Understanding Maternal Mortality using the medical and social contexts. In explaining the social contexts, the presentation will present a case of the Zuellig Family Foundation on Maternal Death Reviews.
A powerpoint presentation on maternal mortality during a resident's presentation at Komfo Anokye Teaching Hospital, obstetrics and gynecology directorate.
definitions, causes, prevention and way forward for maternal mortality in Ghana
Physician and public health researcher Mitchell Besser visited the School of Public Affairs on Oct. 4, delivering a presentation on the prevention of mother-to-child transmission of HIV in Africa. Besser is the founder of Mothers2mothers, an organization that trains mothers with HIV to work in health centers to educate and support pregnant women who are HIV-positive.
Besser talked about "task shifting" some of the responsibilities of health care education from nurses and doctors (that are always in short supply and high demand) to the mothers, and utilizing new technologies such as mobile phones to expand the scope of care.
As an obstetrician and gynecologist, Dr. Besser professional career has been dedicated to the public health needs of women. In 1999, Dr. Besser joined the University of Cape Town's Department of Obstetrics and Gynecology, assisting with the development of services to meet the needs of pregnant women living with HIV and to prevent the transmission of HIV from mothers to their children (PMTCT). Dr. Besser recognized the need for an education and psychosocial support program that would contribute to PMTCT services achieving the best medical and social outcomes. Hoping to fill this void, he founded mothers2mothers in which mothers with HIV are employed to work in health centers, educating and supporting pregnant women and new mothers with HIV; reducing the workload of doctors and nurses and increasing the effectiveness of interventions that reduce the number of babies born with HIV and keep mothers healthy and alive to raise their children. Since its inception in 2001, the program has grown to provide services in more than 680 health care facilities in nine countries in Africa, with more than 3 million contacts with woman each year, reaching 20% of the HIV-positive pregnant women in the world. Dr. Besser has received Global Health Council’s Best Practice Award, Skoll Award for Social Entrepreneurship, Presidential Citizens Award of the United States Government and is an Ashoka and Schwab Fellow. He has presented at TED, appeared on BBC’s Forum and has given a Friday Evening Discourse at the Royal Institution of Great Britain.
Understanding Maternal Mortality using the medical and social contexts. In explaining the social contexts, the presentation will present a case of the Zuellig Family Foundation on Maternal Death Reviews.
A powerpoint presentation on maternal mortality during a resident's presentation at Komfo Anokye Teaching Hospital, obstetrics and gynecology directorate.
definitions, causes, prevention and way forward for maternal mortality in Ghana
Physician and public health researcher Mitchell Besser visited the School of Public Affairs on Oct. 4, delivering a presentation on the prevention of mother-to-child transmission of HIV in Africa. Besser is the founder of Mothers2mothers, an organization that trains mothers with HIV to work in health centers to educate and support pregnant women who are HIV-positive.
Besser talked about "task shifting" some of the responsibilities of health care education from nurses and doctors (that are always in short supply and high demand) to the mothers, and utilizing new technologies such as mobile phones to expand the scope of care.
As an obstetrician and gynecologist, Dr. Besser professional career has been dedicated to the public health needs of women. In 1999, Dr. Besser joined the University of Cape Town's Department of Obstetrics and Gynecology, assisting with the development of services to meet the needs of pregnant women living with HIV and to prevent the transmission of HIV from mothers to their children (PMTCT). Dr. Besser recognized the need for an education and psychosocial support program that would contribute to PMTCT services achieving the best medical and social outcomes. Hoping to fill this void, he founded mothers2mothers in which mothers with HIV are employed to work in health centers, educating and supporting pregnant women and new mothers with HIV; reducing the workload of doctors and nurses and increasing the effectiveness of interventions that reduce the number of babies born with HIV and keep mothers healthy and alive to raise their children. Since its inception in 2001, the program has grown to provide services in more than 680 health care facilities in nine countries in Africa, with more than 3 million contacts with woman each year, reaching 20% of the HIV-positive pregnant women in the world. Dr. Besser has received Global Health Council’s Best Practice Award, Skoll Award for Social Entrepreneurship, Presidential Citizens Award of the United States Government and is an Ashoka and Schwab Fellow. He has presented at TED, appeared on BBC’s Forum and has given a Friday Evening Discourse at the Royal Institution of Great Britain.
