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PubMed1987

Failures of intravenous Rh immune globulin prophylaxis: an analysis of the reasons for such failures.

Universal administration of an ion exchange column prepared Rh immune globulin (RhIG-IV) antepartum at 28 weeks' gestation and postpartum to 9,295 Rh negative women delivering Rh positive babies has reduced the prevalence of Rh immunization from the expected 601 to 25 (a protection rate of 95.9%). Rh immunization, despite universal Rh prophylaxis, developed in 25 women; eight before antenatal prophylaxis was administered, 17 after antenatal prophylaxis was administered. Residual Rh immunization is caused by small fetal transplacental hemorrhages (TPH) (greater than or equal to 0.01 mL of fetal blood) before antenatal prophylaxis (15%) and by significant fetal TPH (greater than or equal to 0.05 mL of fetal blood) between 30 and 38 weeks' gestation (18%); TPH was too great, in some instances, for residual passive Rh antibody to give protection. Although a reduction of 62% (five of eight) of early Rh immunization and 82% (14 of 17) of later Rh immunization might be achieved by addition of 16 weeks' to 20 weeks' gestation and 34 weeks' gestation Rh prophylaxis; and a reduction of 84% overall (21 of 25) might be achieved by universal fetal TPH screening every 2 weeks from 10 weeks' gestation until delivery, with administration of RhIG when a small early fetal TPH or a significant later fetal TPH is detected, all of these programs are costly in terms of prevention of perinatal mortality and in terms of cost per quality adjusted life year gained. We believe that the costs outweigh the benefit that would be achieved. Therefore, a residual Rh immunization prevalence of 0.24% to 0.31% during or after each Rh positive pregnancy in patients at risk is to be expected despite universal 28 weeks' gestation antenatal and postnatal Rh prophylaxis.

Female↗
PubMed1995

Evidence suggesting that the odortypes of pregnant women are a compound of maternal and fetal odortypes.

Odortypes--namely, body odors that distinguish one individual from another on the basis of genetic polymorphism at the major histocompatibility complex and other loci--are a fundamental element in the social life and reproductive behavior of the mouse, including familial imprinting, mate choice, and control of early pregnancy. Odortypes are strongly represented in urine. During mouse pregnancy, an outcrossed mother's urine acquires fetal major histocompatibility complex odortypes of paternal origin, an observation that we took as the focus of a search for odortypes in humans, using a fully automated computer-programmed olfactometer in which trained rats are known to distinguish precisely the odortypes of another species. Five women provided urine samples before and after birth, which in each case appropriately trained rats were found to distinguish in the olfactometer. Whether this olfactory distinction of mothers' urine before and after birth reflects in part the odortype and hence genotype of the fetus, and not just the state of pregnancy per se, was tested in a second study in which each mother's postpartum urine was mixed either with urine from her own infant or with urine of a different, same-aged infant. Responses of trained rats were more positive with respect to the former (congruous) mixtures than to the latter (incongruous) mixtures, implying that, as in the mouse, human fetal odortypes of paternal genomic origin are represented in the odortype of the mother, doubtless by circulatory transfer of the pertinent odorants.

Animals↗
PubMed2003

Prevalence of prenatal drinking assessed at an urban public hospital and a suburban private hospital.

BACKGROUND: Although the prevalence of fetal alcohol syndrome (FAS) varies within the population, few data are available concerning variation in the prevalence of prenatal drinking. METHODS: Postpartum women delivering singleton infants at two Atlanta hospitals in 1993 or 1994 were interviewed. Those delivering infants who were small for gestational age (SGA) (n = 638) were over-sampled relative to those delivering infants with birth weights that were appropriate for gestational age (AGA) (n = 247). The prevalence of prenatal drinking was estimated as a weighted average of reports from mothers of SGA and AGA infants. Estimates of the prevalence of FAS come from the Metropolitan Atlanta Congenital Defects Program (MACDP) of the Centers for Disease Control and Prevention. RESULTS: The prevalence of first-trimester drinking was half that reported for the three previous months (private hospital: 72% vs. 35%; public hospital: 52% vs. 28%). Most women (85%) reported abstaining throughout the second trimester. Fewer than 10% of women delivering at the public hospital (7.5%), but one-quarter of those delivering at the private hospital, reported third-trimester drinking. Binge, moderate and heavy drinking in pregnancy were more common among women delivering at the public hospital. Eight infants born at the public hospital during this period, but none of those born at the private hospital, were identified as possibly having FAS; four of the eight were identified as probably having FAS. CONCLUSIONS: These results have implications for health education programs. For example, obstetricians in private practice may wish to reaffirm their advice to abstain from drinking in the third trimester. They also suggest that prenatal abstinence programs be targeted at populations identified as most likely to engage in risky drinking.

