Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review

BACKGROUND

Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs).

OBJECTIVES

To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature.

SEARCH STRATEGY

The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS.

SELECTION CRITERIA

English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included.

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework.

MAIN RESULTS

Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels.

CONCLUSIONS

There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.

Methods and Measures to Assess Health Care Provider Behavior and Behavioral Determinants in Reproductive, Maternal, Newborn, and Child Health: A Rapid Review

BACKGROUND

Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming.

METHODS

Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010-2021). Information on study identifiers (e.g., type of provider), select domains from Green and Kreuter's PRECEDE-PROCEED framework (e.g., predisposing factors such as attitudes), study characteristics (e.g., study type and design), and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized.

RESULTS

More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors.

CONCLUSION

A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes.

Signaling and crosstalk of rhizobacterial and plant hormones that mediate abiotic stress tolerance in plants

Agricultural areas exhibiting numerous abiotic stressors, such as elevated water stress, temperatures, and salinity, have grown as a result of climate change. As such, abiotic stresses are some of the most pressing issues in contemporary agricultural production. Understanding plant responses to abiotic stressors is important for global food security, climate change adaptation, and improving crop resilience for sustainable agriculture, Over the decades, explorations have been made concerning plant tolerance to these environmental stresses. Plant growth-promoting rhizobacteria (PGPR) and their phytohormones are some of the players involved in developing resistance to abiotic stress in plants. Several studies have investigated the part of phytohormones in the ability of plants to withstand and adapt to non-living environmental factors, but very few have focused on rhizobacterial hormonal signaling and crosstalk that mediate abiotic stress tolerance in plants. The main objective of this review is to evaluate the functions of PGPR phytohormones in plant abiotic stress tolerance and outline the current research on rhizobacterial hormonal communication and crosstalk that govern plant abiotic stress responses. The review also includes the gene networks and regulation under diverse abiotic stressors. The review is important for understanding plant responses to abiotic stresses using PGPR phytohormones and hormonal signaling. It is envisaged that PGPR offer a useful approach to increasing plant tolerance to various abiotic stresses. However, further studies can reveal the unclear patterns of hormonal interactions between plants and rhizobacteria that mediate abiotic stress tolerance.

Microsecond Isomer at the N=20 Island of Shape Inversion Observed at FRIB

Excited-state spectroscopy from the first experiment at the Facility for Rare Isotope Beams (FRIB) is reported. A 24(2)-μs isomer was observed with the FRIB Decay Station initiator (FDSi) through a cascade of 224- and 401-keV γ rays in coincidence with ^{32}Na nuclei. This is the only known microsecond isomer (1  μs≤T_{1/2}<1  ms) in the region. This nucleus is at the heart of the N=20 island of shape inversion and is at the crossroads of the spherical shell-model, deformed shell-model, and ab initio theories. It can be represented as the coupling of a proton hole and neutron particle to ^{32}Mg, ^{32}Mg+π^{-1}+ν^{+1}. This odd-odd coupling and isomer formation provides a sensitive measure of the underlying shape degrees of freedom of ^{32}Mg, where the onset of spherical-to-deformed shape inversion begins with a low-lying deformed 2^{+} state at 885 keV and a low-lying shape-coexisting 0_{2}^{+} state at 1058 keV. We suggest two possible explanations for the 625-keV isomer in ^{32}Na: a 6^{-} spherical shape isomer that decays by E2 or a 0^{+} deformed spin isomer that decays by M2. The present results and calculations are most consistent with the latter, indicating that the low-lying states are dominated by deformation.

Down But Not Out: Vasectomy Is Faring Poorly Almost Everywhere-We Can Do Better To Make It A True Method Option

INTRODUCTION

Demand for vasectomy-1 of 2 contraceptive methods for men-has been low, with deep-seated myths, misconceptions, and provider bias against it widespread. Programmatic attention and donor funding have been limited and sporadic.

METHODS

We analyzed vasectomy use in 84 low- and middle-income countries (LMICs) plus the 11 high-income countries with vasectomy prevalence above 1%. These 95 countries comprise 90% of the world's population. Data come from United Nations survey compilations, population estimates, and gender inequality rankings. We also reviewed recent articles on vasectomy and analyses of chronic challenges to vasectomy service provision.

RESULTS

Vasectomy use is 61% lower now than 2 decades ago. Of 922 million women using contraception worldwide, 17 million rely on vasectomy-27 million fewer than in 2001. In contrast, 219 million women use tubectomy-8 million more than in 2001. Of 84 LMICs, 7 report vasectomy prevalence above 2%. In 56 LMICs, no more than 1 in 1,000 women relies on vasectomy. Female-to-male disparities in permanent method use widened globally, from 5:1 to 13:1, and are much higher in some regions and countries (e.g., 76:1 in India). Countries with the highest vasectomy prevalence are among those with the highest gender equality and vice versa.

CONCLUSION

Vasectomy use is surprisingly low globally and declining. Use remains negligible in almost all LMICs, reflecting low demand and program priority. For vasectomy to become an accessible, rights-based option, program efforts need to be holistic, ensuring an enabling environment while coordinating demand- and service-focused efforts. Vasectomy champions at all levels should be supported on a sustained basis. On the demand side, harnessing mass and social media to increase accurate knowledge and normalize vasectomy as a method and service will be particularly valuable. Evidence from Bolivia suggests relatively few trained providers and procedures could result in a country's attaining 1% vasectomy prevalence.

Capacity building in operational research on obstetric fistula: Experience in the Democratic Republic of Congo, 2017-2021

OBJECTIVE

To implement a Flexible Operational Research Training (FORT) course within the Fistula Care Plus Project, Democratic Republic of Congo, from 2017 to 2021.

METHODS

A descriptive study using design and implementation (process and outcome) data. Two to four members of medical teams from three supported sites were selected for the training based on their research interests and level of involvement in the program.

RESULTS

Two courses (13-14 months each) involving nine facilitators and 17 participants overall were conducted between 2017 and 2021. Most participants in both courses were medical doctors (67% and 71%, respectively) from the supported hospitals (83% and 77%, respectively). About half were women. In addition to classic face-to-face didactic modules, the courses integrated online platforms to cope with the changing contexts (Ebola virus and COVID-19). Most participants reported having gained new skills in developing research protocols, collecting, managing, and analyzing data, and developing research manuscripts. The two courses resulted in six scientific manuscripts and three presentations at international conferences. Participants subsequently published five papers from their research after the first course. The total direct costs for both courses were representing a cost of $3669 per participant trained.

CONCLUSION

The FORT model proved feasible, efficient, and successful. However, scaling up will require more adaptation efforts from programs and participating sites.

Crossing N=28 Toward the Neutron Drip Line: First Measurement of Half-Lives at FRIB

New half-lives for exotic isotopes approaching the neutron drip-line in the vicinity of N∼28 for Z=12-15 were measured at the Facility for Rare Isotope Beams (FRIB) with the FRIB decay station initiator. The first experimental results are compared to the latest quasiparticle random phase approximation and shell-model calculations. Overall, the measured half-lives are consistent with the available theoretical descriptions and suggest a well-developed region of deformation below ^{48}Ca in the N=28 isotones. The erosion of the Z=14 subshell closure in Si is experimentally confirmed at N=28, and a reduction in the ^{38}Mg half-life is observed as compared with its isotopic neighbors, which does not seem to be predicted well based on the decay energy and deformation trends. This highlights the need for both additional data in this very exotic region, and for more advanced theoretical efforts.

