The

n e w e ng l a n d j o u r na l

hyperplasias.5 Therefore, we agree that in future experiments it would be relevant to investigate the action of vasopressin on corticotropin release in samples of adrenal hyperplastic tissue. Estelle Louiset, Ph.D. Hervé Lefebvre, M.D., Ph.D. INSERM Unité 982 Rouen, France [email protected] Since publication of their article, the authors report no further potential conflict of interest. 1. Mune T, Murase H, Yamakita N, et al. Eutopic overexpres-

sion of vasopressin v1a receptor in adrenocorticotropin-independent macronodular adrenal hyperplasia. J Clin Endocrinol Metab 2002;87:5706-13. 2. Lacroix A, Bourdeau I, Lampron A, Mazzuco TL, Tremblay J,

of

m e dic i n e

Hamet P. Aberrant G-protein coupled receptor expression in relation to adrenocortical overfunction. Clin Endocrinol (Oxf) 2010;73:1-15. 3. Louiset E, Contesse V, Groussin L, et al. Expression of vasopressin receptors in ACTH-independent macronodular bilateral adrenal hyperplasia causing Cushing’s syndrome: molecular, immunohistochemical and pharmacological correlates. J Endocrinol 2008;196:1-9. 4. Papadimitriou A, Priftis KN. Regulation of the hypothalamic-pituitary-adrenal axis. Neuroimmunomodulation 2009; 16:265-71. 5. Bertherat J, Contesse V, Louiset E, et al. In vivo and in vitro screening for illegitimate receptors in adrenocorticotropin-­ independent macronodular adrenal hyperplasia causing Cushing’s syndrome: identification of two cases of gonadotropin/gastric inhibitory polypeptide-dependent hypercortisolism. J Clin Endocrinol Metab 2005;90:1302-10. DOI: 10.1056/NEJMc1316140

Global Maternal, Newborn, and Child Health To the Editor: In their article on the health of mothers and their children worldwide, Bhutta and Black (Dec. 5 issue)1 say very little about mental health. According to the World Health Organization (WHO), mental health disorders are the leading cause of disability around the world,2 and women of childbearing age shoulder a disproportionate burden of disease. Clinical depression develops after childbirth in as many as one in five women in Africa and South Asia.3 Depression is accompanied by sadness, fatigue, disinterest, and withdrawal — symptoms that interfere with a mother’s ability to adhere to medication regimens, keep appointments, raise resources for family essentials, breast-feed, and meet other needs of their children.4 Although policymakers and host governments have rightly charged ahead with the implementation of new interventions for mothers and children, mental health services have been left frustratingly behind. As we look beyond 2015 to the next iteration of development goals, it would be shortsighted to ignore the centrality of mental health to maternal and child health and development. Samantha Meltzer-Brody, M.D., M.P.H. Elizabeth M. Stringer, M.D. University of North Carolina at Chapel Hill Chapel Hill, NC [email protected] No potential conflict of interest relevant to this letter was reported.

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1. Bhutta ZA, Black RE. Global maternal, newborn, and child

health — so near and yet so far. N Engl J Med 2013;369:2226-35.

2. Depression: fact sheet no. 369. Geneva: World Health Orga-

nization, 2012. 3. Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 2006;91:97-111. 4. Adewuya AO, Ola BO, Aloba OO, Mapayi BM, Okeniyi JA. Impact of postnatal depression on infants’ growth in Nigeria. J Affect Disord 2008;108:191-3. DOI: 10.1056/NEJMc1316332

To the Editor: Bhutta and Black highlight the causes of insufficient progress toward Millennium Development Goals (MDGs) 4 and 5. However, they seriously underplay two widespread, persistent causes of maternal death: unintended pregnancy and unsafe abortion. Worldwide, 41% of all pregnancies are unintended,1 with approximately half of such pregnancies resulting in abortion. Of these procedures, half are unsafe and occur in the developing world.2 Approximately 70,000 women die from unsafe abortions every year,3 and millions more have short-term and long-term abortion-related disorders. Enabling women to control their fertility through access to family planning and safe abortion services will directly reduce preventable, pregnancy-related deaths in every setting, including armed conflict, in which the risks of maternal death and complications from unsafe abortion are high because of widespread rape and social disruption.4 Providing such services will also re-