Alcohol Drinking↗
PubMed2005

Autologous blood transfusion in patients with placenta previa.

BACKGROUND: Several studies have shown that autologous blood storage during pregnancy is relatively safe for mother and fetus. However, the need for reappraisal of autologous blood transfusion in obstetric patients has been proposed. METHODS: We retrospectively reviewed the cases of placenta previa and low-lying placenta among pregnancies at our hospital during an 18-year period, 1985-2002. The utility of autologous blood transfusion program, which started in 1994 for those with placental positional disorders, was evaluated. RESULTS: Of the pregnancies reviewed, there were 158 cases (1.9%) of placenta previa or low-lying placenta. The number of patients transfused with homologous blood decreased from 27.6% (21/76) in the period before implementation of the autologous blood transfusion program to 8.5% (7/82) after its implementation in 1994. In the latter time period, 39.0% (32/82) of patients with placenta previa and low-lying placenta were phlebotomized and had blood stored. Of those, 71.9% (23/32) were reinfused where one patient (3.1%) needed homologous blood as well. The volume of collected blood per phlebotomy was 367 +/- 65 ml, the total volume of collected blood per patient was 803 +/- 350 ml, and the total of estimated blood loss per patient was 1326 +/- 873 ml. The volume of reinfused blood per patient was 578 +/- 326 ml. CONCLUSIONS: The program of autologous blood collection and transfusion in patients with placenta previa resulted in a decrease in homologous blood transfusion. In our program, we recommend starting blood collection and storage at 32 weeks' gestation and phlebotomize 400 ml per week to reach a volume of stored blood of 1200-1500 ml.

Adult↗
PubMed2006

Maternal care associated with methylation of the estrogen receptor-alpha1b promoter and estrogen receptor-alpha expression in the medial preoptic area of female offspring.

Variations in maternal behavior are associated with differences in estrogen receptor (ER)-alpha expression in the medial preoptic area (MPOA) and are transmitted across generations such that, as adults, the female offspring of mothers that exhibit increased pup licking/grooming (LG) over the first week postpartum (i.e. high LG mothers) show increased ERalpha expression in the MPOA and are themselves high LG mothers. In the present studies, cross-fostering confirmed an association between maternal care and ERalpha expression in the MPOA; the biological offspring of low LG mothers fostered at birth to high LG dams show increased ERalpha expression in the MPOA. Cross-fostering the biological offspring of high LG mothers to low LG dams produces the opposite effect. We examined whether the maternal programing of ERalpha expression is associated with differences in methylation of the relevant ERalpha promoter. Levels of cytosine methylation across the ERalpha1b promoter were significantly elevated in the adult offspring of low, compared with high, LG mothers. Differentially methylated regions included a signal transducer and activator of transcription (Stat)5 binding site and the results of chromatin immunoprecipitation assays revealed decreased Stat5b binding to the ERalpha1b promoter in the adult offspring of low, compared with high, LG mothers. Finally, we found increased Stat5b levels in the MPOA of neonates reared by high, compared with low, LG mothers. These findings suggest that maternal care is associated with cytosine methylation of the ERalpha1b promoter, providing a potential mechanism for the programming of individual differences in ERalpha expression and maternal behavior in the female offspring.

Animals↗
PubMed2002

To screen or not to screen--that is the question in perinatal depression.

Significant perinatal distress and depression affects 14% of women, producing short and long term consequences for the family. This suggests that measures for early detection are important, and non-identification of these women may exacerbate difficulties. Screening provides an opportunity to access large numbers of women and facilitate pathways to best-practice care. A valid, reliable, economical screening tool (the Edinburgh Postnatal Depression Scale, EPDS) is available. Arguments against screening pertain largely to lack of evidence about the acceptability of routine use of the EPDS during pregnancy and the postnatal period, and inadequate evidence regarding outcomes and cost-effectiveness. To address these concerns, the National Postnatal Depression Prevention and Early Intervention Program will evaluate outcomes of screening in terms of acceptability, cost-effectiveness, access and satisfaction with management in up to 100 000 women.