Integrating Client Tracker Tool Into Fistula Management: Experience From the Fistula Care Plus Project in the Democratic Republic of Congo, 2017 to 2019

This study aimed to document the experience of integration and the contribution of the Client Tracker (CT) to female genital fistula (FGF) management and data quality in sites supported by the Fistula Care+ Project in the Democratic Republic of Congo (DRC), from 2017 to 2019. It was a parallel mixed methods study using routine quantitative data and qualitative data from in-depth interviews with the project staff. Quantitative findings indicated that CT forms were present in the medical records of 63% of patients; of these, 38% were completely filled out, and 29% were correctly filled out. Qualitative findings suggested that the level of use of CT in the management of FGF was associated with staff familiarity with the CT, staff understanding of concepts in the CT forms, and the CT-related additional workload. The CT has mainly contributed to improving data quality and reporting, quality of care, follow-up of fistula patients, and self-supervision of management activities. A possible simplification of the CT and/or harmonization of its content with existing routine forms, coupled with adequate continuous training of staff on record-keeping, would further contribute to maximizing CT effectiveness and sustainability.

Factors Associated With Persistent Urinary Incontinence Among Women Undergoing Female Genital Fistula Surgery in the Democratic Republic of Congo From 2017 to 2019

Background

Despite high closure rates, residual urinary incontinence remains a common problem after successful closure of a vesico-vaginal fistula. The objective of this study was to identify factors associated with residual urinary incontinence in women with successful fistula closure in sites supported by the Fistula Care Plus project in the Democratic Republic of Congo (DRC).

Material and Methods

This was a retrospective cohort study using routine data extracted from the medical records of women undergoing fistula surgery in three hospitals supported by the Fistula Care Plus project in DRC between 2017 and 2019. We analyzed factors associated with residual urinary incontinence among a subsample of women with closed fistula at discharge. We collected data on sociodemographic, clinical, gynecological-obstetrical characteristics, and case management. Univariate and multivariate analyses were performed to determine the factors associated with residual urinary incontinence.

Results

Overall, 31 of 718 women discharged with closed fistula after repair (4.3%; 95% CI: 3.1–6.1) had residual incontinence. The leading causes identified in these women with residual incontinence were urethral voiding (6 women), short urethra (6 women), severe fibrosis (3 women) and micro-bladder (2 women). The prevalence of residual incontinence was higher among women who received repair at the Heal Africa (6.6%) and St Joseph's (3.7%) sites compared with the Panzi site (1.7%). Factors associated with increased odds of persistent urinary incontinence were the Heal Africa repair site (aOR: 54.18; 95% CI: 5.33–550.89), any previous surgeries (aOR: 3.17; 95% CI: 1.10–9.14) and vaginal surgical route (aOR: 6.78; 95% CI: 1.02–45.21).

Conclusion

Prior surgery and repair sites were the main predictors of residual incontinence after fistula closure. Early detection and management of urinary incontinence and further research to understand site contribution to persistent incontinence are needed.

Factors associated with surgical repair success of female genital fistula in the Democratic Republic of Congo: Experiences of the Fistula Care Plus Project, 2017-2019

Objective

We sought to document outcomes and factors associated with surgical success in hospitals supported by the Fistula Care Plus Project in the Democratic Republic of Congo (DRC), 2017–2019.

Methods

This was a retrospective cohort study analysing routine repair data on women with Female Genital Fistula. Univariate and multivariate analyses were conducted to determine factors associated with successful fistula repair.

Results

A total of 895 women were included in this study, with a mean age of 34 years (±13 years). The majority were married or in union (57.4%) and living in rural areas (82.0%), while nearly half were farmers (45.9%). The average duration living with fistula was 8 years (±7). Vesicovaginal (70.5%) and complex (59.8%) fistulas were the most common fistula types. Caesarean section (34.7%), obstructed labour (27.0%) and prolonged labour (23.0%) were the main aetiologies, with the causal deliveries resulting in stillbirth in 88% of cases. The vaginal route (74.9%) was the primary route for surgical repair. The median duration of bladder catheterization after surgery was 14 days (interquartile range [IQR] 7–21). Multivariate analysis revealed that Waaldijk type I fistula (adjusted odds ratio [aOR]:2.71, 95% confidence interval [CI]:1.36–5.40), no previous surgery (aOR:2.63, 95% CI:1.43–3.19), repair at Panzi Hospital (aOR: 2.71, 95% CI:1.36–5.40), and bladder catheterization for less than 10 days (aOR:13.94, 95% CI: 4.91–39.55) or 11–14 days (aOR: 6.07, 95% CI: 2.21–15.31) were associated with better repair outcomes.

Conclusion

The Fistula Care Plus Project in the DRC recorded good fistula repair outcomes. However, further efforts are needed to promote adequate management of fistula cases.

Epidemiological determinants of COVID-19 in the police personnel: A cross-sectional study

Background:

Police are the frontline warriors who themselves are at risk of getting corona infection. This research with considerable sample size is the first of its kind to assess the epidemiological determinants of coronavirus disease 2019 (COVID-19) infection in the police personnel.

Material and Methods:

The Institutional Ethics Committee (IEC) approval and permission from police authorities were taken. The cross-sectional, descriptive study was planned on randomly selected 375 police personnel in the month of September-November 2020. Police detected with COVID-19 were included and those who were critically ill were excluded from the study. The written informed consent was taken and data was collected by pretested questionnaire. The data were entered and analyzed using SPSS version 21.

Results:

The mean age of study subjects was 34.25 ± 9.1 years with 84% being males. There was no significant difference in age and sex distribution of study subjects. The most commonly affected police personnel were police constables (222 out of 375) followed by police nayak (42 out of 375). Around 88.2% were symptomatic. Symptoms were fever (64%), weakness (54.4%), cough (38.4%), loss of smell sensation (35.2%), cold (32.3%), shortness of breath (13.9%), diarrhea (11.7%), and pain in the abdomen (6.4%). “Cold” symptom was significantly higher in the younger age group as compared with the older age group. Shortness of breath was significantly higher in males as compared with females (P value < 0.05). The perceived probable sources of infection were from a colleague (33.9%), family member (4.5%), residential society member (2.4%) while performing duty (23.2%), and while traveling in public transport (4%). Regarding preventive measures, almost 99%, 94%, and 87%, followed hand hygiene, mask-wearing, and physical distancing, respectively, prior to getting corona infection. AYUSH self-care practices such as daily drinking of turmeric milk, warm water, and breathing exercises were practiced by 66.9%, 85.9%, and 54.1% of the police personnel, respectively.

Conclusions:

There is male preponderance for corona infection among police personnel. Breathlessness is common in males as compared with female police. The cold symptom is mostly observed in young police personnel. Police personnel needs to judiciously follow physical distancing and practice general measures recommended by AYUSH.

Social Immersion for Women After Repair for Obstetric Fistula: An Experience in Guinea

Background: Reintegration of women after repair of their female genital fistula remains a challenge. The objective of this study was to document the medical pathway and the reintegration process of women through the “social immersion” program of EngenderHealth in Kissidougou and Labé (Guinea).

