High Incidence of Neonatal Danger Signs and Its Implications for Postnatal Care in Ghana: A Cross-Sectional Study

Background

Reducing neonatal mortality is a major public health priority in sub-Saharan Africa. Numerous studies have examined the determinants of neonatal mortality, but few have explored neonatal danger signs which potentially cause morbidity. This study assessed danger signs observed in neonates at birth, determined the correlations of multiple danger signs and complications between neonates and their mothers, and identified factors associated with neonatal danger signs.

Methods

A cross-sectional study was conducted in three sites across Ghana between July and September in 2013. Using two-stage random sampling, we recruited 1,500 pairs of neonates and their mothers who had given birth within the preceding two years. We collected data on their socio-demographic characteristics, utilization of maternal and neonatal health services, and experiences with neonatal danger signs and maternal complications. We calculated the correlations of multiple danger signs and complications between neonates and their mothers, and performed multiple logistic regression analysis to identify factors associated with neonatal danger signs.

Results

More than 25% of the neonates were born with danger signs. At-birth danger signs in neonates were correlated with maternal delivery complications (r = 0.20, p < 0.001), and neonatal complications within the first six weeks of life (r = 0.19, p < 0.001). However, only 29.1% of neonates with danger signs received postnatal care in the first two days, and 52.4% at two weeks of life. In addition to maternal complications during delivery, maternal age less than 20 years, maternal education level lower than secondary school, and fewer than four antenatal care visits significantly predicted neonatal danger signs.

Conclusions

Over a quarter of neonates are born with danger signs. Maternal factors can be used to predict neonatal health condition at birth. Management of maternal health and close medical attention to high-risk neonates are crucial to reduce neonatal morbidity in Ghana.     

Assessing Community Based Improved Maternal Neonatal Child Survival (IMNCS) Program in Rural Bangladesh

Objectives

A community based approach before, during and after child birth has been proven effective address the burden of maternal, neonatal and child morbidity and mortality in the low and middle income countries. We aimed to examine the overall change in maternal and newborn health outcomes due the “Improved Maternal Newborn and Child Survival” (IMNCS) project, which was implemented by BRAC in rural communities of Bangladesh.

Methods

The intervention was implemented in four districts for duration of 5-years, while two districts served as comparison areas. The intervention was delivered by community health workers who were trained on essential maternal, neonatal and child health care services. A baseline survey was conducted in 2008 among 7, 200 women with pregnancy outcome in last year or having a currently alive child of 12–59 months. A follow-up survey was administered in 2012–13 among 4, 800 women of similar characteristics in the same villages.

Findings

We observed significant improvements in maternal and essential newborn care in intervention areas over time, especially in health care seeking behaviors. The proportion of births taking place at home declined in the intervention districts from 84.3% at baseline to 71.2% at end line (P<0.001). Proportion of deliveries with skilled attendant was higher in intervention districts (28%) compared to comparison districts (27.4%). The number of deliveries was almost doubled at public sector facility comparing with baseline (P<0.001). Significant improvement was also observed in healthy cord care practice, delayed bathing of the new-born and reduction of infant mortality in intervention districts compared to that of comparison districts.

Conclusions

This study demonstrates that community-based efforts offer encouraging evidence and value for combining maternal, neonatal and child health care package. This approach might be considered at larger scale in similar settings with limited resources.     

Optimal Timing of Delivery among Low-Risk Women with Prior Caesarean Section: A Secondary Analysis of the WHO Multicountry Survey on Maternal and Newborn Health

Objective

To investigate optimal timing of elective repeat caesarean section among low-risk pregnant women with prior caesarean section in a multicountry sample from largely low- and middle-income countries.

Design

Secondary analysis of a cross-sectional study.

Setting

Twenty-nine countries from the World Health Organization Multicountry Survey on Maternal and Newborn Health.

Population

29,647 women with prior caesarean section and no pregnancy complications in their current pregnancy who delivered a term singleton (live birth and stillbirth) at gestational age 37–41 weeks by pre-labour caesarean section, intra-partum caesarean section, or vaginal birth following spontaneous onset of labour.

Methods

We compared the rate of short-term adverse maternal and newborn outcomes following pre-labour caesarean section at a given gestational age, to those following ongoing pregnancies beyond that gestational age.

Main Outcome Measures

Severe maternal outcomes, neonatal morbidity, and intra-hospital early neonatal mortality.

