CUSTODIA COMPARTIDA
5. LA GUARDA Y CUSTODIA COMPARTIDA EN LA LEGISLACIÓN AUTONÓMICA
Accurate assessment of key data elements in births reached by the data system, including vital status at birth, gestational age and birthweight, is required for their accurate categorisation. Currently, many births that are reached by the data system do not have these key data items assessed accurately. Closing this measurement gap will require improvements in knowledge, understanding, and technical ability to assess these amongst frontline healthcare workers. For births captured outside the health sector, data collectors such as community scouts and survey interviewers are responsible for assessing these data elements. Assessment of these births will depend on the mother or informant’s knowledge about the baby’s vital status at birth, gestational age and birthweight, their understanding of the questions (which will depend in part on the interviewer’s skill in asking these questions) and their ability to accurately recall these. As assessments of these key data elements have specific challenges, approaches to address each key data element are discussed separately below with further details in Annex A.6.2.
Improving assessment of vital status at birth
For births occurring with a skilled attendant, providing training for healthcare workers in neonatal resuscitation is an effective way of both improving survival, and reducing the misclassification between fresh stillbirths and early neonatal deaths in the delivery room; hence reducing measurement error of vital status at birth.272 This is especially important in LMIC
settings where over half of all stillbirths are recorded as ‘fresh’ in appearance.25,340 This training
should be coupled with an enabling environment, including non-blame perinatal audit, to reduce misreporting.
Births occurring outside the health sector and with no skilled attendant may be captured later through community informants such as ‘scouts’ used by many Health and Demographic Surveillance sites, community health workers, or by survey interviewers. In such cases, substantial misclassification between stillbirth and neonatal death remains common.279 The use
of a verbal autopsy may assist in the differentiation between stillbirth and live birth followed by early neonatal death. Where this is not possible adding additional questions to survey or data collection tools to seek to establish if the baby showed any signs of life and birth such as “Did
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that baby cry, move, or breathe when it was born?” could potentially improve retrospective assessment at the time of data collection. Further work is underway to assess these.309
Improving assessment of gestational age
Early USS remains the gold standard for measuring gestational age, but coverage in LMICs is low.341 New technologies bring potential to extend its use across LMIC settings including lower-
cost, increasingly portable machines,342 with the option of telemedicine to monitor the quality
of measurement in the field and provide guidance and support.343,344 Routine early USS can
improve gestational age assessment. This has the potential to improve preterm birth and stillbirth categorisation and data, reduce erroneous ‘post-term inductions’, and improve outcomes in placenta praevia and multiple pregnancy through early detection allowing for increased monitoring and timely intervention to reduce risks for the mother and her baby.345,346
Traditional methods require a ‘dating scan’ scan by a skilled sonographer prior to 18 weeks of gestation. In some settings availability of USS may increase early antenatal clinic attendance,347,348 but this association is not universal.349 However, concerns have also been
raised about potential unintended consequences of routine early pregnancy USS, including sex- selective termination of pregnancy in cultures where the male child is more highly valued,350
excessive costs to the women from repeated, non-medically indicated USS,351 and the potential
for increased unnecessary obstetric intervention.138 In addition to the costs associated with
routine USS, a certain amount of infrastructure including electricity, ongoing training and buy- in from clinical, technical and maintenance staff, feasibility of referral if high-risk conditions diagnosed and political will are required. These may act as barriers to USS scale-up.352,353 In view
of these systems challenges, it is unlikely that universal routine early pregnancy ultrasound assessment of gestational age will be feasible in the short-term in many settings.
Innovations are being developed to seek to overcome these barriers. Recent research has also focused on improving the accuracy of late (third trimester) ultrasound dating. The INTER- GROWTH-21st Fetal Growth Longitudinal Study developed equations for estimating GA from USS
in late pregnancy using fetal head circumference and fetal length biometric data from 4,229 singleton pregnancies (compared to 361 used in the development of the previous standards). The estimates were associated with uncertainty of +13.2, 14.3, 15.4 and 16.5 days at 28, 30, 32 and 34 weeks respectively.354 The Alliance for Maternal and Newborn Health Improvement
(AMANHI) has also undertaken methodological work in this area in three of their sites, Pakistan, Tanzania and Bangladesh investigating the potential of using trans cerebellar diameter on USS to date pregnancies in the third trimester as the cerebellum is relatively spared with fetal growth restriction.355 Amongst 1319 singleton pregnancies the trans cerebellar diameter predicted GA
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includes an ultrasound probe coupled to an Android app to automatically recognise and measure the cerebellum, could enable health workers with minimal or no training in sonography to undertake more accurate gestational age assessment from 15 to around 34 weeks of gestation.356
Where there is no USS, LMP is routinely used alone for gestational age assessment. Data on LMP can be of variable quality; however, measures can be put in place to improve this. For example, the quality of LMP data was improved in rural Bangladesh through prospective collection of LMP data together with the use of a home calendar, resulting in a high sensitivity (86%) and specificity (96%) for classifying preterm birth.125 This may be a potential method to improve reliability of
preterm birth classification in settings without access to early USS.