Methods: This was a qualitative descriptive study with 55 participants, including women seeking fistula care and stakeholders involved in the social immersion for repaired women in Kissidougou and Labé. The study included collecting demographic and clinical data of women, interviews with women before and after surgery, after social immersion, and 3 months post-discharge. Municipal officials, health providers, and members of host families were also interviewed. The study protocol was approved by the Guinea National Ethics Committee for Health Research.

Results: The study confirmed that obstetric fistula still occurs among women living in rural and underserved areas. Most women attended at least two to five antenatal care visits, but nine over 10 reported a tragic experience of child loss associated with the occurrence of fistula. Most of them received support from their husband/partner during referral after the obstructed labor and later in the search for treatment. Women and stakeholders reported a good experience of surgery and social immersion in both Kissidougou and Labé. About 3 months after discharge, women who were continent reported being happy with their new life compared to women discharged with repair failure and residual incontinence.

Conclusion: The study found the positive impacts of social immersion on the quality of life of women after fistula repair, particularly for those women who had a successful repair. The approach can be included in fistula care programs, either through direct provision or through referral to programs that can provide this service.

Toward a complete estimate of physical and psychosocial morbidity from prolonged obstructed labour: a modelling study based on clinician survey

Introduction

Prolonged obstructed labour often results from lack of access to timely obstetrical care and affects millions of women. Current burden of disease estimates do not include all the physical and psychosocial sequelae from prolonged obstructed labour. This study aimed to estimate the prevalence of the full spectrum of maternal and newborn comorbidities, and create a more comprehensive burden of disease model.

Methods

This is a cross-sectional survey of clinicians and epidemiological modelling of the burden of disease. A survey to estimate prevalence of prolonged obstructed labour comorbidities was developed for prevalence estimates of 27 comorbidities across seven categories associated with prolonged obstructed labour. The survey was electronically distributed to clinicians caring for women who have suffered from prolonged obstructed labour in Asia and Africa. Prevalence estimates of the sequelae were used to calculate years lost to disability for reproductive age women (15 to 49 years) in 54 low- and middle-income countries that report any prevalence of obstetric fistula.

Results

Prevalence estimates were obtained from 132 participants. The median prevalence of reported sequelae within each category were: fistula (6.67% to 23.98%), pelvic floor (6.53% to 8.60%), genitourinary (5.74% to 9.57%), musculoskeletal (6.04% to 11.28%), infectious/inflammatory (5.33% to 9.62%), psychological (7.25% to 24.10%), neonatal (13.63% to 66.41%) and social (38.54% to 59.88%). The expanded methodology calculated a burden of morbidity associated with prolonged obstructed labour among women of reproductive age (15 to 49 years old) in 2017 that is 38% more than the previous estimates.

Conclusions

This analysis provides estimates on the prevalence of physical and psychosocial consequences of prolonged obstructed labour. Our study suggests that the burden of disease resulting from prolonged obstructed labour is currently underestimated. Notably, women who suffer from prolonged obstructed labour have a high prevalence of psychosocial sequelae but these are often not included in burden of disease estimates. In addition to preventative and public health measures, high quality surgical and anaesthesia care are urgently needed to prevent prolonged obstructed labour and its sequelae.

Attitudes towards risk-reducing early salpingectomy with delayed oophorectomy for ovarian cancer prevention: a cohort study

OBJECTIVE

To determine risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) acceptability and effect of surgical prevention on menopausal sequelae/satisfaction/regret in women at increased ovarian cancer (OC) risk.

DESIGN

Multicentre, cohort, questionnaire study (IRSCTN:12310993).

SETTING

United Kingdom (UK).

POPULATION

UK women without OC ≥18 years, at increased OC risk, with/without previous RRSO, ascertained through specialist familial cancer/genetic clinics and BRCA support groups.

METHODS

Participants completed a 39-item questionnaire. Baseline characteristics were described using descriptive statistics. Logistic/linear regression models analysed the impact of variables on RRESDO acceptability and health outcomes.

MAIN OUTCOMES

RRESDO acceptability, menopausal sequelae, satisfaction/regret.

RESULTS

In all, 346 of 683 participants underwent risk-reducing salpingo-oophorectomy (RRSO). Of premenopausal women who had not undergone RRSO, 69.1% (181/262) found it acceptable to participate in a research study offering RRESDO. Premenopausal women concerned about sexual dysfunction were more likely to find RRESDO acceptable (odds ratio [OR] = 2.9, 95% CI 1.2-7.7, P = 0.025). Women experiencing sexual dysfunction after premenopausal RRSO were more likely to find RRESDO acceptable in retrospect (OR = 5.3, 95% CI 1.2-27.5, P < 0.031). In all, 88.8% (143/161) premenopausal and 95.2% (80/84) postmenopausal women who underwent RRSO, respectively, were satisfied with their decision, whereas 9.4% (15/160) premenopausal and 1.2% (1/81) postmenopausal women who underwent RRSO regretted their decision. HRT uptake in premenopausal individuals without breast cancer (BC) was 74.1% (80/108). HRT use did not significantly affect satisfaction/regret levels but did reduce symptoms of vaginal dryness (OR = 0.4, 95% CI 0.2-0.9, P = 0.025).

CONCLUSION

Data show high RRESDO acceptability, particularly in women concerned about sexual dysfunction. Although RRSO satisfaction remains high, regret rates are much higher for premenopausal women than for postmenopausal women. HRT use following premenopausal RRSO does not increase satisfaction but does reduce vaginal dryness.

TWEETABLE ABSTRACT

RRESDO has high acceptability among premenopausal women at increased ovarian cancer risk, particularly those concerned about sexual dysfunction.

Frequency and management of non-obstetric fistula in the Democratic Republic of Congo: experience from the Fistula Care Plus project

Objective

To describe the frequency, causes and post‐repair outcomes of NOF in hospitals supported by the Fistula Care Plus (FC+) project in the Democratic Republic of Congo.

Methods

Retrospective cohort study from 1 January 2015 to 31 December 2017 in three FC + supported fistula repair sites.

Results

Of 1984 women treated for female genital fistula between 2015 and 2017 in the three FC + supported hospitals, 384 (19%) were considered to be non‐obstetric fistula (NOF) cases. 49.3% were married/in a relationship at the time of treatment vs. 69% before the fistula, P < 0.001. Type III (n = 247; 64.3%) and type I (n = 121; 31.5%) fistulas according to Kees/Waaldijk classification were the most common. The main causes of NOF were medical procedure (n = 305; 79.4%); of these, caesarean section (n = 234; 76.7%) and hysterectomy (n = 54; 17.7%) were the most common. At hospital discharge, the fistula was closed and dry in 353 women (95.7%).

Conclusion

Non‐obstetric fistula, particularly due to iatrogenic causes, was relatively common in the DRC, calling for more prevention that includes improved quality of care in maternal health services.

