This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
INTRODUCTION Undernutrition is a significant public health concern in the developing world and fa... more INTRODUCTION Undernutrition is a significant public health concern in the developing world and factors such as high parity and short birth intervals are significant contributors to maternal undernutrition. This study aimed to assess determinants of undernutrition among women of reproductive age in Sindh, Pakistan, using the national demographic health survey. METHODS Data of 4050 ever married women of reproductive age from the Pakistan Demographic and Health Survey (PDHS) 2012-2013 were analyzed. These included sociodemographic and fertility-related variables. Logistic regression was applied to assess the determinants of undernutrition. RESULTS Women having ≥5 children were 47% less likely to be undernourished compared to women having <5 children (OR=0.53; 95% CI: 0.43-0.63). Undernourished women included those who belonged to rural areas (adjusted odds ratio, AOR=3.47; 95% CI: 2.76-4.36), those who breastfed their infants (AOR=1.40; 95% CI: 1.16-1.68), were smokers (AOR=4.35; 95% CI: 2.58-7.34) or worked (AOR=1.22; 95% CI: 1.09-1.47). CONCLUSIONS The highest rates of undernourishment were found among working women as well as those who breastfed, smoked or belonged to the rural setting. We recommend that breastfeeding and working women should be provided awareness through teaching sessions and other means to improve their nutritional status as this subset of patients typically require additional calories.
Background: In Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of materna... more Background: In Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of maternal deaths reported at tertiary care hospitals. To reduce the morbidity and mortality associated with PE/E, an accessible strategy is to support pregnant women at high risk for preeclampsia (HRPE) by closely monitoring their blood pressures at home (i.e., telemonitoring) for the earliest signs of preeclampsia. This could lead to the earliest possible detection of high blood pressure, resulting in early intervention such as through medications, hospitalization, or delivery of the baby. The study aims to explore the perspectives, preferences and needs of telemonitoring (TM) for pregnant women at HRPE in Karachi, to inform future implementation strategies. Methods: The study will employ an exploratory qualitative research design. The study will be conducted at the Jinnah Postgraduate Medical Centre (JPMC) hospital and Aga Khan University Hospital (AKUH) in Karachi, Sindh, Pakistan. Data will be collected through key-informant interviews (KIIs) and in-depth patient interviews (IDPIs). IDPIs will be conducted with the pregnant women at HRPE who are visiting the outpatient department/ antenatal clinics of JPMC hospital for antenatal checkups and immunizations. KIIs will be conducted with the obstetricians, Maternal, neonatal and child health (MNCH) specialists and health care providers at JPMC, as well as TM experts from Karachi. Study data will be analyzed through conventional content analysis. Interviews are anticipated to begin in April 2020 and to be completed during the summer of 2020. Discussion: This is the first study to explore the use of TM program for pregnant women at HRPE in a tertiary health facility in Karachi. The research will help explore perceived benefits associated with the use of a TM program alongside potential facilitators and barriers that may help inform the future implementation of a TM program for pregnant women at HRPE in Karachi.
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Introduction: Optimal human milk (HM) B-vitamin concentrations remain undefined, especially in ar... more Introduction: Optimal human milk (HM) B-vitamin concentrations remain undefined, especially in areas where undernutrition is prevalent. The impact of supplementation pre-conception through pregnancy on HM B-vitamin composition remains unknown. Methods: Human milk (HM) was collected at 2-weeks postpartum from 200 women in Guatemala, India, and Pakistan (the Women First Trial). The women were randomized to start a lipid-based nutrient supplement before conception, at end of the first trimester, or not at all; intervention continued until delivery. HM concentrations of eight B-vitamins and choline were assessed via ultra-performance liquid chromatography-tandem mass spectrometry. Maternal diet was assessed in early pregnancy, and infant growth followed through 6 months post-delivery. Results: Despite supplement exposure averaging 15.7 (pre-conception arm) and 6.0 months (prenatal arm), HM B-vitamins did not differ between arms, but site differences were evident. Guatemala had higher HM concentrations of vitamin B3 than Pakistan and India. Pakistan had higher HM concentrations of thiamin and vitamin B6 than India and Guatemala. Cohort average HM vitamin B2 (162 ± 79 µg/L) and B6 (31.8 ± 24.6 µg/L) fell below values defined as deficient in 81.5 and 85.5% of samples, potentially reflecting sampling procedures and timing. Maternal dietary intakes of only vitamin B6 and choline were associated with the corresponding concentrations in HM (p < 0.005). No HM B-vitamin concentrations were associated with infant growth. Young et al. International Human Milk B-Vitamins Conclusion: Prenatal supplementation for at least 6 months had no impact on HM B-vitamin concentrations at 2-weeks postpartum. Results suggest that the adequacy of HM composition was generally maintained, with potential exceptions of vitamin B2 and B6.