Other potential tools to improve assessment of gestational age after birth include the use of simplified newborn gestational age algorithms, such as that being developed in the AMANHI project across 5 countries in S. Asia and sub-Saharan Africa.355 The potential of newborn skin
assessment to estimate gestational age is currently under investigation including skin reflection,357 and skin thickness.358,359 The vascularity of the anterior lens capsule has long been
recognised as a marker of gestational age.144 New technology has led to the development of a
Smartphone Ophthalmoscope, which if successful could allow bedside or community gestational age assessment.360 There is also interest in using smartphone technology and machine learning
to assess gestational age using facial, foot and ear appearance.361 However, most of the newborn
assessment tools currently under development are only possible for live births, and not stillbirths.
Recent interest is also being directed towards the development of neonatal dry blood sample metabolic profile analyses to predict gestational age, with some encouraging early results.362,363
However, as these methods involve tandem mass spectrometry, high costs and feasibility considerations would currently prohibit their widespread use in LMICs. In addition, these methods have the disadvantage of a 24 – 72-hour time lag for results, compared to real time information for driving clinical decision making for other methods.
In household surveys, as detailed above, a standard birth history is most commonly used. This only includes questions attempting to assess gestational age from maternal report for pregnancy losses to be able to define stillbirths. Such information is not collected on live births in view of concerns regarding the reliability of gestational age assessments based on maternal reports. Work is currently underway to assess the feasibility of revised questions to assess gestational age retrospectively at the time of the survey.309 In line with the principle of collecting
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should be included in these surveys also for live births. This is already standard in the minority of surveys that have used a pregnancy history approach.180 However, ultimately improving the
quality of gestational age data in surveys is likely to require improvements in coverage and quality of gestational age assessments by healthcare workers and linking these to survey data systems through handheld or facility paper or electronic records.
Improving the assessment of birthweight
Methods to overcome the specific challenges of recording an accurate birthweight will vary depending on the place of birth. Substantial challenges remain for capturing birthweight for home births; however accurate birthweight measurement and recording should be feasible for all facility births. This would assist both with recognition of individual risk e.g. need for extra care for small or exceptionally large infants, but also in monitoring population low birthweight rates, and providing disaggregated data on neonatal outcomes including morbidity and mortality.
There is limited literature on potential innovations to improve the measurement of birthweight, although the provision of weighing scales, training and community engagement have been shown to increase coverage of weighing at birth for homebirths.364-366 In sub-populations where
coverage of weighing at birth remains low, for example stillbirths or rural Ethiopian populations, specific cultural behavioural interventions will need to be designed and implemented to close the gap.
Ensuring that a functional, suitable weighing device is available for every birth is challenging. Weighing machines are frequently not calibrated.367 Most digital scales are expensive, require
batteries and lack the robustness required for heavy use in facility or community settings. As highlighted in Chapter 5 developing affordable, robust, portable and accurate devices is a priority. Despite this, little research is evident in this area.368,369
Where suitable devices are available, improving the accuracy of birthweight in babies who are weighed at birth could be achieved through training, standards, guidelines and support. Whilst multiple sources of standard guidance, best practice protocols and job aides are available for weighing older infants or children in a variety of settings, few include specific guidance around weighing at birth.370,371 WHO has produced guidance for weighing of newborns at home visits
which have been adapted for use in many community health worker training packages, however these recommend weighing the baby whilst dressed, which is contrary to best practice.372 WHO
has not produced standard guidance on the weighing of newborns at birth, but guidance, such as produced by All India Institute of Medical Sciences (AIIMS) could be adapted for more widespread use.373
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Ideally an accurate birthweight would be measured for all babies. However, where this is not possible, prediction models based on anthropometric surrogates such as head circumference and chest circumference are a potential promising innovation to estimate birthweight which could, after further validation, be included in a paper-based or mobile phone app-based tool in community settings with high levels of homebirths in LMIC settings.374
In household surveys, for births occurring outside the health sector, perceived size at birth was previously used to estimate whether an individual birth was low birthweight or not. This approach is no longer recommended as mother’s recollection of size at birth has been shown not to be accurate at an individual level.375 Efforts should be focused on weighing babies, or
using anthropometric surrogates where weighing is not feasible, and use methods such as handheld cards to link this information to the survey data system (see 7.3.1.). Most household surveys include birthweight only for live births in the 2 – 5 years preceding the survey. In line with the principle of collecting the same information on every birth, whether live or stillborn, questions on birthweight should be included in these surveys also for stillbirths.