This presentation is all about the epidemiology of stillbirths, in India. It talks about the different challenges in controlling the stillbirths and the strategies of controlling it. The INAP guideline of Government of India, which is a stepping stone for controlling stillbirths in India, is also discussed here.
Perinatal deaths declined by 6,8% from the 22 948 in 2014 to 21 378 in 2015. Here is a closer look at the number.
http://www.statssa.gov.za/?page_id=1854&PPN=P0309.4&SCH=7047
The presentation will discuss; Increasing trend for fertility at midlife; Reasons; Problems; Advantages; Challenges; Chances of success naturally or with IUI or with IVF, role of PGT A; Delphi consensus Posieden criteria; Newer techniques with ovarian rejuvenation and CRISPR and ASRM recommendations and conclusions. We are seeing celebrities with millions of followers having babies at an older age. Aishwarya rai at 37 Rani mukherjee 37 Neha Dhupia 38 Kareen Kapoor 36 Farah Khan triplets at 40 yrs of age. An excellent publication from 2013 titled: Age shock: mis perceptions of the impact of age on fertility before and after IVF in women who conceived after age 40 K. Mac Dougall, Hum Reprod. 2013 Feb has put forth reasons for a mistaken belief in robust fertility
Mission Down’s Syndrome
we are running
Mission Down Syndrome and
congenital heart defetcts detecion Program
in pregnant mothers in antenatal period.
Now we wish more Gynaecologists to join hands and extend this noble facility to larger section of INDIAN society .
Mother /parent to child transmission of HIV is a real threat to the continuance of human race.We must have to fight and look forward for a HIV free world .
Since no study has claimed the relationship between the corona vaccine and menstrual cycle, there is no certain cause for the same. However, some experts suggest the following possible causes.
Leandro Mena, MD, MPH
Chair and Professor of Population Health Science
Department of Population Health Science
University of Mississippi Medical Center
Disparity of access_quality_review_of_maternal_mortality_in_5_regions_in_indo...tetitejayanti1969
cause of death maternal mortality, maternal mortality in Indonesia, quality health care of maternal, characteristic maternal mortality, disparity health care
This presentation is all about the epidemiology of stillbirths, in India. It talks about the different challenges in controlling the stillbirths and the strategies of controlling it. The INAP guideline of Government of India, which is a stepping stone for controlling stillbirths in India, is also discussed here.
Perinatal deaths declined by 6,8% from the 22 948 in 2014 to 21 378 in 2015. Here is a closer look at the number.
http://www.statssa.gov.za/?page_id=1854&PPN=P0309.4&SCH=7047
The presentation will discuss; Increasing trend for fertility at midlife; Reasons; Problems; Advantages; Challenges; Chances of success naturally or with IUI or with IVF, role of PGT A; Delphi consensus Posieden criteria; Newer techniques with ovarian rejuvenation and CRISPR and ASRM recommendations and conclusions. We are seeing celebrities with millions of followers having babies at an older age. Aishwarya rai at 37 Rani mukherjee 37 Neha Dhupia 38 Kareen Kapoor 36 Farah Khan triplets at 40 yrs of age. An excellent publication from 2013 titled: Age shock: mis perceptions of the impact of age on fertility before and after IVF in women who conceived after age 40 K. Mac Dougall, Hum Reprod. 2013 Feb has put forth reasons for a mistaken belief in robust fertility
Mission Down’s Syndrome
we are running
Mission Down Syndrome and
congenital heart defetcts detecion Program
in pregnant mothers in antenatal period.
Now we wish more Gynaecologists to join hands and extend this noble facility to larger section of INDIAN society .
Mother /parent to child transmission of HIV is a real threat to the continuance of human race.We must have to fight and look forward for a HIV free world .
Since no study has claimed the relationship between the corona vaccine and menstrual cycle, there is no certain cause for the same. However, some experts suggest the following possible causes.
Leandro Mena, MD, MPH
Chair and Professor of Population Health Science
Department of Population Health Science
University of Mississippi Medical Center
Disparity of access_quality_review_of_maternal_mortality_in_5_regions_in_indo...tetitejayanti1969
cause of death maternal mortality, maternal mortality in Indonesia, quality health care of maternal, characteristic maternal mortality, disparity health care
Study on utilization of antenatal care and outcome of pregnancy in a medical ...Sudipta Naskar
A study on Ante-natal care utilization by the mothers in Calcutta National Medical College & Hospital done by the 3rd Professional (Part I) M.B.B.S. students of Calcutta National Medical College under the guidance of the teachers of Community Medicine.