One of the major drivers of mistreatment during childbirth includes the lack of staff training on... more One of the major drivers of mistreatment during childbirth includes the lack of staff training on interpersonal skills and psychosocial support, which resulted in providers lacking the understanding that patients' rights also include equity, respect, and satisfaction-and not only the right to high-quality clinical care. n Providers restricted the presence of birth companions, particularly males, based on providers' own cultural preferences and comfort, thus denying women a source of support during childbirth. n Provider's physical and verbal abuse, neglect, and abandonment of patients, particularly of those from lower castes and minority ethnic groups, in response to patients' lack of cooperation and compliance was common and justified. Stronger performance monitoring systems and patient feedback mechanisms would help hold staff accountable for mistreatment and contribute to improving respectful maternity care.
BJOG: An International Journal of Obstetrics & Gynaecology
ObjectiveGroup B streptococcus (GBS) has been associated with adverse pregnancy outcomes, but few... more ObjectiveGroup B streptococcus (GBS) has been associated with adverse pregnancy outcomes, but few prospective studies have assessed its prevalence in low‐ and middle‐income country settings. We sought to evaluate the prevalence of GBS by polymerase chain reaction (PCR) in internal organ tissues and placentas of deceased neonates and stillbirths.DesignThis was a prospective, observational study.SettingThe study was conducted in hospitals in India and Pakistan.PopulationPregnant women with stillbirths or preterm births were recruited at delivery, as was a group of women with term, live births, to serve as a control group.MethodsA rectovaginal culture was collected from the women in Pakistan to assess GBS carriage. Using PCR, we evaluated GBS in various tissues of stillbirths and deceased neonates and their placentas, as well as the placentas of live‐born preterm and term control infants.Main outcome measuresGBS identified by PCR in various tissues and the placentas; rate of stillbirth...
Introduction Mistreatment, discrimination, and poor psycho-social support during childbirth at he... more Introduction Mistreatment, discrimination, and poor psycho-social support during childbirth at health facilities are common in lower- and middle-income countries. Despite a policy directive from the World Health Organisation (WHO), no operational model exists that effectively demonstrates incorporation of these guidelines in routine facility-based maternity services. This early-phase implementation research aims to develop, implement, and test the feasibility of a service-delivery strategy to promote the culture of supportive and dignified maternity care (SDMC) at public health facilities. Methods Guided by human-centred design approach, the implementation of this study will be divided into two phases: development of intervention, and implementing and testing feasibility. The service-delivery intervention will be co-created along with relevant stakeholders and informed by contextual evidence that is generated through formative research. It will include capacity-building of maternity...
American Journal of Obstetrics and Gynecology, 2017
diabetes, prior bariatric surgery, and IVF. The intervention included an individualized dietitian... more diabetes, prior bariatric surgery, and IVF. The intervention included an individualized dietitian-prescribed calorie-specific DASH-type diet, physical activity, internet-based self-monitoring of diet adherence, and weekly coaching calls, with opportunities for group visits, webinars, and podcasts. Usual care participants were provided websites, electronic newsletters, and non-diet related pregnancy information. Obstetric providers and data collectors were not aware of patient group assignment. RESULTS: 281 participants were randomized to the intervention or usual care, with complete data available for all but 2 patients. Baseline characteristics of maternal age, parity, gestational age at randomization, race, ethnicity, and pre-pregnancy BMI were similar. There were 4 pregnancy losses after randomization but before 24 weeks (data not included), and 1 fetal death after 24 weeks. The intervention group gained significantly less weight from enrollment to 36 weeks than the usual care group, and fewer participants exceeded the IOM recommendations (table). This did not result in fewer diagnoses of gestational diabetes, preeclampsia or gestational hypertension, or birth weight >4 kg; a higher rate of cesarean birth was observed in the intervention group. CONCLUSION: The MOMFIT behaviorally adapted, nutrient-dense, energy-balanced diet and lifestyle intervention resulted in better adherence to IOM guidelines for gestational weight gain, but improvements in pregnancy outcomes were not observed.
Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 2015
Twin-reversed arterial perfusion (TRAP) sequence affects 1% of monochorionic twin pregnancies and... more Twin-reversed arterial perfusion (TRAP) sequence affects 1% of monochorionic twin pregnancies and is caused by abnormal vascular connections between a pump twin and an acardiac mass. The effects of abnormal vascular connections on cerebral vasculature in the pump twin are unknown. We hypothesize that abnormal cerebral vascular impedance, as assessed by the pulsatility index (PI), is present in pump twins and that fetal intervention alters cerebral impedance. Fetal echocardiograms performed between 2010 and 2013 in pregnancies diagnosed with TRAP (n = 19), recorded at presentation, and uncomplicated monochorionic twin pregnancies (controls, n = 18; 36 fetuses) were analyzed. In all subjects, the middle cerebral artery (MCA)-PI, combined cardiac output (CCO) and cardiothoracic ratio were calculated, and the values for cases and controls were compared. The mean gestational age at the time of echocardiography was 20 weeks in both groups. MCA-PI was lower in TRAP cases than in controls (...
Carolina Digital Repository (University of North Carolina at Chapel Hill), 2010
Infection is an important cause of stillbirths worldwide: in low-income and middle-income countri... more Infection is an important cause of stillbirths worldwide: in low-income and middle-income countries, 50% of stillbirths or more are probably caused by infection. By contrast, in high-income countries only 10-25% of stillbirths are caused by infection. Syphilis, where prevalent, causes most infectious stillbirths, and is the infection most amenable to screening and treatment. Ascending bacterial infection is a common cause of stillbirths, but prevention has proven elusive. Many viral infections cause stillbirths but aside from vaccination for common childhood diseases, we do not have a clear prevention strategy. Malaria, because of its high prevalence and extensive placental damage, accounts for large numbers of stillbirths. Intermittent malarial prophylaxis and insecticide-treated bednets should decrease stillbirths. Many infections borne by animals and vectors cause stillbirths, and these types of infections occur frequently in low-income countries. Research that better defi nes the relation between these infections and stillbirths, and develops strategies to reduce associated adverse outcomes, should play an important part in reduction of stillbirths in low-income countries.
Stillbirth, one of the most common adverse pregnancy outcomes, is especially prevalent in low and... more Stillbirth, one of the most common adverse pregnancy outcomes, is especially prevalent in low and middle-income countries (LMICs). Understanding the causes of stillbirth is crucial to developing effective interventions. In this commentary, investigators working across several LMICs discuss the most useful investigations to determine causes of stillbirths in LMICs. Useful data were defined as 1) feasible to obtain accurately and 2) informative to determine or help eliminate a cause of death. Recently, new tools for LMIC settings to determine cause of death in stillbirths, including minimally invasive tissue sampling (MITS) – a method using needle biopsies to obtain internal organ tissue from deceased fetuses for histology and pathogen identification in those tissues have become available. While placental histology has been available for some time, the development of the Amsterdam Criteria in 2016 has provided a useful framework to categorize placental lesions. The authors recommend f...
Human subjects research protections have historically focused on mitigating risk of harm and prom... more Human subjects research protections have historically focused on mitigating risk of harm and promoting benefits for research participants. In many low-resource settings (LRS), complex and often severe challenges in daily living, poverty, geopolitical uprisings, sociopolitical, economic, and climate crises increase the burdens of even minimal risk research. While there has been important work to explore the scope of ethical responsibilities of researchers and research teams to respond to these wider challenges and hidden burdens in global health research, less attention has been given to the ethical dilemmas and risk experienced by frontline researcher staff as they perform research-related activities in LRS. Risks such as job insecurity, moral distress, infection, or physical harm can be exacerbated during public health crises, as recently highlighted by the COVID-19 pandemic. We highlight the layers of risk research staff face in LRS and present a conceptual model to characterize d...
