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Takeshita M, Toyomoto R, Marui K, Ito M, Eto H, Takehara K, Matsui M. Cardiotocography use for fetal assessment during labor in low- and middle-income countries: A scoping review. Int J Gynaecol Obstet 2024. [PMID: 38287690 DOI: 10.1002/ijgo.15390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/31/2023] [Accepted: 01/09/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND The use of cardiotocography (CTG) to improve neonatal outcomes is controversial. The medical settings, subjects, utilizations, and interpretation guidelines of CTG are unclear for low- and middle-income countries (LMICs). OBJECTIVES To assess and review CTG use for studies identified in LMICs and provide insights on the potential for effective use of CTG to improve maternal and neonatal outcomes. SEARCH STRATEGY The databases Medline, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for published and unpublished literature through September 2023. SELECTION CRITERIA Publications were identified which were conducted in LMICs, based on the World Bank list of economies for 2019; targeting pregnant women in childbirth; and focusing on the utilization of CTG and neonatal outcomes. DATA COLLECTION AND ANALYSIS Publications were screened, and duplicates were removed. A scoping review was conducted using PRISMA-ScR guidelines. RESULTS The searches generated 1157 hits, of which 67 studies were included in the review. In the studies there was considerable variation and ambiguity regarding the study settings, target populations, utilizations, timing, frequency, and duration of CTG. While cesarean section rates were extensively investigated as an outcome of studies of CTG itself and the effect of additional techniques on CTG, other clinically significant outcomes, including neonatal mortality, were not well reported. CONCLUSIONS Variations and ambiguities were found in the use of CTG in LMICs. Due to the limited amount of evidence, studies are needed to examine CTG availability in the context of LMICs.
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Affiliation(s)
- Mai Takeshita
- Department of Health Informatics, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Rie Toyomoto
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Kanae Marui
- Department of Health Informatics, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Masami Ito
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Hiromi Eto
- Department of Reproductive Health, Institute of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Kenji Takehara
- Department of Health Policy, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuaki Matsui
- Department of Global Health, Nagasaki University School of Tropical Medicine and Global Health, Nagasaki, Japan
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
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Abubakar HD, Galadanci HS, Farouk ZL. Predictive accuracy of admission cardiotocography as a screening tool for perinatal asphyxia in high-risk parturients in Northern Nigeria. Int J Gynaecol Obstet 2022; 159:796-802. [PMID: 35332538 DOI: 10.1002/ijgo.14191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/17/2022] [Accepted: 03/16/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine the predictive accuracy of admission cardiotocography (CTG) as a screening test for perinatal asphyxia in high-risk parturients. METHODS A prospective study was done on a group of 180 high-risk parturients in the labor ward of Aminu Kano Teaching Hospital were subjected to a 30-min admission cardiotocography. Results were categorized based on the RCOG criteria. Those with normal results were allowed to progress in labor, while those with abnormal results had their delivery expedited. Umbilical artery blood gas analysis was done at delivery. Measured variables were expressed in descriptive statistics. Tests of association for categorical variables were done using the non-parametric chi-square test (P-value of ≤0.05). The Binary logistic regression model was used to control potential confounders. RESULTS After excluding five cord blood samples, 175 samples were analyzed. The CTG was reassuring in 149 (85.1%), non-reassuring in 15 (8.6%), and abnormal in 11 (6.3%) women. Fetal distress developed in 5 (3.4%) and 7 (46.7%) of reassuring and non-reassuring groups, respectively. The test had 91% sensitivity, specificity was 68.8%, and the predictive accuracy was 88.6% for asphyxia using base deficit. CONCLUSION The admission that cardiotocography is useful in detecting fetuses at risk of perinatal asphyxia in high-risk deliveries.
