The feasibility of task-sharing the identification,emergency treatment,and referral for women with pre-eclampsia by community health workers in India

Background

Hypertensive disorders are the second highest direct obstetric cause of maternal death after haemorrhage, accounting for 14% of maternal deaths globally. Pregnancy hypertension contributes to maternal deaths, particularly in low- and middle-income countries, due to a scarcity of doctors providing evidence-based emergency obstetric care. Task-sharing some obstetric responsibilities may help to reduce the mortality rates. This study was conducted to assess acceptability by the community and other healthcare providers, for task-sharing by community health workers (CHW) in the identification and initial care in hypertensive disorders in pregnancy.

Methods

This study was conducted in two districts of Karnataka state in south India. A total of 14 focus group discussions were convened with various community representatives: women of reproductive age (N = 6), male decision-makers (N = 2), female decision-makers (N = 3), and community leaders (N = 3). One-to-one interviews were held with medical officers (N = 2), private healthcare OBGYN specialists (N = 2), senior health administrators (N = 2), Taluka (county) health officers (N = 2), and obstetricians (N = 4). All data collection was facilitated by local researchers familiar with the setting and language. Data were subsequently transcribed, translated and analysed thematically using NVivo 10 software.

Results

There was strong community support for home visits by CHW to measure the blood pressure of pregnant women; however, respondents were concerned about their knowledge, training and effectiveness. The treatment with oral antihypertensive agents and magnesium sulphate in emergencies was accepted by community representatives but medical practitioners and health administrators had reservations, and insisted on emergency transport to a higher facility. The most important barriers for task-sharing were concerns regarding insufficient training, limited availability of medications, the questionable validity of blood pressure devices, and the ability of CHW to correctly diagnose and intervene in cases of hypertensive disorders of pregnancy.

Conclusion

Task-sharing to community-based health workers has potential to facilitate early diagnosis of the hypertensive disorders of pregnancy and assist in the provision of emergency care. We identified some facilitators and barriers for successful task-sharing of emergency obstetric care aimed at reducing mortality and morbidity due to hypertensive disorders of pregnancy.

     

Impact of training of traditional birth attendants on the newborn care

Objective  To study the impact of training of Traditional Birth Attendants (TBAs) on the Newborn care in resource poor setting in rural area. Methods  A community based study in the Primary Health Center (PHC) area was conducted over one year period between March 2006 to February 2007. The study participants were 50 Traditional Birth Attendants (TBAs)who conduct home deliveries in the PHC area. Training was conducted for two days which included topics on techniques of conducting safe delivery and newborn care practices. Pre-test evaluation regarding knowledge and practices about newborn care was done. Post-test evaluation was done at first month (early) and at fifth month (late) after the training. Analysis was done by using Mc. Nemer’s test, Chi- square test with Yates’s correction and Fischer’s exact test. Results  Pre-test evaluation showed that, knowledge and practices about newborn care services provided by the previously trained TBAs and untrained TBAs were poor. Early and late post-test evaluation showed that, there was a progressive improvement in the newborn care provided by both the groups. Preintervention period (one year prior to the training) and postintervention period (one year after the training) showed that, there was a statistically significant (p<0.05) reduction in the perinatal deaths (11 to 3) and neonatal deaths (10 to 2) among the deliveries conducted by TBAs after the training. Conclusion  Training programme for TBAs with regular reinforcements in the resource poor setting will not only improve the quality of newborn care but also reduces perinatal deaths.     

Morbidity among infants in South India: A longitudinal study

To study the incidence and types of morbidity in the first year of life in a birth cohort, a longitudinal study. This study was undertaken in northern part of Karnataka state in India. Birth cohort consisted of all the children born during first six months of the study period. They were assessed at the time of enrollment and monthly follow up was done till they attained one yr of age. Out of the 194 newborns, 46.4% were boys and 53.6% were girls. 24.8% of newborns were of low birth weight and 5.1% were preterm. Four (2.1%) had congenital anomalies and 2.5% developed birth asphyxia. Diarrhea (10.8%) and skin diseases (8.2%) were the commonest morbidities in the neonatal period. The incidence of morbidity was 3.28 per infant per yr. It was more among boys and in the second half of infancy. Commonest morbidities during infancy were respiratory tract infection (62.4%), diarrhea 42.8% and skin diseases (21.6%). Incidence of disease in infancy highlights the need to improve and plan health programmes.     

Impact of training of traditional birth attendants on the newborn care

Objective  

To study the impact of training of Traditional Birth Attendants (TBAs) on the Newborn care in resource poor setting in rural area.     