Traditional birth attendants (TBAs) have provided delivery care throughout the world prior to the... more Traditional birth attendants (TBAs) have provided delivery care throughout the world prior to the development of organized systems of medical care. In 2016, an estimated 22% of pregnant women delivered with a TBA, mostly in rural or remote areas that lack formal health services. Still active in many regions of LMICs, they provide care, including support and advice, to women during pregnancy and childbirth. Even though they generally have no formal training and are not
Lot Quality Assurance Sampling (LQAS) is a special form of cross-sectional study which classifies... more Lot Quality Assurance Sampling (LQAS) is a special form of cross-sectional study which classifies exposure or outcome into binary categories such as adequate or inadequate. LQAS can be used at a local level with the modest amount of supervision to empower local supervisors and to identify successes and challenges in their supervision areas. Through LQAS, a small sample size of 35 subjects per supervision area will provide enough evidence for the local supervisors to ensure coverage and quality data. The study aims to assess the coverage of maternal and newborn health birth registry and data quality in Thatta district of Pakistan using LQAS methodology. The study will employ LQAS methodology which is a special form of cross-sectional study design. The study will be conducted in Thatta District of Karachi, Pakistan about a representative sample of married women of reproductive age (15-45 years) in order to evaluate data quality and coverage of maternal and newborn health birth registry, and to investigate reasons for non-coverage and poor data quality. The study will determine coverage and quality of maternal and newborn health birth registry in Thatta District of Karachi. The study will inform areas such as identification of supervision area with low coverage, find out the reason for low coverage and help worker to cover the area. For example, provide transport and training to ensure maximum coverage and data quality of MNH registry. The study will help to assess broad range of local health problems concerning MNH registry and will help to determine the performance of individual subunits in a given area to ensure quality management of health services
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
INTRODUCTION Undernutrition is a significant public health concern in the developing world and fa... more INTRODUCTION Undernutrition is a significant public health concern in the developing world and factors such as high parity and short birth intervals are significant contributors to maternal undernutrition. This study aimed to assess determinants of undernutrition among women of reproductive age in Sindh, Pakistan, using the national demographic health survey. METHODS Data of 4050 ever married women of reproductive age from the Pakistan Demographic and Health Survey (PDHS) 2012-2013 were analyzed. These included sociodemographic and fertility-related variables. Logistic regression was applied to assess the determinants of undernutrition. RESULTS Women having ≥5 children were 47% less likely to be undernourished compared to women having <5 children (OR=0.53; 95% CI: 0.43-0.63). Undernourished women included those who belonged to rural areas (adjusted odds ratio, AOR=3.47; 95% CI: 2.76-4.36), those who breastfed their infants (AOR=1.40; 95% CI: 1.16-1.68), were smokers (AOR=4.35; 95% CI: 2.58-7.34) or worked (AOR=1.22; 95% CI: 1.09-1.47). CONCLUSIONS The highest rates of undernourishment were found among working women as well as those who breastfed, smoked or belonged to the rural setting. We recommend that breastfeeding and working women should be provided awareness through teaching sessions and other means to improve their nutritional status as this subset of patients typically require additional calories.