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Affiliation(s)
- Hanifah D Abubakar
- Department of Obstetrics and Gynecology, Muhammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
| | - Hadiza S Galadanci
- Africa Center of Excellence for Population Health and Policy, Bayero University Kano, Kano, Nigeria
| | - Zubaida L Farouk
- Centers for Infectious Diseases Research, Bayero University Kano/Department of Pediatrics Aminu Kano Teaching Hospital, Kano, Nigeria
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Agena AG, Modiba LM. Labour admission assessment results of index pregnancy as predictors of intrapartum stillbirth in public health facilities of Addis Ababa: A case-control study. PLoS One 2020; 15:e0230478. [PMID: 32240197 PMCID: PMC7117700 DOI: 10.1371/journal.pone.0230478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/02/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Approximately one-third of the global stillbirth burden occurs during intrapartum period. The ability to assess obstetric parameters including effacement, dilatation, uterine contraction, decent, rupture of the uterus, and moulding of the foetal head are among the essential competencies required by obstetric service providers admitting women for labour in health facilities. Misdiagnosis of these conditions could result in unnecessary obstetric interventions and unfavourable obstetric outcomes including intrapartum stillbirth. This study aimed to assess associations between missed diagnosis plus complication of labour on admission and intrapartum stillbirth. METHODS A case-control study using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 20 public health centres and three public hospitals of Addis Ababa between 01 July 2010 and 30 June 2015 was conducted. Data were collected from charts of all cases meeting the inclusion criteria. Medical records of women with livebirths were randomly selected and reviewed from each public health facilities in two to one (2:1) control to case ratio. Accordingly, 728 cases of stillbirth out of 1,056 charts met the inclusion criteria whereas 1,551 controls out of 1,705 were also considered in the study. RESULTS Proportionally, more women in the stillbirth group (39.4%) than in the livebirth group (30.2%) experienced ruptured membrane on admission, with the difference being statistically significant (OR 1.7, 95% CI 1.37-2.03). Significantly higher proportion of women in the intrapartum stillbirth group experienced FRH lower than 110/min, a result suggestive of foetal distress on admission. Proportionally, more women in the intrapartum stillbirth group (14.5%) than in the livebirth group (4.5%) had breech foetal presentation on admission for labour, the difference being statistically significant (aOR 3.26 95% CI 1.93-5.50). Intrapartum stillbirth was slightly higher among women with cervical dilatation 4cm or more on admission (OR 1.2, 95% CI 1.00-1.45). This could be owing to delay in seeking obstetric care or misdiagnosis of the condition, a situation that seeks more rigorous study to determine the underlying causal links. Diagnosis of foetal member was missed among more cases than controls where the difference was statistically significant (aOR 1.51, CI 1.03-2.19). CONCLUSION Low FHR, non-vertex foetal presentations and ruptured cervical membrane were predictors of intrapartum stillbirth. Health facilities could avert unnecessary foetal loss by undertaking timely actions to manage obstetric emergencies on admission to labour.
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Affiliation(s)
| | - Lebitsi M. Modiba
- Department of Health Studies, College of Human Sciences, University of South Africa, Pretoria, South Africa
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Das MK, Tripathi R, Kashyap NK, Fotedar S, Bisht SS, Rathore AM, Raghav A. Clinical Validation of Mobile Cardiotocograph Device for Intrapartum and Antepartum Monitoring Compared to Standard Cardiotocograph: An Inter-Rater Agreement Study. J Family Reprod Health 2019; 13:109-115. [PMID: 31988647 PMCID: PMC6969888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective: Electronic fetal monitoring (EFM) using cardiotocograph (CTG) is commonly used both to assess fetal wellbeing in late antepartum and for intervention during intrapartum period. We validated the performance of indigenously developed mobile cardiotocograph (CTG) device with wireless probes compared to standard CTG device. Materials and methods: We sequentially used mobile and standard CTG devices in 495 pregnant women in labour and 359 pregnant women with gestation > 32 weeks. The CTG interpreted by two independent obstetricians in a blinded manner were compared to estimate the agreement by kappa (k) statistic. Results: High level of agreements between mobile and standard CTG devices for both intrapartum (87.9%; kappa 0.61) and antepartum monitoring (91.2%; kappa 0.60) were observed. Most of the pregnant women (80% in intrapartum and 70% in antepartum groups) and all nurses and obstetricians preferred the mobile CTG device over standard CTG device. Conclusion: The mobile CTG device can reliably be used for both intrapartum and antepartum monitoring instead of the standard CTG devices. The smaller size, portability and ability to transmit the recordings for second opinion make it suitable for use by midwives for appropriate triaging and referral. Wider availability of CTG and interpretation support at the peripheral facilities would assist identifying at-risk pregnancies and foetuses for timely referral and appropriate action to reduce perinatal deaths, stillbirths and birth asphyxi.