Hospital based study on perinatal mortality in RIMS,Manipuriosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Factors Associated with Growth in the First 1,000 Days CHECKLEYCORE Group
CORE Group GHPC15
October 8, 2015
Concurrent Session: Factors Associated with Growth in the First 1,000 Days: Translating Evidence into Programs for Stunting, Wasting, and the Double Burden of Malnutrition
As part of the Strong Start for Mothers and Newborns effort, the CMS Innovation Center hosted a webinar to discuss why it is important to reduce early elective deliveries and share best practices on how reducing early elective deliveries improves the health of mothers and newborns across the country. Individuals representing the American College of Obstetricians and Gynecologists, the March of Dimes, providers and payers conveyed examples of successes and how reducing early elective deliveries can be accomplished. All interested parties were invited to attend this event.
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CMS Innovations
http://innovations.cms.gov
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An investigation of the proportion of unintended pregnancies and associated f...Gwinyai Masukume
The following presentation by fourth year medical students (as presented on October 27th 2007) won a prize in the best young presenter category at the University of Zimbabwe Annual Medical Research Day.
The Early Age Onset (EAO) Colorectal Cancer (CRC) Summit was a novel meeting designed for Early Age Onset (EAO) colorectal cancer (CRC) survivors, affected families as well as physicians and scientists who were interested in advancing their understanding of the rapidly increasing incidence of rectal and colon cancer among young adults under 50 years of age.
Co-hosted by the Colon Cancer Challenge Foundation and the CME office of Memorial Sloan Kettering Cancer Center the program provided an opportunity to hear leading clinicians and scientists on the epidemiology, pathogenesis, genomics and lifestyle challenges of EAO-CRC.
The course also included lectures as well as workshops and panel discussions designed to facilitate multidisciplinary consensus regarding the priorities of EAO-CRC prevention, clinical care and research moving forward.
Professor Soo Downe presenting at the Doctoral Midwifery Research Society Alcohol & Medication in Pregnancy Conferene about 'Which horse for which courses? The EBM Problem in studies of pharmacological substances in maternity care'.
This presents the trends, issues, and challenges in the Philippine Health Care Delivery System. The data were mostly taken from the Philippine Department of Health (DOH) website and DOH Region VI Office.
Associate Professor Ian Scott - Princess Alexandra Hospital; University of Qu...Informa Australia
Associate Professor Ian Scott
Director
Internal Medicine & Clinical Epidemiology; Associate Professor of Medicine
Princess Alexandra Hospital; University of Queensland
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
1. SYDNEY MEDICAL SCHOOL
Ending Preventable Stillbirths
Adrienne Gordon
Neonatologist, RPA Women and Babies
NHMRC Early Career Fellow
Discipline of Obstetrics, Gynaecology and Neonatology
Project Lead BABY1000 Study
Charles Perkins Centre
The University of Sydney
2. The Big Picture
2
Global burden = 2.6 million stillbirths
10 countries account for two-thirds of stillbirths in 2015
and also the majority of maternal and neonatal deaths
Same as if ALL the babies born in Western Europe
in one year had died
3. But…not counted
3
– NOT routinely reported to the
World Health Organization
– NOT included in the Global
Burden of Disease metrics
– NOT measured appropriately in
most national surveys
– NOT counted in the Millennium
Development Goals
– NOT included as a target under
UN SDG - health goal
5. 5
“Almost no burden affecting families is so
big and yet so invisible both in society and
on the global public health agenda.”
Joy Lawn, M.D., PhD, Director of Global Evidence and Policy, Saving
Newborn Lives/Save the Children and a lead author of The Lancet’s
Stillbirths Series
6. International Comparisons – high income countries
Source: Flenady V et al. Lancet 2016.