Availability and use of magnesium sulphate at health care facilities in two selected districts of North Karnataka,India

Background

Pre-eclampsia and eclampsia are major causes of maternal morbidity and mortality. Magnesium sulphate is accepted as the anticonvulsant of choice in these conditions and is present on the WHO essential medicines list and the Indian National List of Essential Medicines, 2015. Despite this, magnesium sulphate is not widely used in India for pre-eclampsia and eclampsia. In addition to other factors, lack of availability may be a reason for sub-optimal usage. This study was undertaken to assess the availability and use of magnesium sulphate at public and private health care facilities in two districts of North Karnataka, India.

Methods

A facility assessment survey was undertaken as part of the Community Level Interventions for Pre-eclampsia (CLIP) Feasibility Study which was undertaken prior to the CLIP Trials (NCT01911494). This study was undertaken in 12 areas of Belagavi and Bagalkote districts of North Karnataka, India and included a survey of 88 facilities. Data were collected in all facilities by interviewing the health care providers and analysed using Excel.

Results

Of the 88 facilities, 28 were public, and 60 were private. In the public facilities, magnesium sulphate was available in six out of 10 Primary Health Centres (60%), in all eight taluka (sub-district) hospitals (100%), five of eight community health centres (63%) and both district hospitals (100%). Fifty-five of 60 private facilities (92%) reported availability of magnesium sulphate.Stock outs were reported in six facilities in the preceding six months – five public and one private. Twenty-five percent weight/volume and 50% weight/volume concentration formulations were available variably across the public and private facilities. Sixty-eight facilities (77%) used the drug for severe pre-eclampsia and 12 facilities (13.6%) did not use the drug even for eclampsia. Varied dosing schedules were reported from facility to facility.

Conclusions

Poor availability of magnesium sulphate was identified in many facilities, and stock outs in some. Individual differences in usage were identified. Ensuring a reliable supply of magnesium sulphate, standard formulations and recommendations of dosage schedules and training may help improve use; and decrease morbidity and mortality due to pre-eclampsia/ eclampsia.

Trial registration

The CLIP trial was registered with ClinicalTrials.gov (NCT01911494).

     

Determination of palatal rugae patterns among two ethnic populations of India by logistic regression analysis

Palatal rugae patterns are relatively unique to an individual and are well protected by the lips, buccal pad of fat and teeth. They are considered to be stable throughout life following completion of growth, although there is considerable debate on the matter, they can be used successfully in post mortem identification provided an antemortem record exists. Thus the aim of this study was to examine palatal rugae shape among two Indian populations and determine the accuracy in defining the Indian population using logistic regression analysis. The study comprises two groups from geographically different regions of India with basic origin from Maharashtra and Karnataka state. The sample includes 100 plaster cast equally distributed between two populations and genders with age ranging between 18 and 40 years. Impression of maxillary arch was obtained using alginate impression material and plaster cast was made. The rugae was delineated on the cast using a sharp graphite pencil under adequate light and magnification and recorded according to classification given by Kapali et?al. and Thomas and Kotze (1983). Chi-Square analysis showed significant difference in wavy, circular and divergent pattern between the two populations. The straight and wavy forms were significant in logistic regression analysis. A predictive value of 71% was obtained in determining the original cases correctly when straight, wavy, curved and circular patterns were assessed. 70% of predictive value was achieved when all rugae patterns were assessed. Mean number of rugae was greater in females compared to males with straight pattern showing statistically significant difference between males and females. Significant difference was recorded among straight, wavy, circular and divergent pattern between two populations. Consequently this study demonstrates moderate accuracy of palatal rugae pattern using logistic regression analysis in identification of Indians.     

Factors Associated with Morbidities Among Infants in Three Sub Centre Areas of Belgaum District of South India: A Longitudinal Study

Background:

Health status of infants is a sensitive indicator of development and factors influencing it need to be better understood.

Objectives:

This study was conducted to search for factors associated with morbidity among infants and to find out their influence on weight gain during infancy.

Materials and Methods:

This longitudinal study was undertaken in south India from November 2004 till April 2006. A birth cohort of all children born during first 6 months of the study period were assessed at enrollment and followed up monthly till they attained 1 year of age.

Results:

Incidence of morbidity among infants was found to be least among those exclusively breast fed (EBF) for 6 months and most when EBF for less than 6 months (P = 0.045). It was also more when infants were weaned with a combination of animal milk, formula milk, semi-solids and solid diet and least when weaned only with semi-solids and solids (P = 0.018). Diarrheal episodes were more in infants who were bottle-fed (P < 0.001). Weight gain between 6^th and 12^th month of infancy was found to be significantly affected by various morbidities (P = 0.001). Incidence of morbidities was less among preterm babies and more among partially immunized (P < 0.001) babies with birth order ≥ 3 (P = 0.012), babies of mothers with low socio-economic and educational status. Delayed milestones during infancy was seen more in babies with history of birth asphyxia (P = 0.018).

Conclusion:

Several factors influenced incidence of morbidities and these morbidities had a negative effect on weight gain. Hence these factors need to be addressed to promote better child health.