Australia↗
PubMedDate not supplied

Preventing repeat adolescent pregnancies with early adoption of the contraceptive implant.

CONTEXT: Even in intensive, adolescent-oriented programs, in which access to highly effective contraceptives is guaranteed, repeat adolescent pregnancies commonly occur. METHODS: To assess whether adoption of the contraceptive implant would lower the rate of repeat pregnancy, contraceptive use and pregnancy outcomes were tracked among 309 adolescent mothers--171 "early" implant users who began use within six months of delivery and 138 who either adopted another method or had used no method. Participants were interviewed at delivery and at six-month intervals through the second year postpartum. Multivariate logistic regression analyses were conducted to ascertain the likelihood of a repeat pregnancy within the first and second year postpartum. RESULTS: During the first year postpartum, although 7% of the early implant users had their implants removed, pregnancy rates were significantly (p < .0001) lower among early implant users (less than 1%) than among the other adolescent mothers in the sample (20%). By the end of the second year postpartum, 37% of early implant users had discontinued use. Nevertheless, their two-year pregnancy rate (12%) remained significantly lower (p < .0001) than that of the other adolescent mothers (46%). The multivariate analysis showed that early implant use was the only independent predictor of a repeat pregnancy within the first year postpartum, while early use, parity and number of risk factors for repeat pregnancy were independently associated with the likelihood of another pregnancy in the second year postpartum. CONCLUSIONS: Although early implant insertion significantly decreased the rate of rapid, repeat adolescent pregnancies, the rates of removal and of pregnancy by the end of the second year postpartum were high. Thus, health care providers need to address the motivational components of adolescent pregnancy even among those who accept ostensibly long-term methods.

Adolescent↗
PubMed2006

Effect of prenatal food supplementation on birth weight: an observational study from Bangladesh.

BACKGROUND: National nutrition programs in Bangladesh have included prenatal food supplementation to reduce maternal and child malnutrition. The knowledge base is weak regarding the effect of prenatal food supplementation on the birth weight (BW) of infants in populations in whom low BW is prevalent and regarding any variation in effect based on maternal nutritional status. OBJECTIVE: We examined whether observational data support an effect of daily prenatal food supplementation on BW by considering the duration of supplementation and whether the effect is modified by maternal postpartum weight (a proxy of prepregnancy weight) groups. DESIGN: A cohort of undernourished pregnant women (n = 777) who received prenatal food supplementation (608 kcal/d) was followed. The association between the uptake of food supplements and BW was analyzed after adjustment for potential confounders (n = 619 with complete information). Differential effects in lower and higher maternal postpartum weight groups were examined. RESULTS: The average BW was 2521 g. On average, the women received daily supplements for 4 mo, which resulted in an increase in BW of 118 g (1.0 g/d). The strongest effect was found for births occurring in January and February. There was a linear dose-response relation between duration of supplementation and BW for women with higher postpartum weights (> or = 42 kg, above the median). In women with lower weights (< 42 kg, below median), a shorter duration of supplementation (< 4 mo) had no such dose-response relation with BW, but there was a linear dose-response relation for longer durations of supplementation. CONCLUSIONS: The association between duration of prenatal food supplementation and BW varies with maternal postpartum weight. A large effect was observed after the season with food insecurity (mid-August to mid-November).

Adult↗
PubMed1997

Sexuality, reproduction, and family planning in women with schizophrenia.

This article reviews data about how schizophrenia affects sexuality, pregnancy, the puerperium, parenting, and family planning. Women with schizophrenia have high rates of coerced sex, sexual risk behavior, and unwanted pregnancies. High rates of obstetric complications and custody loss increase morbidity for women and their offspring. Since untreated psychosis increases these problems, the risks of withholding pharmacotherapy must be weighed against the risks of prescribing medications during pregnancy. The puerperium is a time when women are especially vulnerable to exacerbations of schizophrenia. Mothers with schizophrenia may have a reduced ability to read children's cues, and they often have weak social support networks. Their children may be more difficult to raise than other children. Parenting rehabilitation can address some of these problems. Often, women with schizophrenia who are sexually active and do not wish to become pregnant do not use contraception. Incorporating family planning measures into mental health care delivery systems may reduce unwanted pregnancies.