› ~ 46,200 stillbirths in 2015
› ~ 20,000 avoidable stillbirths
if country rate were ≤ 2/1000
in all countries
› 1.8% per year average
reduction but large variation
› Netherlands had fastest
progress with ARR 6.8%
3630
4830
80
2140
720
300
640
2970
320 420
130 210
0
2000
4000
6000
8000
10000
12000
United
States of
America
Russian
Federa=on
Japan France United
Kingdom
Germany Italy Ukraine Spain Canada Poland Australia
Es=mated number of s=llbirths 2015
Top 12 HICs with highest burden
Avoidable s=llbirths (if country rate was 2/1000)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Series1
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Series1
Annual Rate of Reduction (2000-2015)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Series1
HICs should not be ignored – thousands of preventable deaths every year
still occur and care after stillbirth is often inadequate
AUSTRALIA RANKING - 49 HIC
Stillbirth rate (after 28 weeks)
2.7 /1000 - ranked 16th
over double that of best performing
country -Iceland 1.3/1000
SBR Reduction 1.4% - ranked 35th
Over 6 times slower than best country
Over 200 late gestation stillbirths
could be prevented every year if
rates <2/1000
( 6 countries achieved this)
7. A significant bereavement
› For families the death of an infant is among one of the
most stressful life events an adult may experience
› Also staff - “...nearly one in 10 obstetricians reported they
had considered giving up obstetric practice because of the
emotional difficulty in caring for a patient with a stillbirth”
Fish, W., Differences in grief intensity in bereaved parents1986, Champaigne, IL: Research Press Co.
Gold, K.J., I. Leon, and M.C. Chames, National survey of obstetrician attitudes about timing the subsequent
pregnancy after perinatal death. American Journal of Obstetrics & Gynecology, 2010. 202(4): p. 357.e1-6.
12. Unexplained stillbirth
› 28% of Australian stillbirths
› 41% of NSW stillbirths
› More common near term
12
0
10
20
30
40
50
60
70
20 - 24 weeks 25 - 29 weeks 30 - 36 weeks >/= 37 weeks
%
Unexplained stillbirth
Gordon, A & Jeffery H, Classification and description of stillbirths in New South Wales, 2002-2004. MJA 2008.188(11):p.645-8.
17. Unexplained = underexplored
Unexplained
Congenital Abnormality
Spontaneous Preterm
Specific Perinatal Conditions
APH
Infection
Fetal Growth Restriction
Maternal Conditions
Hypertension
PRE POST
33%
29%
21%
20%
13%
30%
Headley, E., A. Gordon, and H. Jeffery, Reclassification of unexplained stillbirths using clinical practice guidelines. Australian & New
Zealand Journal of Obstetrics & Gynaecology, 2009. 49(3): p. 285-9.
19. Risk factors for stillbirth in HIC
› Maternal obesity & overweight;
PAR 12% (8000 stillbirths each
year across all HIC)
› Maternal age > 35 years; PAR
11% (4000 stillbirths)
› Smoking; PAR 6 % (around
3000 stillbirths)
Flenady V, Koopmans L, Middleton P et al Major risk factors for stillbirth in high-income
countries: a systematic review and meta-analysis. Lancet 2011; published online April 14.
DOI:10.1016/S0140-6736(10)62233-7.
22. Contributing Factors Victoria
Suspected
Contributing
factor
Stillbirths % of SB
factors
identified
Neonates % of NND
factors
identified
Total
Perinatal
Deaths
% of total
Antenatal care 49 26.9 14 9.9 63 19.5
Inadequate
management of
medical conditions
24 13.2 3 2.1 27 8.4
Inadequate
antenatal
monitoring
25 13.7 11 7.8 36 11.1
Factors relating to
the pregnant
woman, her family
and her social
situation
49 26.9 18 12.8 67 20.7
Intrapartum care 29 15.9 50 35.5 79 24.5
Inadequate
intrapartum
management
6 3.3 10 7.1 16 5
22
Victoria’s mothers, babies and children 2014 and 2015
23. Risk Factors Victoria
› 3 public hospitals
› Monash, Dandenong and Casey
› 2001 – 2011
› 44326 births over 10 years