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Affiliation(s)
| | - Reva Tripathi
- Maulana Azad Medical College, New Delhi, India,Hamdard Institute of Medical Sciences and Research, New Delhi, India
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Housseine N, Punt MC, Browne JL, Meguid T, Klipstein-Grobusch K, Kwast BE, Franx A, Grobbee DE, Rijken MJ. Strategies for intrapartum foetal surveillance in low- and middle-income countries: A systematic review. PLoS One 2018; 13:e0206295. [PMID: 30365564 PMCID: PMC6203373 DOI: 10.1371/journal.pone.0206295] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 10/10/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The majority of the five million perinatal deaths worldwide take place in low-resource settings. In contrast to high-resource settings, almost 50% of stillbirths occur intrapartum. The aim of this study was to synthesise available evidence of strategies for foetal surveillance in low-resource settings and associated neonatal and maternal outcomes, including barriers to their implementation. METHODS AND FINDINGS The review was registered with Prospero (CRD42016038679). Five databases were searched up to May 1st, 2016 for studies related to intrapartum foetal monitoring strategies and neonatal outcomes in low-resource settings. Two authors extracted data and assessed the risk of bias for each study. The outcomes were narratively synthesised. Strengths, weaknesses, opportunities and threats analysis (SWOT) was conducted for each monitoring technique to analyse their implementation. There were 37 studies included: five intervention and 32 observational studies. Use of the partograph improved perinatal outcomes. Intermittent auscultation with Pinard was associated with lowest rates of caesarean sections (10-15%) but with comparable perinatal outcomes to hand-held Doppler and Cardiotocography (CTG). CTG was associated with the highest rates of caesarean sections (28-34%) without proven benefits for perinatal outcome. Several tests on admission (admission tests) and adjunctive tests including foetal stimulation tests improved the accuracy of foetal heart rate monitoring in predicting adverse perinatal outcomes. CONCLUSIONS From the available evidence, the partograph is associated with improved perinatal outcomes and is recommended for use with intermittent auscultation for intrapartum monitoring in low resource settings. CTG is associated with higher caesarean section rates without proven benefits for perinatal outcomes, and should not be recommended in low-resource settings. High-quality evidence considering implementation barriers and enablers is needed to determine the optimal foetal monitoring strategy in low-resource settings.
