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BACKGROUND: Adequate gestational weight gain (GWG) is essential for healthy fetal growth. However, in low- and middle-income countries, where malnutrition is prevalent, little information is available about GWG and how it might be modified by nutritional status and interventions. OBJECTIVE: We describe GWG and its associations with fetal growth and birth outcomes. We also examined the extent to which prepregnancy BMI, and preconception and early weight gain modify GWG, and its effects on fetal growth. METHODS: This was a secondary analysis of the Women First Trial, including 2331 women within the Democratic Republic of Congo (DRC), Guatemala, India, and Pakistan, evaluating weight gain from enrollment to ∼12 weeks of gestation and GWG velocity (kg/wk) between ∼12 and 32 weeks of gestation. Adequacy of GWG velocity was compared with 2009 Institute of Medicine recommendations, according to maternal BMI. Early weight gain (EWG), GWG velocity, and adequacy of GWG were related to birth outcomes using linear and Poisson models. RESULTS: GWG velocity (mean ± SD) varied by site: 0.22 ± 0.15 kg/wk in DRC, 0.30 ± 0.23 in Pakistan, 0.31 ± 0.14 in Guatemala, and 0.39 ± 0.13 in India, (P <0.0001). An increase of 0.1 kg/wk in maternal GWG was associated with a 0.13 cm (95% CI: 0.07, 0.18, P <0.001) increase in birth length and a 0.032 kg (0.022, 0.042, P <0.001) increase in birth weight. Compared to women with inadequate GWG, women who had adequate GWG delivered newborns with a higher mean length and weight: 47.98 ± 2.04 cm compared with 47.40 ± 2.17 cm (P <0.001) and 2.864 ± 0.425 kg compared with 2.764 ± 0.418 kg (P <0.001). Baseline BMI, EWG, and GWG were all associated with birth length and weight. CONCLUSIONS: These results underscore the importance of adequate maternal nutrition both before and during pregnancy as a potentially modifiable factor to improve fetal growth.

OBJECTIVE: To describe the causes of maternal death in a population-based cohort in six low and middle-income countries using a standardized, hierarchical, algorithmic cause of death (COD) methodology DESIGN: A population-based, prospective observational study SETTING: Seven sites in six low-middle income countries including the Democratic Republic of the Congo (DRC), Guatemala, India (2), Kenya, Pakistan and Zambia. POPULATION: All deaths amongst pregnant women resident in the study sites from 2014 to December 2016. METHODS: For women who died, we used a standardized questionnaire to collect clinical data regarding maternal conditions present during pregnancy and delivery. These data were analyzed using a computer-based algorithm to assign cause of maternal death based on the International Classification of Disease - Maternal Mortality system (trauma, abortion-related, eclampsia, hemorrhage, pregnancy-related infection and medical conditions). We also compared the COD results to health care provider assigned maternal COD. MAIN OUTCOME MEASURES: Assigned causes of maternal mortality RESULTS: Amongst 158,205 women, there were 221 maternal deaths. The most common algorithm-assigned maternal COD were obstetric hemorrhage (38.6%), pregnancy-related infection (26.4%) and preeclampsia/eclampsia (18.2%). Agreement between algorithm-assigned COD and COD assigned by health care providers ranged from 75% for hemorrhage to 25% for medical causes coincident to pregnancy. CONCLUSIONS: The major maternal COD in the Global Network sites were hemorrhage, pregnancy-related infection and preeclampsia/eclampsia. This system could allow public health programs in low and middle-income countries to generate transparent and comparable data for maternal COD across time or regions.

BACKGROUND: The daily use of low-dose aspirin may be a safe, widely available, and inexpensive intervention for reducing the risk of preterm birth. Data on the potential side effects of low-dose aspirin use during pregnancy in low- and middle-income countries are needed. OBJECTIVE: This study aimed to assess differences in unexpected emergency medical visits and potential maternal side effects from a randomized, double-blind, multicountry, placebo-controlled trial of low-dose aspirin use (81 mg daily, from 6 to 36 weeks' gestation). STUDY DESIGN: This study was a secondary analysis of data from the Aspirin Supplementation for Pregnancy Indicated Risk Reduction In Nulliparas trial, a trial of the Global Network for Women's and Children's Health conducted in India (2 sites), Pakistan, Guatemala, Democratic Republic of the Congo, Kenya, and Zambia. The outcomes for this analysis were unexpected emergency medical visits and the occurrence of the following potential side effects—overall and separately—nausea, vomiting, rash or hives, diarrhea, gastritis, vaginal bleeding, allergic reaction, and any other potential side effects. Analyses were performed overall and by geographic region. RESULTS: Between the aspirin (n=5943) and placebo (n=5936) study groups, there was no statistically significant difference in the risk of unexpected emergency medical visits or the risk of any potential side effect (overall). Of the 8 potential side effects assessed, only 1 (rash or hives) presented a different risk by treatment group (4.2% in the aspirin group vs 3.5% in the placebo group; relative risk, 1.20; 95% confidence interval, 1.01–1.43; P=.042). CONCLUSION: The daily use of low-dose aspirin seems to be a safe intervention for reducing the risk of preterm birth and well tolerated by nulliparous pregnant women between 6 and 36 weeks' gestation in low- and middle-income countries.