23
Drysdale et al
25. Risk factors show preventability
25
Population attributable risk for stillbirth, by region, for 12 potentially modifiable risk factors
Lawn et al Lancet EPS 2016
31. Maternal Age risks
Maternal Age
at Delivery
Risk of trisomy
21
Risk of any
chromosomal
abnormality
Risk of SB
after 37 weeks
multipara
Risk of SB
after 37 weeks
nullipara
20 – 34 1/1667 – 1/485 1/562 – 1/538 1/775 1/269
35 – 39 1/378 1/192 1/502 1/156
40 + 1/106 1/66 1/304 1/116
Seminars in Perinatology : The case for antepartum surveillance or timed delivery for women of
advanced maternal age Ruth Fretts
35. RCT of delivery timing in older women
35
N = 619
No difference in CS – IOL 32% (98/304) and expectant 33 % (103/314) RR 0.99; 95%
CI 0.87-1.14)
No difference in vaginal delivery (38% vs 33% RR1.30; 95% CI 0.96-1.77)
No difference in adverse outcomes
No deaths
39. Monitoring of fetal movements
› Grant et al 1989, cluster randomised trial of 68000 women
- No difference in late stillbirth with formal fetal movement counting
- Therefore NOT recommended
› Systematic review of > 44,000 pregnancies 2004 found antepartum
mortality
- 1.9 per 1000 when the mother felt normal fetal movement
- 80.4 per 1000 when fetal movements were reduced (OR 16.1, 95% CI 9.0–28.9, p<0.0001)
› Saastad et al 2010 found providing women with information on reduced
movements resulted in a reduction of:
- Delayed reporting >48hrs (OR 0.61 95% CI 0.47 – 0.81)
- Stillbirths (OR 0.36 95% CI 0.19 – 0.69)
Monitoring of FM is cheap and easy
BUT…consensus is limited on :
- Definition of normal
- Which method of counting to use
- Which assessment tools should be used
- What intervention should be performed
40. Cases
n = 99 (%)
Controls
n = 190 (%)
OR (95% CI)
Increase in strength
no change
increased
decreased
69 (69.7)
14 (14.1)
16 (16.2)
74 (38.9)
99 (52.1)
17 (8.9)
1.0*
0.08 (0.03 – 0.21)
1.33 (0.51 – 3.48)
Advice received from
caregiver
44 (42.7) 107 (55.7) 0.6 (0.36 – 0.96)
Increase in frequency
no change
increased
decreased
46 (46.5)
7 (7.1)
46 (46.5)
75 (39.5)
66 (34.7)
49 (25.8)
1.0*
0.14 (0.05 – 0.37)
1.36 (0.69 – 2.67)
Sudden vigorous 5 (4.9) 2 (1.0) 8.3 (1.3 - 50)
40
Sydney SB Study: Fetal Movements
44. Do the Guidelines Work?
Cohort Term Group
Pre n (%) Post n(%) Pre n(%) Post n(%)
Labour onset
Spontaneous
Induction
No labour
249 (52.6)
154 (32.6)
70 (14.8)
257 (50)
197 (38.3)
60 (11.7)
238 (54)
145 (32.9)
58 (13.2)
242 (51.3)
187 (39.6)
43 (9.1)
P= 0.107 P=0.038
Delivered specifically for
RFM
FDIU
47 (9.9)
2 (0.4)
67 (13)
3 (0.6)
43 (9.8)
1 (0.2)
64 (13.5)
0
P= 0.296 P= 0.123
Delivery type
NVD
LSCS
Instrumental
219 (46.3)
161 (34)
93 (19.7)
287 (56.1)
128 (25)
97 (18.9)
205 (46.5)
146 (33.1)
90 (20.4)
273 (58)
104 (22.1)
94 (20)
P= 0.003 P= 0.001
Chaku et al Impact of a DFM policy on workload and perinatal outcome submitted BJOG 2017
45. Do the Guidelines Work?
Cohort Term Group
Pre Post Pre Post
Mean birthweight (g)
SGA
3321(565)
61 (12.9%)
3314 (543)
53 (10.3%)
3394 (553)
59 (13.4%)
3407(546)
45 (9.5%)
ns P = 0.066
APGAR 5min ≤7 29 (6.1%) 17 (3.3%) 27 (6.1%) 12 (2.5%)
P=0.05 P=0.007
Resuscitation
None
IPPV
Intubation
CPR
422 (89.2%)
46 (9.7%)
3 (0.6%)
2 (0.4%)
474 (92%)
34 (6.6%)
3 (0.6%)
4 (0.8%)
396 (89.8%)
41 (9.3%)
2 (0.5%)
2 (0.5%)
444 (93.9%)
23 (4.9%)
3 (0.6%)
3 (0.6%)
ns P=0.069
Cord pH (av) 7.208 7.222 7.205 7.219
P=0.07 ns
Admission to NICU 55 (11.6%) 50 (9.7%) 41 (9.3%) 24 (5.1%)
ns P=0.013
46. Deaths
Pre policy N
(rate per
1000)
Post
policy
N
(rate per
1000)
P- value
Perinatal
mortality rate
RPAH
73/5781 12.6 80/6009 13.3 ns
RFM total cohort
RFM term births
5 /473
3 /441
10.6
6.8
3 /515
0 /473
5.8
0
P=0.406
P=0.072
Chaku et al Impact of a DFM policy on workload and perinatal outcome submitted BJOG 2017
