techniques can reduce this risk substantially, and LNg IUDs may cause no increase in risk. IUDs, like both sterilization and Norplant, provide no protection against sexually transmitted disease. The TCu380A IUD is extremely cost-effective. There is as yet no public sector price for the LNg IUD, which has not been approved by the U.S. Food and Drug Administration and is not provided by family planning donor organizations. If it can be made available to the public sector at a price substantially less than its present market price, the LNg IUD would be a useful addition to the contraceptive armamentarium for developing countries. CONCLUSION: Providers, consumers and family planning program managers should begin to see IUDs as potential substitutes for both surgical sterilization and Norplant.
Re: authors and authorship.
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Maternal death and birth spacing.
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The postpartum period: the key to maternal mortality.
OBJECTIVES: To assess postpartum care at an international level, we reviewed published literature on postpartum maternal deaths. METHODS: Meta-analysis was used to summarize the literature reviewed. Postpartum deaths in developing countries were compared with those in the United States. RESULTS: In both developing countries and the United States, > 60% of maternal deaths occurred in the postpartum period; 45% of postpartum deaths occurred within 1 day of delivery, > 65% within 1 week, > 80% within 2 weeks. In developing countries, 80% of postpartum deaths caused by obstetric factors occurred within 1 week. CONCLUSIONS: The first 24 h postpartum and the first postpartum week is the high risk of postpartum deaths, and the risk remains significant until the second week after delivery. In developing countries, hemorrhage, pregnancy-induced hypertension complications, and obstetric infection are commonest causes of postpartum deaths. We suggest primary prevention, early detection, and secondary prevention of postpartum deaths.
Genital burns and vaginal delivery.
Obstetric complications may result from burn scarring in the genital area. Women in developing countries typically squat around cooking fires, and burns are common. This recent case in Nepal describes obstructed labor in a young woman whose genital area had extensive scarring from a cooking fire injury. Proper antenatal assessment by health care providers can reduce the risk to mothers and infants of the consequences of a birth canal damaged or obstructed by burn scarring.
Racial differences in North Carolina infant mortality.
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Bone mineral density and history of oral contraceptive use.
To examine the relationship between oral contraceptive (OC) use and bone mineral density (BMD), we conducted a cross-sectional study on 352 white, nonsmoking, perimenopausal women aged 40-54 years. We measured bone mineral density of lumbar vertebrae 2-4 with dual photon absorptiometry and mid-radius and distal radius with single photon absorptiometry. After controlling for age, body mass, current physical activity, current calcium intake and history of breastfeeding, our analysis did not find substantial differences in BMD at any site between OC ever users and never users. However, OC ever users had slightly higher lumbar BMD among premenopausal women. No significant association was identified between recency of OC use and BMD. The results of our study suggest that when other factors are accounted for, OC use is not strongly associated with BMD among perimenopausal women, although we cannot exclude a slight beneficial effect.
Re: "Pregnancy and lactation as determinants of bone mineral density in postmenopausal women".
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The validity of self-reported height and weight in perimenopausal women.
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