Heather Winter

Bio: Heather Winter is an academic researcher from University of Birmingham. The author has contributed to research in topics: Postnatal Care & Population. The author has an hindex of 13, co-authored 23 publications receiving 2402 citations.

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan.

Abstract: methods We performed a cluster-randomized, controlled trial involving seven subdistricts ( talukas ) of a rural district in Pakistan. In three talukas randomly assigned to the intervention group, traditional birth attendants were trained and issued disposable delivery kits; Lady Health Workers linked traditional birth attendants with established services and documented processes and outcomes; and obstetrical teams provided outreach clinics for antenatal care. Women in the four control talukas received usual care. The primary outcome measures were perinatal and maternal mortality. results Of the estimated number of eligible women in the seven talukas, 10,114 (84.3 percent) were recruited in the three intervention talukas, and 9443 (78.7 percent) in the four control talukas. In the intervention group, 9184 women (90.8 percent) received antenatal care by trained traditional birth attendants, 1634 women (16.2 percent) were seen antenatally at least once by the obstetrical teams, and 8172 safe-delivery kits were used. As compared with the control talukas, the intervention talukas had a cluster-adjusted odds ratio for perinatal death of 0.70 (95 percent confidence interval, 0.59 to 0.82) and for maternal mortality of 0.74 (95 percent confidence interval, 0.45 to 1.23). conclusions Training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. This model could result in large improvements in perinatal and maternal health in developing countries.

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan

Abstract: Much remains to be learned about how to encourage the development of effective maternity services so as to lower current very high rates of neonatal and maternal deaths in developing countries. In this randomized, controlled trial, women in 3 of 7 subdistricts in Pakistan were randomly assigned to an intervention in which female health workers linked traditional birth attendants, equipped with disposable delivery kits, with established services. Processes and outcomes were documented. Obstetric teams provided antenatal care at outreach clinics. Women in the other 4 subdistricts were cared for conventionally in the setting of monthly home visits to women and children. The intervention was designed to further antepartum care using available infrastructure and to be a low-cost and sustainable process. Obstetricians and female paramedics trained traditional birth attendants over a 3-day period using picture cards conveying proper antepartum, intrapartum, and postpartum care. Trainees were instructed in how to perform clean deliveries and were told when to refer women for emergency care. The attendants were asked to visit each woman at least 3 times during pregnancy, at 3, 6, and 9 months. The 10,114 women in the intervention group and 9443 control women represented 84% and 79%, respectively, of those eligible. Nearly all participants were followed up to 42 days postpartum. Rates of spontaneous abortion were 2.5% in the intervention group and 3.3% in the control group. Baseline maternal features were comparable in the 2 groups. Crude perinatal death rates were 85 per 1000 and 120 per 1000, respectively, in the intervention and control groups. Analysis by random-effects multilevel modeling yielded an odds ratio for perinatal death in the intervention group, compared with control women, of 0.70 (95% confidence interval [CI], 0.59-0.82). Similar results were obtained for stillbirths and neonatal deaths. Maternal mortality rates were 268 and 360 per 100,000 pregnancies, respectively, in the intervention and control groups. The odds ratio for maternal death in the intervention group was 0.74 (95% CI, 0.45-1.23). Puerperal sepsis and hemorrhage were less frequent in the intervention group, but obstructed labors were significantly more frequent in this group. There were no significant differences in rates of eclampsia. Women in the intervention group were likelier than control women to be referred to emergency obstetric care. Sustainable and substantial improvement in pregnancy outcomes was achieved in this large-scale trial by training traditional birth attendants and making them part of an improved healthcare system. This approach holds promise for major improvements in perinatal and maternal health in developing countries.

The causal relation between human papillomavirus and cervical cancer

Abstract: The causal role of human papillomavirus infections in cervical cancer has been documented beyond reasonable doubt. The association is present in virtually all cervical cancer cases worldwide. It is the right time for medical societies and public health regulators to consider this evidence and to define its preventive and clinical implications. A comprehensive review of key studies and results is presented.

Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions

Abstract: BACKGROUND: Human papillomavirus types 16 (HPV-16) and 18 (HPV-18) cause approximately 70% of cervical cancers worldwide. A phase 3 trial was conducted to evaluate a quadrivalent vaccine against HPV types 6, 11, 16, and 18 (HPV-6/11/16/18) for the prevention of high-grade cervical lesions associated with HPV-16 and HPV-18. METHODS: In this randomized, double-blind trial, we assigned 12,167 women between the ages of 15 and 26 years to receive three doses of either HPV-6/11/16/18 vaccine or placebo, administered at day 1, month 2, and month 6. The primary analysis was performed for a per-protocol susceptible population that included 5305 women in the vaccine group and 5260 in the placebo group who had no virologic evidence of infection with HPV-16 or HPV-18 through 1 month after the third dose (month 7). The primary composite end point was cervical intraepithelial neoplasia grade 2 or 3, adenocarcinoma in situ, or cervical cancer related to HPV-16 or HPV-18. RESULTS: Subjects were followed for an average of 3 years after receiving the first dose of vaccine or placebo. Vaccine efficacy for the prevention of the primary composite end point was 98% (95.89% confidence interval [CI], 86 to 100) in the per-protocol susceptible population and 44% (95% CI, 26 to 58) in an intention-to-treat population of all women who had undergone randomization (those with or without previous infection). The estimated vaccine efficacy against all high-grade cervical lesions, regardless of causal HPV type, in this intention-to-treat population was 17% (95% CI, 1 to 31). CONCLUSIONS: In young women who had not been previously infected with HPV-16 or HPV-18, those in the vaccine group had a significantly lower occurrence of high-grade cervical intraepithelial neoplasia related to HPV-16 or HPV-18 than did those in the placebo group.

Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a meta-analysis update.

Abstract: Data on human papillomavirus (HPV) type distribution in invasive and pre-invasive cervical cancer is essential to predict the future impact of HPV16/18 vaccines and HPV-based screening tests. A meta-analyses of HPV type distribution in invasive cervical cancer (ICC) and high-grade squamous intraepithelial lesions (HSIL) identified a total of 14,595 and 7,094 cases, respectively. In ICC, HPV16 was the most common, and HPV18 the second most common, type in all continents. Combined HPV16/18 prevalence among ICC cases was slightly higher in Europe, North America and Australia (74-77%) than in Africa, Asia and South/Central America (65-70%). The next most common HPV types were the same in each continent, namely HPV31, 33, 35, 45, 52 and 58, although their relative importance differed somewhat by region. HPV18 was significantly more prevalent in adeno/adenosquamous carcinoma than in squamous cell carcinoma, with the reverse being true for HPV16, 31, 33, 52 and 58. Among HSIL cases, HPV16/18 prevalence was 52%. However, HPV 16, 18 and 45 were significantly under-represented, and other high-risk HPV types significantly over-represented in HSIL compared to ICC, suggesting differences in type-specific risks for progression. Data on HPV-typed ICC and HSIL cases were particularly scarce from large regions of Africa and Central Asia.