47. AFFIRM
47
Stepped – wedge cluster RCT
Sample size in protocol 143,000 total births
Package of care
25 – 30% reduction in stillbirth
50. Table 7. Birth weight percentiles among preterm and term stillbirths and live births.
Bukowski R, Hansen NI, Willinger M, Reddy UM, Parker CB, et al. (2014) Fetal Growth and Risk of Stillbirth: A Population-Based
Case–Control Study. PLoS Med 11(4): e1001633. doi:10.1371/journal.pmed.1001633
http://journals.plos.org/plosmedicine/article?id=info:doi/10.1371/journal.pmed.1001633
51. Universal third trimester US
51
Triples detection
of SGA
Higher false +ve
For every
additional SGA
baby identified
there are 2 false
positives
AC GV plus
EFW < 10th = 40
x risk of severe
adverse
perinatal
outcome
53. 1.Overview of key recommendations
2.Institutional perinatal mortality audit
3.Psychological and social aspects of
bereavement care
4.Perinatal postmortem examination
5.Investigation of stillbirth
6.Investigation of neonatal deaths
7.Perinatal mortality classification
PSANZ Perinatal Mortality Guidelines
Available from:
https://psanz.com.au/guidelines/
54. Clinical Practice Guideline
• Assist parents with cause of
death
• Assist parents and clinicians in
future pregnancy
• Enhance monitoring of
strategies to reduce PND
• Aim to reduce perinatal death
55. Clinical Practice Guideline
• Assist parents with cause of
death
• Assist parents and clinicians in
future pregnancy
• Enhance monitoring of
strategies to reduce PND
• Aim to reduce perinatal death
57. Station 1:
Communicating with
parents about
perinatal autopsy
Station 2:
Autopsy and placental
examination
Station 3:
Investigation of
perinatal deaths
Station 4:
Examination of babies
who die in the
perinatal period
Station 5:
Audit and
classification of
perinatal death
Station 6:
Psychological and
social aspects of
perinatal bereavement
IMPROVE Skills Stations
Study Guide
Teaching Stations
Formative Assessment
SCORPIO Methodology: Hill DA, Medical Teacher 1992; 14: 37-41
60. Perinatal Autopsy: The gold standard investigation
Examination WA MMH
Total Perinatal Deaths 1326 136
Full/Limited Perinatal Autopsy 792 (60%) 50 (37%)
Non-Invasive Examination Data not collected 11 (8%)
Declined 493 (37%) 75 (55%)
Outcomes
Confirmed clinical findings 21% 39%
Provided a new diagnosis 20% 25%
Provided additional information 22% 10%
Remained unexplained 35% 25%
Western Australian Data: The 13th report of the perinatal and infant mortality committee of Western Australia for Deaths in the Triennium 2005-2007.
http://www.health.wa.gov.au/publications/subject_index/p/perinatal_infant_maternal.cfm
Mater Mother’s Hospital Brisbane Data: 1/6/2010-31/5/2011. MMH Bereavement Support Service
62. • External examination by specialist
• Babygram (X-ray)
• UItrasound scan
• MRI
• Blood sample / DNA for storage
• Limited autopsy
• Directed biopsy – tissue sample
Alternative investigations where permission for full
autopsy is not obtained
64. New perinatal audit tool Scotland
› NPSA Intrapartum perinatal loss tool
› Web based
› Demographics and care elements
› MBRRACE dataset
› Drop down boxes for guidance
› Includes taxonomy
› Generates action plan
› Standardised grading of care
64
69. What is grief?
› Grief is the normal affective response of a person to a
significant loss
- Sadness, irritability, disturbed sleep and appetite, a sense of longing for the lost
person, and occasionally visual or auditory hallucinations of the deceased.
› An acute sense of loss generally gives way to feelings of low
mood or depression.