Results

Odds of neonatal morbidity and intra-hospital early neonatal mortality were 0.48 (95% confidence interval [CI] 0.39–0.60) and 0.31 (95% CI 0.16–0.58) times lower for ongoing pregnancies compared to pre-labour caesarean section at 37 weeks. We did not find any significant change in the risk of severe maternal outcomes between pre-labour caesarean section at a given gestational age and ongoing pregnancies beyond that gestational age.

Conclusions

Elective repeat caesarean section at 37 weeks had higher risk of neonatal morbidity and mortality compared to ongoing pregnancy, however risks at later gestational ages did not differ between groups.     

Neutralizing Dengue Antibody in Pregnant Thai Women and Cord Blood

Background

The WHO ‘Global Strategy for Dengue Prevention and Control, 2012–2020’ addresses the growing need for the treatment of dengue, and targets a 25% reduction in morbidity and 50% in mortality (using 2010 estimates as baseline). Achieving these goals requires future dengue prevention strategies that will employ both potential vaccines and sustainable vector-control measures. Maternally transferred dengue antibody is an important factor in determining the optimal age for dengue vaccination.

Objectives

To estimate the seroprevalence of dengue antibodies among mothers living in an area of high endemicity – Ban Pong, Ratchaburi Province – and to assess maternal dengue antibodies transferred to cord blood.

Materials & Methods

A cross-sectional study was conducted with 141 pregnant women who delivered at Ban Pong Hospital, Ratchaburi, Thailand. Maternal-cord paired sera were tested for dengue neutralizing (NT) antibody by PRNT₅₀ assay. A ratio of ≥ 1:10 NT titer to dengue serotype was considered seropositive.

Results

Most mothers (137/141, 97.2%) had NT antibodies to at least one dengue serotype in their sera. At birth, the proportion of cord sera with NT antibodies to DEN-1, DEN-2, DEN-3, and DEN-4, were high and similar to the sera of their mothers, at 93.6%, 97.2%, 97.9%, and 92.2%, respectively. The dengue geometric mean titers (GMT) in cord blood were significantly higher than the maternal antibodies (p<0.001): highest in DEN-2, followed by DEN-3, and then DEN-1. The GMT of DEN-4 was the lowest among all four serotypes.

Conclusions

Dengue infection is highly prevalent among pregnant women in this dengue-endemic area. Most of the cord blood had transferred dengue antibodies, which may have an impact on the disease burden in this population.     

Adequately Diversified Dietary Intake and Iron and Folic Acid Supplementation during Pregnancy Is Associated with Reduced Occurrence of Symptoms Suggestive of Pre-Eclampsia or Eclampsia in Indian Women

Background/Objective

Pre-eclampsia or Eclampsia (PE or E) accounts for 25% of cases of maternal mortality worldwide. There is some evidence of a link to dietary factors, but few studies have explored this association in developing countries, where the majority of the burden falls. We examined the association between adequately diversified dietary intake, iron and folic acid supplementation during pregnancy and symptoms suggestive of PE or E in Indian women.

Methods

Cross-sectional data from India’s third National Family Health Survey (NFHS-3, 2005-06) was used for this study. Self-reported symptoms suggestive of PE or E during pregnancy were obtained from 39,657 women aged 15-49 years who had had a live birth in the five years preceding the survey. Multivariable logistic regression analysis was used to estimate the association between adequately diversified dietary intake, iron and folic acid supplementation during pregnancy and symptoms suggestive of PE or E after adjusting for maternal, health and lifestyle factors, and socio-demographic characteristics of the mother.

Results

In their most recent pregnancy, 1.2% (n=456) of the study sample experienced symptoms suggestive of PE or E. Mothers who consumed an adequately diversified diet were 34% less likely (OR: 0.66; 95% CI: 0.51-0.87) to report PE or E symptoms than mothers with inadequately diversified dietary intake. The likelihood of reporting PE or E symptoms was also 36% lower (OR: 0.64; 95% CI: 0.47-0.88) among those mothers who consumed iron and folic acid supplementation for at least 90 days during their last pregnancy. As a sensitivity analysis, we stratified our models sequentially by education, wealth, antenatal care visits, birth interval, and parity. Our results remained largely unchanged: both adequately diversified dietary intake and iron and folic acid supplementation during pregnancy were associated with a reduced occurrence of PE or E symptoms.