Background: In Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of materna... more Background: In Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of maternal deaths reported at tertiary care hospitals. To reduce the morbidity and mortality associated with PE/E, an accessible strategy is to support pregnant women at high risk for preeclampsia (HRPE) by closely monitoring their blood pressures at home (i.e., telemonitoring) for the earliest signs of preeclampsia. This could lead to the earliest possible detection of high blood pressure, resulting in early intervention such as through medications, hospitalization, or delivery of the baby. The study aims to explore the perspectives, preferences and needs of telemonitoring (TM) for pregnant women at HRPE in Karachi, to inform future implementation strategies. Methods: The study will employ an exploratory qualitative research design. The study will be conducted at the Jinnah Postgraduate Medical Centre (JPMC) hospital and Aga Khan University Hospital (AKUH) in Karachi, Sindh, Pakistan. Data will be collected through key-informant interviews (KIIs) and in-depth patient interviews (IDPIs). IDPIs will be conducted with the pregnant women at HRPE who are visiting the outpatient department/ antenatal clinics of JPMC hospital for antenatal checkups and immunizations. KIIs will be conducted with the obstetricians, Maternal, neonatal and child health (MNCH) specialists and health care providers at JPMC, as well as TM experts from Karachi. Study data will be analyzed through conventional content analysis. Interviews are anticipated to begin in April 2020 and to be completed during the summer of 2020. Discussion: This is the first study to explore the use of TM program for pregnant women at HRPE in a tertiary health facility in Karachi. The research will help explore perceived benefits associated with the use of a TM program alongside potential facilitators and barriers that may help inform the future implementation of a TM program for pregnant women at HRPE in Karachi.
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Introduction: Optimal human milk (HM) B-vitamin concentrations remain undefined, especially in ar... more Introduction: Optimal human milk (HM) B-vitamin concentrations remain undefined, especially in areas where undernutrition is prevalent. The impact of supplementation pre-conception through pregnancy on HM B-vitamin composition remains unknown. Methods: Human milk (HM) was collected at 2-weeks postpartum from 200 women in Guatemala, India, and Pakistan (the Women First Trial). The women were randomized to start a lipid-based nutrient supplement before conception, at end of the first trimester, or not at all; intervention continued until delivery. HM concentrations of eight B-vitamins and choline were assessed via ultra-performance liquid chromatography-tandem mass spectrometry. Maternal diet was assessed in early pregnancy, and infant growth followed through 6 months post-delivery. Results: Despite supplement exposure averaging 15.7 (pre-conception arm) and 6.0 months (prenatal arm), HM B-vitamins did not differ between arms, but site differences were evident. Guatemala had higher HM concentrations of vitamin B3 than Pakistan and India. Pakistan had higher HM concentrations of thiamin and vitamin B6 than India and Guatemala. Cohort average HM vitamin B2 (162 ± 79 µg/L) and B6 (31.8 ± 24.6 µg/L) fell below values defined as deficient in 81.5 and 85.5% of samples, potentially reflecting sampling procedures and timing. Maternal dietary intakes of only vitamin B6 and choline were associated with the corresponding concentrations in HM (p < 0.005). No HM B-vitamin concentrations were associated with infant growth. Young et al. International Human Milk B-Vitamins Conclusion: Prenatal supplementation for at least 6 months had no impact on HM B-vitamin concentrations at 2-weeks postpartum. Results suggest that the adequacy of HM composition was generally maintained, with potential exceptions of vitamin B2 and B6.
One of the major drivers of mistreatment during childbirth includes the lack of staff training on... more One of the major drivers of mistreatment during childbirth includes the lack of staff training on interpersonal skills and psychosocial support, which resulted in providers lacking the understanding that patients' rights also include equity, respect, and satisfaction-and not only the right to high-quality clinical care. n Providers restricted the presence of birth companions, particularly males, based on providers' own cultural preferences and comfort, thus denying women a source of support during childbirth. n Provider's physical and verbal abuse, neglect, and abandonment of patients, particularly of those from lower castes and minority ethnic groups, in response to patients' lack of cooperation and compliance was common and justified. Stronger performance monitoring systems and patient feedback mechanisms would help hold staff accountable for mistreatment and contribute to improving respectful maternity care.
BJOG: An International Journal of Obstetrics & Gynaecology
ObjectiveGroup B streptococcus (GBS) has been associated with adverse pregnancy outcomes, but few... more ObjectiveGroup B streptococcus (GBS) has been associated with adverse pregnancy outcomes, but few prospective studies have assessed its prevalence in low‐ and middle‐income country settings. We sought to evaluate the prevalence of GBS by polymerase chain reaction (PCR) in internal organ tissues and placentas of deceased neonates and stillbirths.DesignThis was a prospective, observational study.SettingThe study was conducted in hospitals in India and Pakistan.PopulationPregnant women with stillbirths or preterm births were recruited at delivery, as was a group of women with term, live births, to serve as a control group.MethodsA rectovaginal culture was collected from the women in Pakistan to assess GBS carriage. Using PCR, we evaluated GBS in various tissues of stillbirths and deceased neonates and their placentas, as well as the placentas of live‐born preterm and term control infants.Main outcome measuresGBS identified by PCR in various tissues and the placentas; rate of stillbirth...