Introduction Neonatal mortality associated with preterm birth can be reduced with antenatal corticosteroids (ACS), yet 36.0 weeks GA. In phase 1, UH measurements were collected prospectively in the Democratic Republic of Congo, India and Pakistan, using distinct tapes to address variation across regions and ethnicities. In phase 2, we tested accuracy in 250 pregnant women with known GA from early ultrasound enrolled at prenatal clinics in Argentina, India, Pakistan and Zambia. Providers masked to the ultrasound GA measured UH. Receiver operating characteristics (ROC) analysis was conducted. Results 1,029 pregnant women were enrolled. In all countries the tapes were most effective identifying pregnancies between 20.0–35.6 weeks, compared to the other GAs. The ROC areas under the curves and 95% confidence intervals were: Argentina 0.69 (0.63, 0.74); Zambia 0.72 (0.66, 0.78), India 0.84 (0.80, 0.89), and Pakistan 0.83 (0.78, 0.87). The sensitivity and specificity (and 95% confidence intervals) for identifying pregnancies between 20.0–35.6 weeks, respectively, were: Argentina 87% (82%–92%) and 51% (42%–61%); Zambia 91% (86%–95%) and 50% (40%–60%); India 78% (71%–85%) and 89% (83%–94%); Pakistan 63% (55%–70%) and 94% (89%–99%). Conclusions We observed moderate-good accuracy identifying pregnancies ≤35.6 weeks gestation, with potential usefulness at the community level in low-middle income countries to facilitate the preterm identification and interventions to reduce preterm neonatal mortality. Further research is needed to validate these findings on a population basis.

Introduction: Neonatal mortality associated with preterm birth can be reduced with antenatal corticosteroids (ACS), yet 36.0 weeks GA. In phase 1, UH measurements were collected prospectively in the Democratic Republic of Congo, India and Pakistan, using distinct tapes to address variation across regions and ethnicities. In phase 2, we tested accuracy in 250 pregnant women with known GA from early ultrasound enrolled at prenatal clinics in Argentina, India, Pakistan and Zambia. Providers masked to the ultrasound GA measured UH. Receiver operating characteristics (ROC) analysis was conducted. Results: 1,029 pregnant women were enrolled. In all countries the tapes were most effective identifying pregnancies between 20.0-35.6 weeks, compared to the other GAs. The ROC areas under the curves and 95% confidence intervals were: Argentina 0.69 (0.63, 0.74); Zambia 0.72 (0.66, 0.78), India 0.84 (0.80, 0.89), and Pakistan 0.83 (0.78, 0.87). The sensitivity and specificity (and 95% confidence intervals) for identifying pregnancies between 20.0-35.6 weeks, respectively, were: Argentina 87% (82%-92%) and 51% (42%-61%); Zambia 91% (86%-95%) and 50% (40%-60%); India 78% (71%-85%) and 89% (83%-94%); Pakistan 63% (55%-70%) and 94% (89% -99%). Conclusions: We observed moderate-good accuracy identifying pregnancies ≤35.6 weeks gestation, with potential usefulness at the community level in low-middle income countries to facilitate the preterm identification and interventions to reduce preterm neonatal mortality. Further research is needed to validate these findings on a population basis. ; Fil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina ; Fil: Berrueta, Amanda Mabel. Instituto de Efectividad Clínica y Sanitaria; Argentina ; Fil: Hemingway Foday, Jennifer. Rti International; Estados Unidos ; Fil: Mazzoni, Agustina. Instituto de Efectividad Clínica y Sanitaria; Argentina ; Fil: Bonorino, Carolina Astoul. Instituto de Efectividad Clínica y Sanitaria; Argentina ; Fil: Gowdak, Andrea. Instituto de Efectividad Clínica y Sanitaria; Argentina ; Fil: Gibbons, Luz. Instituto de Efectividad Clínica y Sanitaria; Argentina ; Fil: Bellad, M. B. Jawaharlal Nehru Medical College Belgaum; India ; Fil: Metgud, M. C. Jawaharlal Nehru Medical College Belgaum; India ; Fil: Goudar, Shivaprasad. Jawaharlal Nehru Medical College Belgaum; India ; Fil: Kodkany, Bhalchandra S. Jawaharlal Nehru Medical College Belgaum; India ; Fil: Derman, Richard J. Christiana Care Health System; Estados Unidos ; Fil: Saleem, Sarah. The Aga Khan University; Pakistán ; Fil: Iqbal, Samina. Sobhraj Maternity Hospital; Pakistán ; Fil: Ala, Syed Hasan. Sindh Government Qatar Hospital; Pakistán ; Fil: Goldenberg, Robert L. Columbia University; Estados Unidos ; Fil: Chomba, Elwyn. University Teaching Hospital Lusaka; Zambia ; Fil: Manasyan, Albert. University of North Carolina; Estados Unidos. Centre For Infectious Disease Research In Zambia; Zambia ; Fil: Chiwila, Melody. University Teaching Hospital Lusaka; Zambia ; Fil: Imenda, Edna. University Teaching Hospital Lusaka; Zambia ; Fil: Mbewe, Florence. University Teaching Hospital Lusaka; Zambia ; Fil: Tshefu, Antoinette. Kinshasa School Of Public Health; República Democrática del Congo ; Fil: Lokomba, Victor. Kinshasa School Of Public Health; República Democrática del Congo ; Fil: Bose, Carl L. University of North Carolina; Estados Unidos ; Fil: Moore, Janet. Rti International; Estados Unidos ; Fil: Meleth, Sreelatha. Rti International; Estados Unidos ; Fil: McClure, Elizabeth M. Rti International; Estados Unidos ; Fil: Koso Thomas, Marion. Eunice Kennedy Shriver NICHD; Estados Unidos ; Fil: Buekens, Pierre. University of Tulane; Estados Unidos ; Fil: Belizan, Jose. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Background Ultrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care. Methods Women who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers' exam findings were compared to referred women's recall. Results Among 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral. Conclusions Our study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital. Trial registration: NCT01990625.