Dynamics of gene expression of hormones involved in the growth of broiler chickens in response to the dietary protein and energy changes

The synergy between the genetic potential and the nutrient intake determines the growth performance of meat-type chicken and nutrigenomics approach helps us understand the response of candidate genes of growth in chicken to dietary manipulations. The current study aimed to assess the growth performance and expression of hepatic growth related genes in the naked neck broiler chicken in response to different dietary energy and protein levels with a hypothesis that high plane of nutrition enhances both of these positively. The results revealed that birds have shown significantly better growth performance under high protein (HP) and high energy (HE) dietary regime. The expression profiles of the genes studied revealed upregulation of IGF-1, IGF-2, and GH under dietary HP and HE regime relative to other protein and energy levels with greater upregulation at 3rd week than the 1st and 5th week of age of birds. The IGFR and GHR mRNA expression was significantly higher under HP and HE dietary regimen with an increasing and decreasing trend from 1st to 5th week of age, respectively. A consistent and significant downregulation of IGFBP-2 was observed under HP and HE regime throughout the feeding trial. The myostatin expression was higher at 3rd week of age followed by 1st week expression. The HP and HE as well as LP (Low protein) and HE diet resulted in significant upregulation of myostatin gene expression in liver. In support to the set hypothesis of this study the high protein and high energy diet resulted in better growth performance of broiler chickens with corresponding upregulation of IGF-1, IGF-2, IGFR, GH, GHR, and Myostatin gene expression and downregulation of IGFBP-2 in liver.

Use of interactive voice response technology to address barriers to fistula care in Nigeria and Uganda

BACKGROUND

The use of digital health technologies has expanded across low-resource settings, including in programs seeking to improve maternal health care seeking and service usage. However, there has been limited use of these technologies for screening and referral within maternal health, and many interventions have relied on SMS tools, which may have limited impact in settings with low female literacy. Digital health technologies have the potential to increase access to care for chronic maternal morbidities, such as obstetric fistula, and for women facing stigma, geographic isolation, and other sociocultural barriers to care seeking. This study documented the process of developing and implementing an innovative fistula screening and referral hotline using interactive voice response (IVR) technology, and described the service usage results and stakeholder perspectives associated with the hotline.

METHODS

The IVR hotline was introduced within the context of a broader Fistula Treatment Barriers Reduction Intervention implemented by the USAID-funded Fistula Care Plus project in Ebonyi and Katsina states in Nigeria and Kalungu district in Uganda. The intervention used three communication pathways to disseminate fistula information and conduct fistula screening: trained community agents, trained primary health care providers, and the IVR hotline paired with mass media messaging. All positively-screened women were eligible to receive vouchers for free transportation to an accredited fistula treatment center. Quantitative and qualitative data on intervention implementation and use across all three communication pathways were gathered during intervention implementation, at baseline, midline, and endline; as well as through ongoing program monitoring. This study presents findings specifically on service usage and stakeholder perspectives related to the IVR hotline.

RESULTS

Over a period of ten to twelve months of implementation, depending on the intervention area, a total of 566 women completed the IVR hotline screening process. Across the areas, 415 (73%) hotline callers screened positive for fistula symptoms. Hotline users and implementation partners reported positive impressions of the hotline, particularly the ability to preserve anonymity in seeking information and referral for fistula symptoms. Challenges to hotline use included limited mobile phone ownership and poor cellular network connectivity, affecting operability by women and community agents.

CONCLUSIONS

Implementation of the fistula screening hotline suggests that IVR-based interventions may be useful in expanding access to health services for stigmatized conditions, particularly in settings where literacy is limited. In the current context, such IVR tools require pairing with community and health system partners to complete referral and support clients. Further program experience and evaluation research is required to understand the options for integrating the IVR hotline or other interventions similarly using mobile technologies for screening and referral into broader digital health platforms that are sustained by national health systems or commercial business models.

Age estimation and comparison by dental and skeletal maturity in the age range of 9-18 years in the Mumbai region

Background:

Age estimation is crucial in the identification of juveniles in conflicts with law, survivor of sexual assault, sportsperson, and civil cases.

Aims:

To estimate and compare the age (9–18 years) by dental and skeletal maturity in the Mumbai region.

Settings and Design:

This was a cross-sectional study.

Materials and Methods:

A total of 70 cases from 9 to 18 years of age were studied in 1 year in the urban population of the Mumbai region. Among 70 cases, 45 were males and 25 were females. Orthopantomogram and elbow joint radiographs were taken to assess the dental age through modified Demirjian's method and the radiological age through Sangma et al. staging method, respectively.

Statistical Analysis:

Data were analyzed using SPSS Statistics Version 26; descriptive statistics and regression statistics were used in the study.

Results:

Dental age by Demirjian's method in males with standard deviation was 15.25 (2.17), with a mean difference of 1.08 and significant P = 0.03. However, in females, dental age by Demirjian's method with standard deviation was 14.30 (1.94) with a mean difference of 0.74 and insignificant P = 0.07. Interclass correlation coefficient of dental age with chronological age, in males and females, showed 0.85 and 0.87 correlation, respectively. Correlation between the skeletal maturity and the dental age was reflected by the association of Demirjian stage 9 in the second molar with radiological stage 5 in males and stage 4 in females.

Conclusions:

It was concluded that Demirjian's method shows a significant correlation and P value for the age estimation in males of the Mumbai region.

Removing barriers to fistula care: Applying appreciative inquiry to improve access to screening and treatment in Nigeria and Uganda

A research-to-action collaboration sought to understand and respond to barriers to female genital fistula treatment in Nigeria and Uganda. This was guided by appreciative inquiry, a participatory approach for transformative programing with four phases: (1) inquire, (2) imagine, (3) innovate, and (4) implement. Through this process, partners designed and refined a treatment barrier reduction intervention using multiple communication channels to disseminate a consistent fistula screening algorithm and provide transportation vouchers to those screening positive. Partnership between an implementation organization, a research institution, and local community partners enabled data-driven design and patient-centered implementation to address specific barriers experienced by women.

Measuring the quality of maternal and care processes at the time of delivery in sub-Saharan Africa: development and validation of a short index

BACKGROUND

There is a growing recognition that quality of care must improve in facility-based deliveries to achieve further global reductions in maternal and newborn mortality and morbidity. Better measurement of care quality is needed, but the unpredictable length of labor and delivery hinders the feasibility of observation, the gold standard in quality assessment. This study evaluated whether a measure restricted to actions at or immediately following delivery could provide a valid assessment of the quality of the process of intrapartum and immediate postpartum care (QoPIIPC), including essential newborn care.

METHODS

The study used a comprehensive QoPIIPC index developed through a modified Delphi process and validated by delivery observation data as a starting point. A subset of items from this index assessed at or immediately following delivery was identified to create a "delivery-only" index. This delivery-only index was evaluated across content and criterion validation domains using delivery observation data from Kenya, Madagascar, and Tanzania, including Zanzibar.

RESULTS

The delivery-only index included 13 items and performed well on most validation criteria, including correct classification of poorly and well-performed deliveries. Relative to the comprehensive QoPIIPC index, the delivery-only index had reduced content validity, representing fewer dimensions of QoPIIPC. The delivery-only index was also less strongly associated with overall quality performance in observed deliveries than the comprehensive QoPIIPC index.

CONCLUSIONS

Where supervision resources are limited, a measure of the quality of labor and delivery care targeting the time of delivery may mitigate challenges in observation-based assessment. The delivery-only index may enable increased use of observation-based quality assessment within maternal and newborn care programs in low-resource settings.