Conclusion

Having a adequately diversified dietary intake and iron and folic acid supplementation in pregnancy was associated with a reduced occurrence of symptoms suggestive of PE or E in Indian women.     

The Impact of Integrated Community Case Management of Childhood Diseases Interventions to Prevent Malaria Fever in Children Less than Five Years Old in Bauchi State of Nigeria

Background

Malaria accounts for about 300,000 childhood deaths and 30% of under-five year old mortality in Nigeria annually. We assessed the impact of intervention strategies that integrated Patent Medicines Vendors into community case management of childhood-diseases, improved access to artemisinin combination therapy (ACT) and distributed bed nets to households. We explored the influence of household socioeconomic characteristics on the impact of the interventions on fever in the under-five year olds in Bauchi State Nigeria.

Methods

A cross-sectional case-controlled, interventional study, which sampled 3077 and 2737 under-5 year olds from 1,588 and 1601 households in pre- and post-intervention periods respectively, was conducted from 2013 to 2015. Difference-in-differences and logistic regression analyses were performed to estimate the impact attributable to the interventions: integrated community case management of childhood illness which introduced trained public and private sector health providers and the possession of nets on the prevalence of fever.

Results

Two-week prevalence of fever among under-fives declined from 56.6% at pre-intervention to 42.5% at post-intervention. Fever-prevention fraction attributable to nets was statistically significant (OR = 0.217, 95% CI: 0.08–0.33). Children in the intervention group had significantly fewer incidence of fever than children in the control group had (OR = 0.765, 95% CI: 0.67–0.87). Although being in the intervention group significantly provided 23.5% protection against fever (95% CI: 0.13–0.33), the post-intervention likelihood of fever was also significantly less than at pre-intervention (OR = 0.57, 95% CI: 0.50–0.65). The intervention protection fraction against fever was statistically significant at 43.4% (OR = 0.434, 95% CI: 0.36–0.50). Logistic regression showed that the odds of fever were lower in households with nets (OR = 0.72, 95% CI: 0.60–0.88), among children whose mothers had higher education, in the post-intervention period (OR = 0.39, 95% CI: 0.33–0.46) and in the intervention group (OR = 0.52, 95% CI: 0.48–0.66). The odds of fever increased with higher socio-economic status of households (17.9%-19.5%). Difference-in-differences showed that the interventions significantly reduced occurrence of fever in the intervention group (OR = 1.70, 95% CI: 1.36–2.14).

Conclusion

The interventions were effective in reducing the prevalence and the likelihood of childhood malaria fever. Taken to scale, these can significantly reduce the burden of malaria fever in the under-five year old children.     

Inadequate Knowledge of Neonatal Danger Signs among Recently Delivered Women in Southwestern Rural Uganda: A Community Survey

Background

Early detection of neonatal illness is an important step towards improving newborn survival. Every year an estimated 3.07 million children die during their first month of life and about one-third of these deaths occur during the first 24 hours. Ninety-eight percent of all neonatal deaths occur in low- and middle-income countries like Uganda. Inadequate progress has been made globally to reduce the amount of neonatal deaths that would be required to meet Millennium Development Goal 4. Poor knowledge of newborn danger signs delays care seeking. The aim of this study was to explore the knowledge of key newborn danger signs among mothers in southwestern Uganda.

Methods

Results from a community survey of 765 recently delivered women were analyzed using univariate and multivariate logistic regressions. Six key danger signs were identified, and spontaneous responses were categorized, tabulated, and analyzed.

Results

Knowledge of at least one key danger sign was significantly associated with being birth prepared (adjusted OR 1.7, 95% CI 1.2–2.3). Birth preparedness consisted of saving money, identifying transportation, identifying a skilled birth attendant and buying a delivery kit or materials. Overall, respondents had a poor knowledge of key newborn danger signs: 58.2% could identify one and 14.8% could identify two. We found no association between women attending the recommended number of antenatal care visits and their knowledge of danger signs (adjusted OR 1.0, 95% CI 0.8–1.4), or between women using a skilled birth attendant at delivery and their knowledge of danger signs (adjusted OR 1.2, 95% CI 0.9–1.7).

Conclusions

Our findings indicate the need to enhance education of mothers in antenatal care as well as those discharged from health facilities after delivery. Further promotion of birth preparedness is encouraged as part of the continuum of maternal care.     