Antipsychotic Agents↗
PubMedDate not supplied

Implementing evidence-based practice: reducing risk for low birth weight through pregnancy smoking cessation.

In 1989, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) developed a research utilization program to integrate evidence into practice areas where there were large discrepancies between research evidence and clinical practice. The current program, renamed Research-Based Practice (RBP), uses translational research methods to build from evidence such as that in the Cochrane database and to create protocols for integration of research directly into clinical practice. This article describes the development of the sixth project (RBP6), in which an evidence-based protocol to address smoking in pregnancy was integrated into clinical practice. The protocol includes screening women using descriptive statements and integrates the 5 As (ask, advise, assess, assist, arrange) into prenatal and postpartum care at every visit. By integrating smoking cessation counseling into care, nurses may reduce the risk of low birth weight among pregnant women in both the United States and Canada.

Female↗
PubMedDate not supplied

Bangladesh specialists call for more maternal, child care.

Some 28,000 Bangladesh mothers die during childbirth each year and 375,000 become debilitated, according to a statement from the Obstetrical and Gynecological Society of Bangladesh which held its first international conference in Dhaka in December. 1992. Almost 300,000 babies do not survive childbirth, the society said recently. The society calculates that, of the 4 million births in Bangladesh each year, around 600,000 require clinic or hospital facilities and 200,000 require cesarean section. At present hospitals account for barely 40,000 deliveries and around 25,000 cesarean sections are carried out each year. Bangladesh not only lacks hospital beds, equipment, and nurses but also needs 1000 more specialists in obstetrics and gynecology, the society's statement said. The society called for a National Council on Maternal and Child Health, headed by the prime minister. The council should be supported by a technical committee and Maternal and Child Health should be a full directorate in the Ministry of Health and Family Welfare. The society recommended setting minimum standards for health education, nutrition, and treatment of anemia, immunization, screening for high-risk pregnancies, safe delivery, referral, transport, neonatal and postpartum care, infant care, and treatment of unsafe abortion. Collaboration with non governmental organizations should be the basis for providing more facilities and equipment, training more staff, and ensuring adequate transport to hospital, the society said.

Asia↗
PubMed2005

Reproductive performance of early postpartum Holstein cows where oestrus was synchronised following chronic GnRH agonist treatment.

OBJECTIVE: The objectives of this study were: to compare the recovery of follicular development in early postpartum cows that had been treated for 7, 14 or 21 d with implants containing the GnRH agonist deslorelin; to evaluate the effectiveness of human chorionic gonadotrophin (hCG) for the induction of ovulation when a follicle was at least 10 mm in diameter following implant removal; and to compare final pregnancy rates for treated cows and untreated contemporaries. PROCEDURE: Within 3 d of calving Holstein cows were allocated to receive a single subcutaneous deslorelin implant to be left in place for either 7, 14 or 21 d, or to remain untreated as controls. Every deslorelin treated cow was monitored twice weekly for 35 d to determine the interval from implant removal to resumption of ovulation using serial transrectal ultrasonography and plasma progesterone assay. An injection of 1000 IU hCG was given to induce ovulation when a follicle of at least 10 mm diameter was first observed. Oestrous cycles of every cow were synchronised to facilitate artificial insemination (Al) at the start of the seasonally concentrated Al program and resynchronised for three rounds. Pregnancy testing was performed by ultrasonography 13 weeks after the first round of Al. RESULTS: Deslorelin implants inhibited ovulation for at least 10 d after they were removed. Ovarian follicles were smaller for the group that had implants for 21 d at the time of implant removal. Eighteen cows selected for treatment with hCG ovulated and formed multiple corpora lutea within 7 d. There was no effect of treatment duration on final pregnancy rates. After three rounds of AI the pooled final pregnancy rate for every cow that had received a deslorelin implant was similar to the rest of the herd (67% versus 63%; Deslorelin versus Herd, P > 0.1). The interval from start date of the AI program to conception was also unaffected by treatment (9.6 +/- 3.0 versus 14.8 +/- 1.7 d; Deslorelin versus Herd; P > 0.1). CONCLUSION: No significant effect was detected on the interval from implant removal to first ovulation by altering the duration of deslorelin treatment. Treatment with hCG when a follicle at least 10 mm in diameter was present induced ovulation in most cases. Although no significant improvement in fertility was found, a larger field trial using this model for induced anoestrous is necessary before any effect on fertility could confidently be stated.