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Affiliation(s)
- Natasha Housseine
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Marieke C. Punt
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Joyce L. Browne
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tarek Meguid
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health and Medical Science, State University of Zanzibar (SUZA), Zanzibar, Tanzania
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Barbara E. Kwast
- International Consultant Maternal Health and Safe Motherhood, Leusden, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Diederick E. Grobbee
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marcus J. Rijken
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Akhavan S, Lak P, Rahimi-Sharbaf F, Mohammadi SR, Shirazi M. Admission Test and Pregnancy Outcome. IRANIAN JOURNAL OF MEDICAL SCIENCES 2017; 42:362-368. [PMID: 28761202 PMCID: PMC5523043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The admission test (AT) has been carried out for many years, but there are still debates about the prognostic value of the test. Therefore, we aimed to examine the value of the AT in predicting the adverse outcome in neonates. METHODS In this cross-sectional study, 425 pregnant women with normal vaginal delivery were studied between2009 and 2014at Vali-e-Asr Hospital. Based on the results, the women were divided into 2groups of normal and abnormal ATs. All the patients were followed up until the birth of their baby, when the status of mother and neonate was determined. The main outcomes of the study were cesarean rate, neonatal intensive care unit (NICU) admission, fetus demise, neonatal acidosis, and Apgar score. The independent t-test, chi-square test, Fisher exact test, and logistic regression were used for statistical analysis. The data were analyzed using SPSS (version 17). RESULTS Of 425 pregnant women studied, 142 (33.4%) had abnormal ATs with a mean age of 29 (±4.5) years. Multivariate analysis showed that an abnormal AT was able to predict the incidence of cesarean section, intrauterine growth restriction, turned cord, and Apgar<7, but it could not predict neonatal death and hypoxia. CONCLUSION The AT was shown to be a useful screening test with risk factors such as oligohydramnios, bloody amniotic fluid, meconium amniotic fluid, intrauterine growth restriction, and turned cord. Additionally, the test was also able to predict NICU admission and the need for cesarean section, but it could not predict the occurrence of neonatal death.
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Affiliation(s)
- Setareh Akhavan
- Department of Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvaneh Lak
- Department of Obstetrics and Gynaecology, Shaheed Chamran Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Mahboobeh Shirazi
- Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran,Correspondence: Mahboobeh Shirazi, MD; Department of Obstetrics and Gynaecology, Yas Hospital, Karim Khan Blvd, Ostad Nejatollahi St, Tehran, Iran Tel: +98 912 3903352 Fax: +98 21 88948217
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Admission Cardiotocography: A Predictor of Neonatal Outcome. J Obstet Gynaecol India 2016; 66:321-9. [PMID: 27651624 DOI: 10.1007/s13224-016-0912-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 05/07/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Screening for fetal distress is a big challenge for obstetricians. Labor admission test by cardiotocography (CTG) can be utilized to differentiate between mothers, in whom continuous fetal monitoring is needed and those who can be managed by intermittent auscultation. Admission CTG is commonly used screening test which aims to identify on admission to the delivery unit the fetus at increased risk of intrapartum hypoxia. We conducted a study to evaluate the efficacy of CTG in low- and high-risk women. METHODS A prospective longitudinal study was conducted on 200 low-risk and high-risk antenatal women, beyond 32-week gestation with live pregnancy in labor and admitted in labor ward. RESULTS Correlation of labor admission test with meconium in low risk and high risk was found statistically significant (p = 0.0010 and p = 0.000046, respectively). Correlation of labor admission test with low Apgar score, NICU admission and mortality was found statistically insignificant in low-risk and high-risk groups. CONCLUSION Admission CTG does not benefit the neonatal outcome in normal- or low-risk women and rather results in increased obstetric intervention. Thus, it is not beneficial as a screening test to detect intrapartum fetal distress in normal- or low-risk women.
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Sharbaf FR, Amjadi N, Alavi A, Akbari S, Forghani F. Normal and indeterminate pattern of fetal cardiotocography in admission test and pregnancy outcome. J Obstet Gynaecol Res 2014; 40:694-9. [PMID: 24738115 DOI: 10.1111/jog.12226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to evaluate the prognostic value of normal and indeterminate patterns of cardiotocography in admission test (AT) and pregnancy outcome. MATERIAL AND METHODS A prospective study enrolled 818 intrapartum singleton pregnancies with gestational age of >34 weeks, in the latent phase and with intact membrane. Cases were divided into the high- and low-risk groups. Non-Stress Test was interpreted according to the 2008 National Institute of Child Health and Human Development workshop. Adverse pregnancy outcomes were compared between groups based on AT interpretation. RESULTS Out of 818 patients, 492 (60%) were categorized as low-risk and 326 (40%) as high-risk pregnancies. In low-risk patients, 410 (83.3%) had normal and 82 (16.7%) had indeterminate AT. These figures were 249 (76.4%) and 77 (23.6%) in high-risk patients, respectively, and two cases (0.6%) had abnormal AT. In both groups, thick meconium staining, non-reassuring fetal heart rate pattern, cesarean section and cesarean section due to non-reassuring fetal heart rate pattern were significantly more frequent in indeterminate AT than normal ones (P < 0.001). In high-risk pregnancies with indeterminate AT, the risk of low birthweight and neonatal intensive care unit (NICU) admission increased. The positive predictive value was less than 30% in predicting thick meconium staining, non-reassuring fetal heart rate pattern, PH ≤ 7.2 and NICU admission in both groups. Overall, negative predictive value of AT for neonatal death and NICU admission was 100% and 96%, respectively. CONCLUSIONS Indeterminate patterns of cardiotocography can predict adverse pregnancy outcomes and when facing this condition, obstetricians should act cautiously.