› Anger is common
Psychological aspects of perinatal loss. Badenhorst W. Hughes P. Best Practice & Research in Clinical Obstetrics &
Gynaecology. 21(2):249-59, 2007
70. Grief duration
› 6 months after the loss
- Most parents will have recovered enough to resume normal
activities and be beginning to enjoy life again,
› May continue to feel significant distress for 2 or even more
years after the loss
› Suicidal ideation or psychotic symptoms are rare, and require
urgent psychiatric referral
Psychological aspects of perinatal loss. Badenhorst W. Hughes P. Best Practice & Research in Clinical Obstetrics &
Gynaecology. 21(2):249-59, 2007
71. Evidence for grief interventions
› Cochrane No trials
› Counseling interventions and self-help groups are valued
- no evidence that they reduce psychological symptom levels
› Holding the baby
- Now culturally entrenched
- Highly valued by some parents;
- Association with:
• post-traumatic stress disorder in parents
• disorganization of infant-mother attachment in the next born
Psychological aspects of perinatal loss. Badenhorst W. Hughes P. Best Practice & Research in Clinical Obstetrics &
Gynaecology. 21(2):249-59, 2007
72. Cunningham K. Holding a stillborn baby: does the existing evidence help us provide guidance?
MJA 196 (9) · 21 May 2012
73. Talking with families
Range of birth options
E motional care
S tay in hospital
P rovision of information
E
xtra special
circumstances
Creating memories
T ime
F uneral arrangements
Understanding
L ove and life after
74. Bereaved parents’ experience of care and follow-up
after stillbirth in Sydney hospitals
74
0
10
20
30
40
50
60
70
80
90
100
Waiting area Time spent Info adequate Time to ask Overall satisfied
%ofresponses
Strongly Agree/Agree
Neutral
Disagree/Strongly Disagree
Bond D, Raynes-Greenow C, Gordon A under review ANZJOG 2017
75. Major Themes Identified
75
Inappropriate
comments
Understanding
Being listened to
Integrity/
honesty
Communication
Professionalism
of staff
Empathy
Choice
Creating
memories
Time with caregiver
Continuity of care
Time during appointments
Physical environment
Time spent
with baby
Time for results
Follow-up
visit
Instruction
Support services
Guidance
Brochures
Information
Post mortem
Integrated
Support
After
Infant
Loss
Privacy
76. } Twice weekly service
} In an appropriate setting away from pregnant mothers and babies
} Central coordinator
◦ Informs families and staff
◦ Continuity
} Core team
◦ Obstetrician/Neonatologist
◦ Midwife
◦ SW
◦ Geneticist
◦ Counsellor
An example of a perinatal loss clinic
77. Satisfaction in iSAIL 2015 - 2016
77
0
10
20
30
40
50
60
70
80
90
100
Waiting area Time spent Info adequate Time to ask Overall satisfied
Strongly
agree/Agree
Neutral
Disagree/
Strongly
disagree
78. Some quotes
› Knowing the facts, having compassionate people ask how we are and giving advise
› Getting to speak about the things that I didn't like or upset me with the care of my baby
› Further understanding and a type of closure to our experience. A group empathy and an
ability to discuss any point with the appropriate people at the one time.
› Genuine care expressed by clinic manager and her understanding of the experience. I feel
very fortunate to have had our very worst time with the very best team.
› It helped to answer my questions regarding future pregnancy, potential risks. I felt that
everyone present understood our situation and were very sensitive in the way they
approached the meeting.
› The possibility to thank and ask questions of the people involved in my care. Referral to
ongoing support An opportunity for closure. Diana is amazing - She really understands us
and I felt comfortable and connected to her since our first conversation. She is also
incredibly responsive and helpful. I'm sure she works overtime every week!!
› The support I felt whilst we were there and also I received answers to questions I had been
wanting know.
› The feeling that people cared
› I found it was very helpful. Someone is there to listen and explain
78
80. Subsequent pregnancies
Hughes et al Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a cohort study Lancet 2002;
81. Subsequent pregnancies
Women who had conceived within 12 months after loss had a significantly higher risk
of high state anxiety during the next pregnancy and of depression and both state and
trait anxiety 12 months post partum than women with longer time since loss
Hughes et al Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: cohort study. BMJ 1999;318:1721–4
82. Recurrence Risk
82
Metaanalysis of cohort studies – adjusted risk
Lamont et al Risk of recurrent stillbirth: systematic review and meta-analysis BMJ 2015
86. Summary
› Stillbirth remains a major public health issue
› Potential for prevention for known and newer risk factors
› All deaths deserve adequate investigation
› Standardised perinatal audit with feedback is useful and reduces deaths
› Families need support both at the time, in follow up and in subsequent
pregnancy
86