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correspondence

duce child mortality, which increases both when pregnancies are unwanted and when mothers die, leaving children with no one to care for them. Progress toward MDGs 4 and 5 requires the medical community to assert the necessity of family planning and safe abortion. Ana C. Gonzalez, M.D. Global Doctors for Choice–Colombia Bogota, Colombia [email protected]

J. Koku Awoonor-Williams, M.D., M.P.H. Global Doctors for Choice–Ghana Bolgatanga, Ghana No potential conflict of interest relevant to this letter was reported. 1. Singh S, Sedgh G, Hussain R. Unintended pregnancy: world-

wide levels, trends, and outcomes. Stud Fam Plann 2010;41:24150. 2. Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet 2012;379:625-32. 3. Cohen SA. Facts and consequences: legality, incidence and safety of abortion worldwide. Guttmacher Policy Rev 2009;12:26. 4. Austin J, Guy S, Lee-Jones L, McGinn T, Schlecht J. Reproductive health: a right for refugees and internally displaced persons. Reprod Health Matters 2008;16:10-21. DOI: 10.1056/NEJMc1316332

The Authors Reply: Meltzer-Brody and Stringer point out the importance of mental health issues and interventions for maternal and child health. These are indeed important areas, and evidence of the effectiveness of mental health interventions in child health and growth is emerging.1,2 However, since our focus was on survival and on addressing MDGs 4 and 5, we did not place these interventions on par with others, an approach that is consonant with the consensus on essential interventions for maternal and child health and survival.3 However, this consensus could well change in the future, and we recognize the range of outcomes, such as maternal–infant interaction, cognitive development, and growth, that have been shown to improve with the use of maternal mental health interventions.4 Although we would

dispute the stated centrality of mental health to maternal and child health, we acknowledge that mental health interventions are worth considering for their relevance to health and development. We disagree with Gonzalez and AwoonorWilliams that our article did not do justice to the issue of unintended pregnancies and safe abortion. Space constraints and editorial directives precluded a more thorough discussion of reproductive health issues, but we fully endorsed the critical importance of family planning to maternal and child health and underscored this in the article. Not only did we highlight unsafe abortions as an important contributor to maternal mortality (Fig. 2 of the article), but we also placed both family planning and postabortion care high on our list of essential interventions (Table S1 in the Supplementary Appendix of the article, available at NEJM.org). Zulfiqar A. Bhutta, M.B., B.S., Ph.D. SickKids Centre for Global Child Health Toronto, ON, Canada [email protected]

Robert E. Black, M.D., M.P.H. Johns Hopkins Bloomberg School of Public Health Baltimore, MD Since publication of their article, the authors report no further potential conflict of interest. 1. Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cogni-

tive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372: 902-9. 2. Kieling C, Baker-Henningham H, Belfer M, et al. Child and adolescent mental health worldwide: evidence for action. Lancet 2011;378:1515-25. 3. Rahman A, Fisher J, Bower P, et al. Interventions for common perinatal mental disorders in women in low- and middleincome countries: a systematic review and meta-analysis. Bull World Health Organ 2013;91:593-601I. 4. The Partnership for Maternal Health, Newborn and Child Health, and Aga Khan University. Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health: a global review of the key interventions related to reproductive, maternal, newborn and child health (http://www.who.int/pmnch/topics/part_publications/essential _interventions_18_01_2012.pdf). DOI: 10.1056/NEJMc1316332

Mitochondrial Fission and Fusion in Human Diseases To the Editor: In his review of the diseases in which mitochondrial fission and fusion are implicated, Archer (Dec. 5 issue)1 does not comment on the implications of mitochondria in the age-

related loss of muscle mass (sarcopenia). Impaired mitochondrial biogenesis has been postulated as a key factor in sarcopenia. There is an association between the accumulation of mitochondrial

n engl j med 370;11 nejm.org march 13, 2014

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Global maternal, newborn, and child health.

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