Animals↗
PubMed2005

Position of the American Dietetic Association: Promoting and supporting breastfeeding.

It is the position of the American Dietetic Association (ADA) that exclusive breastfeeding provides optimal nutrition and health protection for the first 6 months of life, and breastfeeding with complementary foods for at least 12 months is the ideal feeding pattern for infants. Breastfeeding is also a public health strategy for improving infant and child health survival, improving maternal morbidity, controlling health care costs, and conserving natural resources. ADA emphasizes the essential role of dietetics professionals in promoting and supporting breastfeeding by providing up-to-date, practical information to pregnant and postpartum women, involving family and friends in breastfeeding education and counseling, removing institutional barriers to breastfeeding, collaborating with community organizations and others who promote and support breastfeeding, and advocating for policies that position breastfeeding as the norm for infant feeding. ADA also emphasizes its own role by providing up-to-date information to the public, encouraging empirical research, providing continuing education opportunities, providing cultural sensitivity and cultural competence training to dietetics professionals, and encouraging universities to review and update undergraduate and graduate training programs.

Adult↗
PubMed1994

The West Los Angeles Preterm Birth Prevention Project: II. Cost-effectiveness analysis of high-risk pregnancy interventions.

OBJECTIVE: To examine the cost-effectiveness of the West Los Angeles Preterm Birth Prevention Project. METHODS: Maternal and neonatal care data were collected on all preterm deliveries (150) and a random sample of term deliveries (140) from high-risk patients at both experimental and control clinic sites. Costs were determined for prenatal care, inpatient preterm labor, delivery and postpartum care, and newborn care. Cost calculations, weighted by the actual proportions of term and preterm births, were confirmed with square-root transformation and trimmed mean (2%) values. RESULTS: When compared to control clinic high-risk patients, experimental clinic high-risk patients had an average cost savings of $2196 for newborn care (P = .02), resulting in a net savings of $1768 per high-risk mother-infant pair. Births before 32 weeks' gestation accounted for the greatest mean cost. CONCLUSION: Programs of comprehensive prenatal care and patient education may be highly cost-effective for prevention of prematurity.

Adult↗
PubMedDate not supplied

The single unit transfusion in post partum hemorrhage: A new perspective.

Every year, about 210 million women become pregnant. Postpartum hemorrhage (PPH) is one of the major complications of pregnancy, accounting for 14 million cases annually. Of these, it is estimated that around 140,000 women die, resulting in a case fatality rate of 1%. PPH is defined by WHO as a blood loss > or = 500 mls. Most instances of PPH occur suddenly and without warning even in women without any of the known risks for this condition. If women do not receive timely medical treatment, as is often the case in many parts of the world, death can occur within two hours. The chance of receiving a safe blood transfusion as part of the therapy for PPH varies enormously from country to country, depending on whether a safe blood transfusion program has been set up as a part of the national health policy. The increasing realization of the potential deleterious effects of blood transfusion, including exposure to HIV and other viral agents, has changed the practices that were previously acceptable for the transfusion of blood, as has the recent recognition of specific patients who will benefit from a single unit of blood. In countries with limited resources, where a majority of women have anemia at the onset of their pregnancies, the slightest deviation from normality during labor and/or delivery leading to excessive hemorrhage can put a women's life at risk. In these instances, the patient needs urgent resuscitation, stabilization and transfer to a nearby center. Available blood, preferably typed cross matched and screened for infections, should be given until the patient receives specific treatment. This is especially true in bled- out obstetrics patients, where one unit may make the difference between a near death state and the possibility of slow recovery and survival.

Anemia, Iron-Deficiency↗
PubMed2000

Training traditional birth attendants in clean delivery does not prevent postpartum infection.