Introduction Mistreatment, discrimination, and poor psycho-social support during childbirth at he... more Introduction Mistreatment, discrimination, and poor psycho-social support during childbirth at health facilities are common in lower- and middle-income countries. Despite a policy directive from the World Health Organisation (WHO), no operational model exists that effectively demonstrates incorporation of these guidelines in routine facility-based maternity services. This early-phase implementation research aims to develop, implement, and test the feasibility of a service-delivery strategy to promote the culture of supportive and dignified maternity care (SDMC) at public health facilities. Methods Guided by human-centred design approach, the implementation of this study will be divided into two phases: development of intervention, and implementing and testing feasibility. The service-delivery intervention will be co-created along with relevant stakeholders and informed by contextual evidence that is generated through formative research. It will include capacity-building of maternity...
American Journal of Obstetrics and Gynecology, 2017
diabetes, prior bariatric surgery, and IVF. The intervention included an individualized dietitian... more diabetes, prior bariatric surgery, and IVF. The intervention included an individualized dietitian-prescribed calorie-specific DASH-type diet, physical activity, internet-based self-monitoring of diet adherence, and weekly coaching calls, with opportunities for group visits, webinars, and podcasts. Usual care participants were provided websites, electronic newsletters, and non-diet related pregnancy information. Obstetric providers and data collectors were not aware of patient group assignment. RESULTS: 281 participants were randomized to the intervention or usual care, with complete data available for all but 2 patients. Baseline characteristics of maternal age, parity, gestational age at randomization, race, ethnicity, and pre-pregnancy BMI were similar. There were 4 pregnancy losses after randomization but before 24 weeks (data not included), and 1 fetal death after 24 weeks. The intervention group gained significantly less weight from enrollment to 36 weeks than the usual care group, and fewer participants exceeded the IOM recommendations (table). This did not result in fewer diagnoses of gestational diabetes, preeclampsia or gestational hypertension, or birth weight >4 kg; a higher rate of cesarean birth was observed in the intervention group. CONCLUSION: The MOMFIT behaviorally adapted, nutrient-dense, energy-balanced diet and lifestyle intervention resulted in better adherence to IOM guidelines for gestational weight gain, but improvements in pregnancy outcomes were not observed.
Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 2015
Twin-reversed arterial perfusion (TRAP) sequence affects 1% of monochorionic twin pregnancies and... more Twin-reversed arterial perfusion (TRAP) sequence affects 1% of monochorionic twin pregnancies and is caused by abnormal vascular connections between a pump twin and an acardiac mass. The effects of abnormal vascular connections on cerebral vasculature in the pump twin are unknown. We hypothesize that abnormal cerebral vascular impedance, as assessed by the pulsatility index (PI), is present in pump twins and that fetal intervention alters cerebral impedance. Fetal echocardiograms performed between 2010 and 2013 in pregnancies diagnosed with TRAP (n = 19), recorded at presentation, and uncomplicated monochorionic twin pregnancies (controls, n = 18; 36 fetuses) were analyzed. In all subjects, the middle cerebral artery (MCA)-PI, combined cardiac output (CCO) and cardiothoracic ratio were calculated, and the values for cases and controls were compared. The mean gestational age at the time of echocardiography was 20 weeks in both groups. MCA-PI was lower in TRAP cases than in controls (...