Early Initiation of ARV During Pregnancy to Move towards Virtual Elimination of Mother-to-Child-Transmission of HIV-1 in Yunnan,China

Objective

To identify factors associated with mother-to-child-transmission and late access to prevention of maternal to child transmission (PMTCT) services among HIV-infected women; and risk factors for infant mortality among HIV-exposed infants in order to assess the feasibility of virtual elimination of vertical transmission and pediatric HIV in this setting.

Design

Observational study evaluating the impact of a provincial PMTCT program.

Methods

The intervention was implemented in 26 counties of Yunnan Province, China at municipal and tertiary health care settings. Log linear regression models with generalized estimating equations were used to identify unadjusted and adjusted correlates for late ARV intervention and MTCT. Cox proportional hazard models with robust sandwich estimation were applied to examine correlates of infant mortality.

Results

Mother-to-child- transmission rate of HIV was controlled to 2%, with late initiation of maternal ARV showing a strong association with vertical transmission and infant mortality. Risk factors for late initiation of maternal ARV were age, ethnicity, education, and having a husband not tested for HIV. Mortality rate among HIV-exposed infants was 2.9/100 person-years. In addition to late initiation of maternal ARV, ethnicity, low birth weight and preterm birth were associated with infant mortality.

Conclusions

This PMTCT program in Yunnan achieved low rates of MTCT. However the infant mortality rate in this cohort of HIV-exposed children was almost three times the provincial rate. Virtual elimination of MTCT of HIV is an achievable goal in China, but more attention needs to be paid to HIV-free survival.     

Increasing Neonatal Mortality among Palestine Refugees in the Gaza Strip

Background

The United Nations Relief and Works Agency for Palestine refugees in the Near East (UNRWA) has periodically estimated infant mortality rates among Palestine refugees in Gaza. These surveys have recorded a decline from 127 per 1000 live births in 1960 to 20.2 in 2008.

Methods

We used the same preceding-birth technique as in previous surveys. All multiparous mothers who came to the 22 UNRWA health centres to register their last-born child for immunization were asked if their preceding child was alive or dead. We based our target sample size on the infant mortality rate in 2008 and included 3128 mothers from August until October 2013. We used multiple logistic regression analyses to identify predictors of infant mortality.

Findings

Infant mortality in 2013 was 22.4 per 1000 live births compared with 20.2 in 2008 (p = 0.61), and this change reflected a statistically significant increase in neonatal mortality (from 12.0 to 20.3 per 1000 live births, p = 0.01). The main causes of the 65 infant deaths were preterm birth (n = 25, 39%), congenital anomalies (n = 19, 29%), and infections (n = 12, 19%). Risk factors for infant death were preterm birth (OR 9.88, 3.98–24.85), consanguinity (2.41, 1.35–4.30) and high-risk pregnancies (3.09, 1.46–6.53).

Conclusion

For the first time in five decades, mortality rates have increased among Palestine refugee newborns in Gaza. The possible causes of this trend may include inadequate neonatal care. We will estimate infant and neonatal mortality rates again in 2015 to see if this trend continues and, if so, to assess how it can be reversed.     

Risk Factors for Maternal Mortality in Rural Tigray,Northern Ethiopia: A Case-Control Study

Background

Maternal mortality continues to have devastating impacts in many societies, where it constitutes a leading cause of death, and thus remains a core issue in international development. Nevertheless, individual determinants of maternal mortality are often unclear and subject to local variation. This study aims to characterise individual risk factors for maternal mortality in Tigray, Ethiopia.

Methods

A community-based case-control study was conducted, with 62 cases and 248 controls from six randomly-selected rural districts. All maternal deaths between May 2012 and September 2013 were recruited as cases and a random sample of mothers who delivered in the same communities within the same time period were taken as controls. Multiple logistic regression was used to identify independent determinants of maternal mortality.

Results

Four independent individual risk factors, significantly associated with maternal death, emerged. Women who were not members of the voluntary Women’s Development Army were more likely to experience maternal death (OR 2.07, 95% CI 1.04–4.11), as were women whose husbands or partners had below-median scores for involvement during pregnancy (OR 2.19, 95% CI 1.14–4.18). Women with a pre-existing history of other illness were also at increased risk (OR 5.58, 95% CI 2.17–14.30), as were those who had never used contraceptives (OR 2.58, 95% CI 1.37–4.85). Previous pregnancy complications, a below-median number of antenatal care visits and a woman’s lack of involvement in health care decision making were significant bivariable risks that were not significant in the multivariable model.