Increasing opportunities for obstetric fistula case detection and treatment by using a multifaceted approach – the case of Kalungu district –Uganda

Aims: To identify fistula treatment barriers and increase treatment access in Kalungu, Uganda. Methods: Responding to treatment barriers identified through formative research, the USAID-funded Fistula Care Plus (FC+) Project is implementing a comprehensive intervention to address fistula treatment barriers. The intervention utilizes multiple communication channels (free fistula screening hotline, health workers, and community agents), a consistent screening algorithm for fistula screening, and a transportation voucher to enable positively-screened women to travel to and from the fistula treatment facility. Results: FC+ trained and oriented 42 health workers and 275 community agents across Kalungu District to raise awareness and identify suspected fistula cases; trainees were provided with fistula hotline advertisements and data collection and referral tools. Thirty drivers were also trained and oriented on the transportation voucher system. From July 2017 to July 2018, the hotline received 120 callers from Kalungu; 88 screened positively. 37 women from Kalungu used the voucher system for free transport. In all, 51 women from Kalungu were referred to the fistula facility through the intervention’s referral channels. Facility records indicate that the number of women seeking fistula treatment from Kalungu District increased during the intervention period compared to the prior year.  Conclusions: Applying client-centered communication, screening, referral, and transportation mechanisms enabled FC+ to address treatment barriers in Uganda. This approach may be replicated in other settings where the backlog of unidentified/untreated fistula cases persists. 

Prevalence findings from a community-based female genital fistula screening program in Bangladesh

Aims: This paper presents the findings of a community-based program to conduct house-to-house fistula screening in a district in Bangladesh. Methods: The USAID-supported Fistula Care Plus (FC+) project in Bangladesh purposively selected a district (Faridpur) for fistula programming. Fistula screening was integrated into the house-to-house activities of a NGO, active in community health. From July to December 2016, all households were reached by field staff for identification of any possible fistula cases using a four questions checklist. Suspected fistula cases were referred to community based fistula diagnosis events at regular intervals. Results: Among 0.5 million women, using the 4Q checklist, field workers identified 604 women as suspected fistula or perineal tear with fecal incontinence cases. Of these, 149 cases were clinically confirmed. The prevalence of fistula was 0.3/1000 ever-married women in the district. Conclusion: The fistula prevalence documented in Faridpur through this screening partnership is much lower than that reported in a 2003 UNFPA/EngenderHealth survey in Bangladesh (1.69/1000 ever-married women). This difference in district-level prevalence also suggests the value of local data in the development and implementation of fistula programs.

Improving fistula data reporting through collaboration, learning and adaptation of fistula tools and indicators in Uganda

Aims: To report on efforts to improve fistula service statistics reporting in Uganda. Methods: A process review assessed the adoption of fistula tools and indicators nationally and in four districts. In addition to HMIS/DHIS2 data review, nine key informant interviews were conducted, at two district hospitals, two specialized hospitals and with the national senior biostatistician.  Results: Two of four were included in the revised HMIS/DHIS2 and three of four hospitals were using standardized fistula tools. From July 2017- June 2018, 595 repairs and 310 fistula cases were reported into DHIS2 and evidence of data use at the district level. However, there was low reporting rate for fistula data, due to low awareness of the new HMIS indicators. Conclusions: Integration of the fistula and obstetrics/gynecology registers, refinement of the fistula register, and development of discharge and follow-up registers were considered by partners thus leading to availability of routine data to support planning.

Bladder care and management of prolonged/obstructed labor for obstetric fistula: A global survey of intrapartum and postpartum clinical practices

Aims: To understand intrapartum and postpartum clinical practices among skilled birth attendants in low- and middle-income countries (LMICs). Methods: This survey, based on clinical guidelines and curricula, was administered online in French and English, from May-Oct, 2017. Summaries of respondent characteristics, knowledge, and practices were generated. Chi-square tests investigated significant disparities by region, facility type, and geography. Data were analyzed using Stata v12. Results: Respondents (222) were primarily midwives (61%) and OB-GYNs (15%); 56% in Africa and 39% in South-East Asia. A majority practice many recommended practices related to intrapartum/postpartum bladder care and P/OL management. Most reported using partograph to monitor labor (99%), monitoring voiding frequency for postpartum patients (95%), and utilizing UC after P/OL (94%). Findings revealed a lack ofprotocols on bladder care and P/OL management, variation in practice by region, and less access to in-service training and supplies in Africa and public facilities. Conclusions: Findings reveal a strong foundation for standardization in intrapartum/postpartum bladder care and P/OL management. UC after P/OL appears feasible and acceptable, meaning its systematic practice can be scaled up to prevent obstetric fistula and other sequelae of P/OL in low-resource settings. However, SBAs need protocols, in-service training, and consistent supplies, especially in Africa and public facilities. 

Stakeholder perceptions on women’s health after obstetric fistula repair: results from a qualitative study in Guinea

Aims: To explore stakeholder perceptions on the health of women after female genital fistula repair in Guinea. Methods: In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with stakeholders involved in fistula prevention and management in Conakry, Labé and Kissidougou regions, where EngenderHealth supports fistula repair hospitals. Results: 41 IDIs and seven FGDs (with 42 participants) were conducted with various stakeholders. Women who underwent fistula surgery and were discharged with a closed fistula were described as carrying several health risks. These women are seen as people more exposed to maternal and neonatal complications during pregnancy and childbirth than women who do not experience fistula. The core category that emerged to describe women treated for fistula was “vulnerability”. Women treated for fistula were described as “vulnerable” as compared to “normal” women who have never experienced fistula. The concept of “vulnerability” included physical, social (including mental) and economic dimensions. Physical vulnerability included the sequalae of the condition and the risk of maternal and neonatal complications such as fistula recurrence, abortion or stillbirth. Social vulnerability that includes mental vulnerability was described through the continuous stigmatization of women, the social pressure to fulfil marital duties i.e. resuming sexual intercourse or becoming pregnant again. Economic vulnerability included poverty related characteristics, lack of autonomy that maintain financial barriers to access health care. Conclusions: Fistula care should go beyond surgery by developing and implementing interventions that address women’s physical, psychosocial and economic vulnerabilities. 

Frequency and management of non-obstetric fistula in the Democratic Republic of Congo: experience from Fistula Care Plus project

Aims: To describe the frequency and management of non-obstetric fistula (NOF) in Democratic Republic of Congo (DRC). Methods: A retrospective cohort study reviewed patients’ medical records in three fistula repair sites supported by the USAID-funded Fistula Care Plus (FC+) Project, covering 1 January 2015 to 31 December 2017. Study variables included demographic characteristics, fistula etiology as reported by surgeon, fistula type (Waaldijk classification), and treatment outcomes. Results: Of 1984 women treated for female genital fistula between 2015 and 2017 in the three sites, 384 (19%) were considered to be NOF cases. 91% of these women resided in rural areas. 49.3% were married/in relationship at time of treatment compared to 69% before the fistula (p<0.001). Most (n=316; 82.3%) had no previous repair attempts and 96.2% had an intact urethra. Type III (n=247; 64.3%) and type I (n=121; 31.5%) fistulas (Waaldijk classification) were most common. The main causes of NOF were medical procedure (n=305; 79.4%), congenital origin (41; 10.7%) or sexual assault (28; 7.3%). Caesarean section (n=234; 76.7%) and hysterectomy (n=54; 17.7%) were the most common causative procedures. 369 women with NOF received surgical repair (96%), mainly through routine services (n=317; 85.9%). At discharge, 353 women were closed and dry (95.7%) and 11 were closed with residual incontinence (3.0%). Conclusions: NOF, particularly due to iatrogenic causes, was relatively common in DRC. Surgical repair at FC+-supported sites led to good clinical outcomes. However, to achieve a fistula-free generation in DRC, prevention of iatrogenic fistula is needed, requiring improved quality of maternal care.