OBJECTIVE: To compare the maternal outcome, in terms of postpartum infection, of deliveries conducted by trained traditional birth attendants (TBAs) with those conducted by untrained birth attendants. METHODS: The study took place in a rural area of Bangladesh where a local NGO (BRAC) had previously undertaken TBA training. Demographic surveillance in the study site allowed the systematic identification of pregnant women. Pregnant women were recruited continuously over a period of 18 months. Data on the delivery circumstances were collected shortly after delivery while data on postpartum morbidity were collected prospectively at 2 and 6 weeks. All women with complete records who had delivered at home with a non-formal birth attendant (800) were included in the analysis. The intervention investigated was TBA training in hygienic delivery comprising the 'three cleans' (hand-washing with soap, clean cord care, clean surface). The key outcome measure was maternal postpartum genital tract infection diagnosed by a symptom complex of any two out of three symptoms: foul discharge, fever, lower abdominal pain. RESULTS: Trained TBAs were significantly more likely to practice hygienic delivery than untrained TBAs (45.0 vs. 19.3%, p < 0.0001). However, no significant difference in levels of postpartum infection was found when deliveries by trained TBAs and untrained TBAs were compared. The practice of hygienic delivery itself also had no significant effect on postpartum infection. Logistic regression models confirmed that TBA training and hygienic delivery had no independent effect on postpartum outcome. Other factors, such as pre-existing infection, long labour and insertion of hands into the vagina were found to be highly significant. CONCLUSIONS: Trained TBAs are more likely to practice hygienic delivery than those that are untrained. However, hygienic delivery practices do not prevent postpartum infection in this community. Training TBAs to wash their hands is not an effective strategy to prevent maternal postpartum infection. More rigorous evaluation is needed, not only of TBA training programmes as a whole, but also of the effectiveness of the individual components of the training.

Bangladesh↗
PubMed2005

Immunizations, neonatal jaundice, and animal-induced injuries.

PURPOSE OF REVIEW: To concisely review data published over the past year on three topics pertinent to the practicing pediatrician: immunizations, neonatal jaundice, and animal-induced injuries. RECENT FINDINGS: Updates on immunizations, including varicella and pneumococcus in the post-vaccine era, use of a polyvalent conjugated meningococcal vaccine, and influenza vaccination during a vaccine shortage are discussed. Mortality and morbidity from varicella, and risk of invasive disease from pneumococcal infections have declined. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention released guidelines for the use of a tetravalent meningococcal conjugate vaccine in adolescents 11 years and older. Infants at younger gestational age are at higher risk for developing hyperbilirubinemia. The American Academy of Pediatrics has released new guidelines emphasizing breastfeeding, systematic pre-discharge assessment for risk factors, early follow-up and intervention. Use of home nursing services in the postnatal period is cost-effective. Although the incidence of rabies is low, many receive postexposure prophylaxis. Spider bites cause fewer systemic effects in children than adults. Pet reptile carriage of salmonella necessitates handwashing after handling of animals. SUMMARY: Recommendations for adolescent meningococcal vaccination, and the impact of varicella and pneumococcal immunization on our communities reflect an evolution in our management of infectious diseases. The latest practice guidelines on hyperbilirubinemia emphasize close follow-up of all newborns after postpartum discharge and even more careful evaluation of those infants near term. Education on rabies prophylaxis, spider bites, and salmonella from pet reptiles should focus on judicious use of resources and the proper handling of pets.

Animals↗
PubMedDate not supplied

Post-maternity outcomes following health care reform in Alberta: 1992-1996.

OBJECTIVE: The effect of Alberta's health reform on length of stay for maternity cases and on subsequent mothers' rehospitalization was examined in the present study. METHODS: The data set included all Alberta acute care hospital separation records from 1991/92 to 1996/97 inclusive. A logistic regression was applied to the data in order to examine the effects of prepartum condition, type of delivery, length of stay, maternal age, and year on the likelihood of readmission. RESULTS: Health reform proved to be associated with a dramatic decrease in length of stay for maternity cases; from 3.8 to 2.4 days on average. This was accompanied by very little variation in the 90-day readmission rate for mothers over the same time period (notably, a slight decrease). Higher readmission rates were associated with the existence of difficulties during the pregnancy and other prenatal conditions, maternal age, and with the type of delivery. There were no dramatic changes in the rates for prepartum diagnoses, nor for the type of delivery. DISCUSSION: The data suggest that the reduction in the length of maternity stay has had no discernible negative health effects on new mothers, perhaps because of the home visiting programs that were put in place. Furthermore, there may still be room to improve outcomes by focussing on those with prepartum conditions and cases involving complicated births.

Adult↗