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    • Despite a substantial reduction in

    2019-06-11

    Despite a substantial reduction in global maternal deaths due to postpartum haemorrhage between 1990 and 2013 (from 71 295 to 44 190), this condition continues to be the main cause of maternal mortality worldwide. In sub-Saharan Africa and south Asia, many women still deliver at home without a skilled attendant, or attended by low-level providers in facilities with limited resources. In these contexts, availability of uterotonics that are easy to administer and are stable in field conditions are fundamental to decrease the morbidity and mortality of postpartum haemorrhage. Oxytocin is recommended by WHO, whereas misoprostol is recommended only when purchase Senexin A is not available or cannot be given. Although the results one of the largest facility-based randomised controlled trials, in which misoprostol was compared with oxytocin in its original vial formulation, showed oxytocin to be significantly more efficacious than misoprostol in settings with well equipped facilities, several questions remained unanswered. For example, the clinical significance of the results was small, study sites differed substantially, and oxytocin was not always given intramuscularly (sometimes it was given intravenously). Furthermore, because of its route of delivery, oxytocin has limited applicability in resource-poor settings, especially when women deliver without a skilled provider. Thus, the debate about misoprostol versus oxytocin during the third stage of labour continued. The Uniject formulation (ie, via a prefilled single-use intramuscular injection) offered hope because it could surmount some of the community-based limitations that vial formulations of oxytocin present. In an Article in , Ayisha Diop and colleagues answer some of these questions. They did a cluster-randomised controlled trial in Senegal to investigate the efficacy of oxytocin in Uniject (10 IU intramuscularly) versus misoprostol (600 μg orally) for the prevention of postpartum haemorrhage. Haemoglobin measurements for 1049 women delivering in maternity huts were gathered for the primary outcome—mean change in haemoglobin concentrations. Results suggested that oxytocin in Uniject was not superior to misoprostol. Furthermore, oxytocin in Uniject was associated with additional programmatic limitations such as its limited shelf life when not refrigerated, making the choice between the two uterotonics clearer in low-resource settings.
    In the past few decades, there has been an impressive decline in the mortality of children younger than 5 years worldwide. Child mortality was given impetus by Millennium Development Goal (MDG) 4, which aimed to reduce the under-5 mortality rate by two-thirds, between 1990 and 2015. Although this figure will not be reached globally, child mortality has nevertheless been reduced by 53% over this period. However, the reduction in neonatal mortality has been much slower, with the result that, by 2012, neonatal mortality constituted 44% of all deaths in children younger than 5 years. To reduce child mortality further, a focus on preventable neonatal deaths is essential. In , Catherine Pitt and colleagues report findings from their cluster-randomised controlled trial of the cost and cost-effectiveness of the Newhints newborn home-visit strategy in rural Ghana. Similar studies have been done in south Asia, but this was the first to be done in sub-Saharan Africa. The Newhints intervention consisted of home visits to pregnant women and their newborn babies by community-based surveillance volunteers. One of the primary objectives of the study was to assess the effect of the intervention on neonatal mortality. In the paper presenting the results of the Newhints trial, Betty Kirkwood and colleagues reported that, although there was a reduction in neonatal mortality of 8% in the intervention group, this did not reach statistical significance. However, the investigators did a meta-analysis by combining their results with three studies from south Asia, which then showed a significant reduction in neonatal mortality of 12%.