The association between female genital fistula symptoms and gender-based violence

Aims: This study examined the association between self-reported female genital fistula symptoms and experience of gender-based violence (GBV) among women interviewed in Demographic and Health Surveys (DHS) surveys. Methods: This study pooled data from 13 recent DHS surveys with both fistula and domestic violence modules. Multivariable logistic regressions controlled for maternal and demographic factors. Results: In this sample of 95,625 women, the prevalence of self-reported fistula symptoms ranges from 0.3% to 1.8% across countries. Among women reporting fistula symptoms,56% report past experience physical violence, more than among women with no symptoms (38%). Twice as many women with fistula symptoms report either lifetime (27%) or recent (16%) experience sexual violence than women not reporting symptoms (13% and 8%, respectively). Women whose first experience of sexual violence was from a non-partner have almost four times the odds of reporting fistula symptoms compared with those who never experienced sexual violence. Conclusions: These findings must be interpreted with caution given the inability to identify temporal and causal relationships through DHS data. However, the increased risk of violence among women with fistula symptoms suggests that fistula treatment programs should incorporate GBV screening, referral, and services into their pre-discharge care. 

Risk factors and management of obstetric fistula associated with bladder calculus at Saint Joseph Hospital, Kinshasa - DR Congo

Aims: Obstetric fistula can be complicated by bladder calculus. The mechanism of lithogenesis is caused by some predisposing factors. The article aims to describe risk factors predisposing to bladder calculus formation and repair outcome. Methods: This was a comprehensive retrospective review from medical records of fistula obstetric repairs associated with bladder calculus at Saint Joseph Hospital in Kinshasa, DR Congo, from January 2007 to December 2017. Results: Among 1416 women who had had obstetric fistula, 30 (2.12%) had bladder calculus. The average age of women was 38 years old and ranged between 22 and 82 years old. The average duration of fistula was 8 years and ranged from 5 months to 31 years. All fistulas were iatrogenic and 86.67% (n = 26) occurred after caesarean section. Size of calculus varied between 1 cm and 15 cm. Risk factors identified were: urinary tract infection 80% (n = 24), foreign bodies 13.33% (n = 4), malnutrition and dehydration in 33.33%. In majority of cases (90%), the removal of the calculus and repair of fistula were performed at the same time by transvesical way. 70.37% of the patients had successful repairs. Conclusions: Iatrogenic fistula after caesarean section, urinary tract infection and foreign bodies are related to the formation of bladder calculi. Fistula repair and extraction of bladder calculus performed at the same time gives good results. Access to Obstetric Emergency Care, qualified personnel and available infrastructure and equipment are important for the prevention of the occurrence of bladder calculus.

Improving quality of life for women with incurable fistula in Uganda

Aims: To understand whether reintegration services can improve quality of life (QoL) for women with incurable fistula (WIF) in Uganda. Methods: Standardized tools measuring health/psychosocial status and QoL were administered before and after intervention to assess impacts: Self-Reporting Questionnaire (SRQ-20), WHO QoL-BREF, and modified King’s Health Questionnaire (KHQ). Results: Before intervention, all participants had SRQ-20 scores >8, indicating psychological distress. After intervention, there was significant reduction (to 37%) in the proportion of participants with scores indicating distress (p=0.0003). As measured by WHO QoL-BREF, self-reported QoL and health satisfaction improved significantly after intervention (p=0.0003 and p<0.0001, respectively). Mean scores on specific domains (physical health, psychological, social relationships, and environment) also significantly increased (p<0.001). Physical health showed the largest increase and psychological the smallest. As measured by modified KHQ, participants’ perception of their health improved significantly after intervention (p<0.0001) as did their perception of how much fistula affects their life (p<0.0001). The KHQ also assesses seven functional domains. Mean scores significantly increased in each after intervention (p<0.01). Conclusions: TERREWODE’s intervention was associated with significant positive changes in participants’ perception of and satisfaction with health and wellbeing. While many effects of incurable fistula cannot be eliminated, individualized support may mitigate QoL impacts. Such interventions may be adapted in other settings; standardized measures enable comparison of approaches.

Fistula Prevention Awareness Activities of Community Volunteerism Niger: A way to improve Access to Information and Care

Aims: To assess the effects of community volunteer (CV) activities on use of maternal and reproductive health services in Niger. The USAID-funded Fistula Care Plus Project (FC+) strengthens fistula prevention, detection, treatment and reintegration. In Niger, FC+ engaged CVs to increase facility delivery, promote pre- and post-natal care and to improve access to family planning (FP) in Tahoua and Maradi health districts. Methods: FC+identified CVs and trained them to explain obstetric fistula, identify pregnancy danger signs, promote safe motherhood, and discuss male involvement. CVs provide community monitoring through household visits and awareness activities. CVs collect data on pregnant women, follow up on antenatal (ANC)/post-natal (PNC) visits, and provide counseling on all FP methods. We used routine facility data to summarize maternal health service usage in Tahoua and Maradi. Results: 774 CVs were trained between March 2015 and April 2016; they held 9,999 community outreach events, reaching 98,654 individuals. The number of women completing their first ANC visit increased from 13,041 in 2015 to 14,978 in 2016 (15%). 12% and 25% increases were documented, respectively, for fourth ANC visit and PNC visit completion in 2016 relative to 2015.A 48% increase in new acceptors of long-acting FP methods also occurred. Data require standardization against population changes and triangulation with qualitative data from community stakeholders. Conclusions: Engaging community volunteers may improve access to information and services, resulting in increased use of FP and maternal health care. A follow-up system to ensure continued engagement among stakeholders could promote sustainability.

Trajectories of women's physical and psychosocial health following obstetric fistula repair in Uganda: a longitudinal study

OBJECTIVES

To explore trajectories of physical and psychosocial health, and their interrelationship, among women completing fistula repair in Uganda for 1 year post-surgery.

METHODS

We recruited a 60-woman longitudinal cohort at surgical hospitalisation from Mulago Hospital in Kampala Uganda (Dec 2014-June 2015) and followed them for 1 year. We collected survey data on physical and psychosocial health at surgery and at 3, 6, 9 and 12 months via mobile phone. Fistula characteristics were abstracted from medical records. All participants provided written informed consent. We present univariate analysis and linear regression results.

RESULTS

Across post-surgical follow-up, most women reported improvements in physical and psychosocial health, largely within the first 6 months. By 12 months, urinary incontinence had declined from 98% to 33% and general weakness from 33% to 17%, while excellent to good general health rose from 0% to 60%. Reintegration, self-esteem and quality of life all increased through 6 months and remained stable thereafter. Reported stigma reduced, yet some negative self-perception remained at 12 months (mean 17.8). Psychosocial health was significantly impacted by the report of physical symptoms; at 12 months, physical symptoms were associated with a 21.9 lower mean reintegration score (95% CI -30.1, -12.4).