Carolina Digital Repository (University of North Carolina at Chapel Hill), 2010
Infection is an important cause of stillbirths worldwide: in low-income and middle-income countri... more Infection is an important cause of stillbirths worldwide: in low-income and middle-income countries, 50% of stillbirths or more are probably caused by infection. By contrast, in high-income countries only 10-25% of stillbirths are caused by infection. Syphilis, where prevalent, causes most infectious stillbirths, and is the infection most amenable to screening and treatment. Ascending bacterial infection is a common cause of stillbirths, but prevention has proven elusive. Many viral infections cause stillbirths but aside from vaccination for common childhood diseases, we do not have a clear prevention strategy. Malaria, because of its high prevalence and extensive placental damage, accounts for large numbers of stillbirths. Intermittent malarial prophylaxis and insecticide-treated bednets should decrease stillbirths. Many infections borne by animals and vectors cause stillbirths, and these types of infections occur frequently in low-income countries. Research that better defi nes the relation between these infections and stillbirths, and develops strategies to reduce associated adverse outcomes, should play an important part in reduction of stillbirths in low-income countries.
Stillbirth, one of the most common adverse pregnancy outcomes, is especially prevalent in low and... more Stillbirth, one of the most common adverse pregnancy outcomes, is especially prevalent in low and middle-income countries (LMICs). Understanding the causes of stillbirth is crucial to developing effective interventions. In this commentary, investigators working across several LMICs discuss the most useful investigations to determine causes of stillbirths in LMICs. Useful data were defined as 1) feasible to obtain accurately and 2) informative to determine or help eliminate a cause of death. Recently, new tools for LMIC settings to determine cause of death in stillbirths, including minimally invasive tissue sampling (MITS) – a method using needle biopsies to obtain internal organ tissue from deceased fetuses for histology and pathogen identification in those tissues have become available. While placental histology has been available for some time, the development of the Amsterdam Criteria in 2016 has provided a useful framework to categorize placental lesions. The authors recommend f...
Human subjects research protections have historically focused on mitigating risk of harm and prom... more Human subjects research protections have historically focused on mitigating risk of harm and promoting benefits for research participants. In many low-resource settings (LRS), complex and often severe challenges in daily living, poverty, geopolitical uprisings, sociopolitical, economic, and climate crises increase the burdens of even minimal risk research. While there has been important work to explore the scope of ethical responsibilities of researchers and research teams to respond to these wider challenges and hidden burdens in global health research, less attention has been given to the ethical dilemmas and risk experienced by frontline researcher staff as they perform research-related activities in LRS. Risks such as job insecurity, moral distress, infection, or physical harm can be exacerbated during public health crises, as recently highlighted by the COVID-19 pandemic. We highlight the layers of risk research staff face in LRS and present a conceptual model to characterize d...
Traditional birth attendants (TBAs) have provided delivery care throughout the world prior to the... more Traditional birth attendants (TBAs) have provided delivery care throughout the world prior to the development of organized systems of medical care. In 2016, an estimated 22% of pregnant women delivered with a TBA, mostly in rural or remote areas that lack formal health services. Still active in many regions of LMICs, they provide care, including support and advice, to women during pregnancy and childbirth. Even though they generally have no formal training and are not
Lot Quality Assurance Sampling (LQAS) is a special form of cross-sectional study which classifies... more Lot Quality Assurance Sampling (LQAS) is a special form of cross-sectional study which classifies exposure or outcome into binary categories such as adequate or inadequate. LQAS can be used at a local level with the modest amount of supervision to empower local supervisors and to identify successes and challenges in their supervision areas. Through LQAS, a small sample size of 35 subjects per supervision area will provide enough evidence for the local supervisors to ensure coverage and quality data. The study aims to assess the coverage of maternal and newborn health birth registry and data quality in Thatta district of Pakistan using LQAS methodology. The study will employ LQAS methodology which is a special form of cross-sectional study design. The study will be conducted in Thatta District of Karachi, Pakistan about a representative sample of married women of reproductive age (15-45 years) in order to evaluate data quality and coverage of maternal and newborn health birth registry, and to investigate reasons for non-coverage and poor data quality. The study will determine coverage and quality of maternal and newborn health birth registry in Thatta District of Karachi. The study will inform areas such as identification of supervision area with low coverage, find out the reason for low coverage and help worker to cover the area. For example, provide transport and training to ensure maximum coverage and data quality of MNH registry. The study will help to assess broad range of local health problems concerning MNH registry and will help to determine the performance of individual subunits in a given area to ensure quality management of health services
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