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Blix E. The admission CTG: is there any evidence for still using the test? Acta Obstet Gynecol Scand 2013; 92:613-9. [DOI: 10.1111/aogs.12091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 01/08/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Ellen Blix
- Department of Clinical Research; University Hospital of North Norway, and Women's Health and Perinatology Research Group; Department of Clinical Medicine, Faculty of Health; University of Tromsø; Tromsø; Norway
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Rahman H, Renjhen P, Dutta S, Kar S. Admission cardiotocography: Its role in predicting foetal outcome in high-risk obstetric patients. Australas Med J 2012; 5:522-7. [PMID: 23173014 PMCID: PMC3494822 DOI: 10.4066/amj.2012.1267] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Routine and continuous electronic monitoring of foetal heart rate (FHR) in labour has become an established obstetric practice in high-risk pregnancies in industrialised countries. However, the same may not be possible in non-industrialised countries where antenatal care is inadequate with a large number of high-risk pregnancies being delivered in crowded settings and inadequate health care provider to patient ratios. AIMS The objective of this study was to evaluate the predictive value of the admission cardiotocogram (CTG) in detecting foetal hypoxia at the time of admission in labour and to correlate the results of the admission CTG with the perinatal outcome in high-risk obstetric cases. METHOD This was a prospective observational study conducted in the labour and maternity ward of a hospital in Gangtok, India, during the period 2008 to 2010. The study included high-risk pregnant women, admitted via the emergency or outpatient department with a period of gestation ≥36 weeks, in first stage of labour with foetus in the cephalic presentation. All women were subjected to an admission CTG, which included a 20 minute recording of FHR and uterine contractions. RESULTS One hundred and sixty patients were recruited. The majority of women were primigravida in the 21-30 years age group. About 42% patients were postdated pregnancy followed by pregnancy-induced hypertension (PIH) (15.6%) and premature rupture of membranes (PROM) (11.3%) as the major risk factors. The admission CTG were 'reactive' in 77%, 'equivocal' in 14.4% and 'ominous' in 8.7% women. Incidence of foetal distress, moderate-thick meconium stained liquor and neonatal intensive care unit (NICU) admission was significantly more frequent among patients with ominous test results compared with equivocal or reactive test results on admission. Incidence of vaginal delivery was more common when the test was reactive. CONCLUSION The admission CTG appears to be a simple non-invasive test that can serve as a screening tool in 'triaging' foetuses of high-risk obstetric patients in non-industrialised countries with a heavy workload and limited resources.
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Affiliation(s)
- Hafizur Rahman
- Department of Obstetrics & Gynaecology, Sikkim Manipal Institute of Medical Sciences, Gangtok, India
| | - Prachi Renjhen
- Department of Obstetrics & Gynaecology, Melaka Manipal Medical College, Malaysia
| | - Sudip Dutta
- Department of Paediatrics, Sikkim Manipal Institute of Medical Sciences, Gangtok, India
| | - Sumit Kar
- Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences Gangtok, India
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