CONCLUSIONS

Our longitudinal cohort experienced dramatic improvements in physical and psychosocial health after surgery. Continuing fistula-related symptoms and the substantial differences in psychosocial health by physical symptoms support additional intervention to support women's recovery or more targeted psychosocial support and reintegration services to ensure that those coping with physical or psychosocial challenges are appropriately supported.

Caesarean section provision and readiness in Tanzania: analysis of cross-sectional surveys of women and health facilities over time

OBJECTIVES

To describe trends in caesarean sections and facilities performing caesareans over time in Tanzania and examine the readiness of such facilities in terms of infrastructure, equipment and staffing.

DESIGN

Nationally representative, repeated cross-sectional surveys of women and health facilities.

SETTING

Tanzania.

PARTICIPANTS

Women of reproductive age and health facility staff.

MAIN OUTCOME MEASURES

Population-based caesarean rate, absolute annual number of caesareans, percentage of facilities reporting to perform caesareans and three readiness indicators for safe caesarean care: availability of consistent electricity, 24 hour schedule for caesarean and anaesthesia providers, and availability of all general anaesthesia equipment.

RESULTS

The caesarean rate in Tanzania increased threefold from 2% in 1996 to 6% in 2015-16, while the total number of births increased by 60%. As a result, the absolute number of caesareans increased almost fivefold to 120 000 caesareans per year. The main mechanism sustaining the increase in caesareans was the doubling of median caesarean volume among public hospitals, from 17 caesareans per month in 2006 to 35 in 2014-15. The number of facilities performing caesareans increased only modestly over the same period. Less than half (43%) of caesareans in Tanzania in 2014-15 were performed in facilities meeting the three readiness indicators. Consistent electricity was widely available, and 24 hour schedules for caesarean and (less systematically) anaesthesia providers were observed in most facilities; however, the availability of all general anaesthesia equipment was the least commonly reported indicator, present in only 44% of all facilities (34% of public hospitals).

CONCLUSIONS

Given the rising trend in numbers of caesareans, urgent improvements in the availability of general anaesthesia equipment and trained anaesthesia staff should be made to ensure the safety of caesareans. Initial efforts should focus on improving anaesthesia provision in public and faith-based organisation hospitals, which together perform more than 90% of all caesareans in Tanzania.

Vibrational spectroscopic study of cationic phosphorus dendrimers with aminoethylpiperidine terminal groups

Two generations of phosphoric dendrimers with piperidine functional groups were synthesized for use in biology and medicine. Neutral samples are soluble in organic solvents but after protonation these dendrimers become water soluble and can be used for biological experiments. The FTIR and FT Raman spectra of two generations of dendrimers G_i constructed from the cyclotriphosphazene core, repeating units OC₆H₄CHNN(CH₃)P(S)< and aminoethylpiperidine end groups NH(CH₂)₂C₅NH₁₁ were recorded. The study of the IR spectra shows that the NH groups form hydrogen bonds. The calculation of the molecular structure and vibrational spectra of the first generation dendrimer was performed by the method of DFT. This molecule has flat, repeating units and a plane of symmetry passing through the core. The calculation of the distribution of potential energy made it possible to classify the bands in the experimental spectra of dendrimers. Amine groups are manifested in the form of a band of NH stretching vibrations at 3389 cm^-1 in the IR spectrum of G₁. NH⁺ stretching bands located at 2646 and 2540 cm^-1 in the IR spectrum of G₂. The stretching vibrations of NH⁺ groups are noticeably shifted to low frequencies due to the formation of a hydrogen bond with the chlorine atom. The line at 1575 cm^-1 in the Raman spectrum of G₁ is characteristic for repeating units.

Demand and capacity to integrate pelvic organ prolapse and genital fistula services in low-resource settings

Introduction and hypothesis

There is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers.

Methods

Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services.

Results

Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts.

Conclusions

Integration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.

Electronic supplementary material

The online version of this article (10.1007/s00192-018-3561-2) contains supplementary material, which is available to authorized users

The association between female genital fistula symptoms and gender-based violence: A multicountry secondary analysis of household survey data

OBJECTIVE

The Demographic and Health Surveys (DHS), which include standardised questions on female genital fistula symptoms, provide a unique opportunity to evaluate the epidemiology of fistula. This study sought to examine associations between self-reported fistula symptoms and experience of gender-based violence (GBV) among women interviewed in DHS surveys.

METHODS

This study used data from thirteen DHS surveys with standardised fistula and domestic violence modules. Data from the most recent survey in each country were pooled, weighting each survey equally. Multivariable logistic regressions controlled for maternal and demographic factors.

RESULTS

Prevalence of fistula symptoms in this sample of 95 625 women ranges from 0.3% to 1.8% by country. The majority of women reporting fistula symptoms (56%) have ever experienced physical violence, and more than one-quarter have ever experienced sexual violence (27%), compared with 38% and 13% among women with no symptoms, respectively. Similarly, 16% of women with fistula symptoms report recently experiencing sexual violence-twice the percentage among women not reporting symptoms (8%). Women whose first experience of sexual violence was from a non-partner have almost four times the odds of reporting fistula symptoms compared with women who never experienced sexual violence. These associations indicate a need to investigate temporal and causal relationships between violence and fistula.

CONCLUSIONS

The increased risk of physical and sexual violence among women with fistula symptoms suggests that fistula programmes should incorporate GBV into provider training and services.

Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study

Background

Female genital fistula is a devastating maternal complication of delivery in developing countries. We sought to analyse the incidence and proportion of fistula recurrence, residual urinary incontinence, and pregnancy after successful fistula closure in Guinea, and describe the delivery-associated maternal and child health outcomes.

Methods

We did a longitudinal study in women discharged with a closed fistula from three repair hospitals supported by EngenderHealth in Guinea. We recruited women retrospectively (via medical record review) and prospectively at hospital discharge. We used Kaplan-Meier methods to analyse the cumulative incidence, incidence proportion, and incidence ratio of fistula recurrence, associated outcomes, and pregnancy after successful fistula closure. The primary outcome was recurrence of fistula following discharge from repair hospital in all eligible women who consented to inclusion and could provide follow-up data.

Findings

481 women eligible for analysis were identified retrospectively (from Jan 1, 2012, to Dec 31, 2014; 348 women) or prospectively (Jan 1 to June 20, 2015; 133 women), and followed up until June 30, 2016. Median follow-up was 28·0 months (IQR 14·6–36·6). 73 recurrent fistulas occurred, corresponding to a cumulative incidence of 71 per 1000 person-years (95% CI 56·5–89·3) and an incidence proportion of 18·4% (14·8–22·8). In 447 women who were continent at hospital discharge, we recorded 24 cases of post-repair residual urinary incontinence, equivalent to a cumulative incidence of 23·1 per 1000 person-years (14·0–36·2), and corresponding to 10·3% (5·2–19·6). In 305 women at risk of pregnancy, the cumulative incidence of pregnancy was 106·0 per 1000 person-years, corresponding to 28·4% (22·8–35·0) of these women. Of 50 women who had delivered by the time of follow-up, only nine delivered by elective caesarean section. There were 12 stillbirths, seven delivery-related fistula recurrences, and one maternal death.

Interpretation

Recurrence of female genital fistula and adverse pregnancy-related maternal and child health outcomes were frequent in women after fistula repair in Guinea. Interventions are needed to safeguard the health of women after fistula repair.

Funding

Belgian Development Cooperation (DGD), Institute of Tropical Medicine of Antwerp (ITM), and Maferinyah Training and Research Center in Rural Health (Guinea).

Cardioprotective potential of curcumin against norepinephrine-induced cell death: a microscopic study

Cardiomyopathy and associated heart failure continues to be one of the most severe complications that threaten a large population. Curcumin, one of the three curcuminoids of the spice turmeric, is very well known for a multitude of health benefits and functions. Norepinephrine (NE), a catecholamine and also a stress hormone may cause the cardiomyocytes to develop increased sensitivity to death with its increasing concentrations. In this study, we investigated the cardioprotective effect of curcumin in NE-induced cardiac apoptosis using several fluorescent and nonfluorescent microscopic techniques like DAPI, PI, Giemsa, PicroSirius and TUNEL. The aim of the study was to assess the effect of curcumin in preventing the occurrence of features underlying apoptosis such as nuclear disruption, chromatin condensation, DNA fragmentation and alterations in mitochondrial membrane permeability. Our results show that curcumin protects the cardiomyocytes against apoptosis significantly and also helps them to revert to their normal physiological state. Hence, we propose that curcumin has the potential to act as a therapeutic agent for the attenuation of NE-induced cardiac cell death and modulation of apoptosis in H9c2 cardiomyocytes.

Novel Peptides Enhance the Production of Nitric Oxide and Inducible Nitric Oxide Synthase (iNOS) Gene Expression in Murine Macrophage

Bioactive novel polypeptide of Anurans skin has a wide range of antimicrobial properties against the infection and tumour cell. Macrophages are known to produce the Nitric oxide (NO) by a variety of cells upon activation. NO produced by the activated macrophages an important mediator for antimicrobial and tumoricidal activity. In-vitro macrophage exposed with medium alone, containing LPS, containing polypepeptides and LPS + polypeptides for 24 h showed enhanced production of NO with respect to control and LPS treated and significant increase in NO production in LPS + polypeptide. Western blot and PCR analysis also showed that increased production of protein expression and mRNA expression of inducible nitric oxide synthase (iNOS). These findings suggest that novel polypeptides are potent activating agent for enhanced production of NO through activation of iNOS gene.

Implementation of the Standards-Based Management and Recognition approach to quality improvement in maternal, newborn, and child health programs in low-resource countries

The Standards-Based Management and Recognition (SBM-R; Jhpiego, Baltimore, MD, USA) approach to quality improvement was developed by Jhpiego to respond to common challenges faced by health systems in low-resource settings, including poor pre-service education, lack of resources for conventional supervisory models, and weak health information systems. Since its introduction in Brazil in 1997, SBM-R has been implemented in approximately 30 countries and continues expanding to new places and service delivery areas. The present article: (1) describes key steps in the SBM-R methodology focusing on provider performance assessment using evidence-based standards; and (2) presents examples of improvements in provider performance in maternal, newborn, and child health care following SBM-R implementation derived from routine program data, quasi-experimental evaluations, and in-depth case studies. SBM-R incorporates evidence-based methods that are known to have positive effects on healthcare quality, including audit and feedback, educational outreach visits, and checklist usage; however, further rigorous research is needed to document the population-level impacts of the SBM-R approach.

Berry phase mechanism of the anomalous Hall effect in a disordered two-dimensional magnetic semiconductor structure

The anomalous Hall effect (AHE) arises from the interplay of spin-orbit interactions and ferromagnetic order and is a potentially useful probe of electron spin polarization, especially in nanoscale systems where direct measurement is not feasible. While AHE is rather well-understood in metallic ferromagnets, much less is known about the relevance of different physical mechanisms governing AHE in insulators. As ferromagnetic insulators, but not metals, lend themselves to gate-control of electron spin polarization, understanding AHE in the insulating state is valuable from the point of view of spintronic applications. Among the mechanisms proposed in the literature for AHE in insulators, the one related to a geometric (Berry) phase effect has been elusive in past studies. The recent discovery of quantized AHE in magnetically doped topological insulators - essentially a Berry phase effect - provides strong additional motivation to undertake more careful search for geometric phase effects in AHE in the magnetic semiconductors. Here we report our experiments on the temperature and magnetic field dependences of AHE in insulating, strongly-disordered two-dimensional Mn delta-doped semiconductor heterostructures in the hopping regime. In particular, it is shown that at sufficiently low temperatures, the mechanism of AHE related to the Berry phase is favoured.

A literature review of quantitative indicators to measure the quality of labor and delivery care

BACKGROUND

Strengthening measurement of the quality of labor and delivery (L&D) care in low-resource countries requires an understanding of existing approaches.

OBJECTIVES

To identify quantitative indicators of L&D care quality and assess gaps in indicators.

SEARCH STRATEGY

PubMed, CINAHL Plus, and Embase databases were searched for research published in English between January 1, 1990, and October 31, 2013, using structured terms.

SELECTION CRITERIA

Studies describing indicators for L&D care quality assessment were included. Those whose abstracts contained inclusion criteria underwent full-text review.

DATA COLLECTION AND ANALYSIS

Study characteristics, including indicator selection and data sources, were extracted via a standard spreadsheet.

MAIN RESULTS

The structured search identified 1224 studies. After abstract and full-text review, 477 were included in the analysis. Most studies selected indicators by using literature review, clinical guidelines, or expert panels. Few indicators were empirically validated; most studies relied on medical record review to measure indicators.

CONCLUSIONS

Many quantitative indicators have been used to measure L&D care quality, but few have been validated beyond expert opinion. There has been limited use of clinical observation in quality assessment of care processes. The findings suggest the need for validated, efficient consensus indicators of the quality of L&D care processes, particularly in low-resource countries.

Facility-based active management of the third stage of labour: assessment of quality in six countries in sub-Saharan Africa

OBJECTIVE

To assess the quality of facility-based active management of the third stage of labour in Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and the United Republic of Tanzania.

METHODS

Between 2009 and 2012, using a cross-sectional design, 2317 women in 390 health facilities were directly observed during the third stage of labour. Observers recorded the use of uterotonic medicines, controlled cord traction and uterine massage. Facility infrastructure and supplies needed for active management were audited and relevant guidelines reviewed.

FINDINGS

Most (94%; 2173) of the women observed were given oxytocin (2043) or another uterotonic (130). The frequencies of controlled cord traction and uterine massage and the timing of uterotonic administration showed considerable between-country variation. Of the women given a uterotonic, 1640 (76%) received it within three minutes of the birth. Uterotonics and related supplies were generally available onsite. Although all of the study countries had national policies and/or guidelines that supported the active management of the third stage of labour, the presence of guidelines in facilities varied across countries and only 377 (36%) of 1037 investigated providers had received relevant training in the previous three years.

CONCLUSION

In the study countries, quality and coverage of the active management of the third stage of labour were high. However, to improve active management, there needs to be more research on optimizing the timing of uterotonic administration. Training on the use of new clinical guidelines and implementation research on the best methods to update such training are also needed.