Conclusions

The findings suggest that interventions aimed at reducing maternal mortality need to focus on encouraging membership of the Women’s Development Army, enhancing husbands’ involvement in maternal health services, improving linkages between maternity care and other disease-specific programmes and ensuring that women with previous illnesses or non-users of contraceptive services are identified and followed-up as being at increased risk during pregnancy and childbirth.     

Antepartum Membrane Stripping in GBS Carriers,Is It Safe? (The STRIP-G Study)

Objective

Stripping of the membranes is an established and widely utilized obstetric procedure associated with higher spontaneous vaginal delivery rates, reduced need for formal induction of labor and a lower likelihood of post-term pregnancy. Due to the theoretical concern of bacterial seeding during the procedure many practitioners choose not to sweep the membranes in Group B Streptococcus (GBS) colonized patients. We conducted ‘the STRIP-G study’ in order to determine whether maternal and neonatal outcomes are affected by GBS carrier status in women undergoing membrane stripping.

Study design

We conducted a prospective study in a tertiary referral center, comparing maternal and neonatal outcomes following membrane stripping among GBS-positive, GBS-negative, and GBS-unknown patients. We compared the incidence of composite adverse neonatal outcomes (primary outcome) among the three study groups, while secondary outcome measure was composite adverse maternal outcomes.

Results

A total of 542 women were included in the study, of which 135 were GBS-positive, 361 GBS-negative, and 46 GBS-unknown status. Demographic, obstetric, and intra-partum characteristics were similar for all groups. Adverse neonatal outcomes were observed in 8 (5.9%), 31 (8.6%), and 2 (4.3%) in the GBS-positive, GBS-negative, and unknown groups, respectively (P = 0.530), (Odds Ratio between GBS-Positive vs. GBS-Negative groups 0.67 (95%, CI = 0.30–1.50)); while composite adverse maternal outcomes occurred in 9 (6.66%), 31 (8.59%), and 5 (10.87%) in the GBS-positive, GBS-negative, and unknown groups, respectively (P = 0.617).

Conclusions

Antepartum membrane stripping in GBS carriers appears to be a safe obstetrical procedure that does not adversely affect maternal or neonatal outcomes.     

Incidence and Risk Factors for Neonatal Tetanus in Admissions to Kilifi County Hospital,Kenya

Background

Neonatal Tetanus (NT) is a preventable cause of mortality and neurological sequelae that occurs at higher incidence in resource-poor countries, presumably because of low maternal immunisation rates and unhygienic cord care practices. We aimed to determine changes in the incidence of NT, characterize and investigate the associated risk factors and mortality in a prospective cohort study including all admissions over a 15-year period at a County hospital on the Kenyan coast, a region with relatively high historical NT rates within Kenya.

Methods

We assessed all neonatal admissions to Kilifi County Hospital in Kenya (1999–2013) and identified cases of NT (standard clinical case definition) admitted during this time. Poisson regression was used to examine change in incidence of NT using accurate denominator data from an area of active demographic surveillance. Logistic regression was used to investigate the risk factors for NT and factors associated with mortality in NT amongst neonatal admissions. A subset of sera from mothers (n = 61) and neonates (n = 47) were tested for anti-tetanus antibodies.

Results

There were 191 NT admissions, of whom 187 (98%) were home deliveries. Incidence of NT declined significantly (Incidence Rate Ratio: 0.85 (95% Confidence interval 0.81–0.89), P<0.001) but the case fatality (62%) did not change over the study period (P = 0.536). Younger infant age at admission (P = 0.001) was the only independent predictor of mortality. Compared to neonatal hospital admittee controls, the proportion of home births was higher among the cases. Sera tested for antitetanus antibodies showed most mothers (50/61, 82%) had undetectable levels of antitetanus antibodies, and most (8/9, 89%) mothers with detectable antibodies had a neonate without protective levels.

Conclusions

Incidence of NT in Kilifi County has significantly reduced, with reductions following immunisation campaigns. Our results suggest immunisation efforts are effective if sustained and efforts should continue to expand coverage.     

A Randomized Controlled Trial of Innovative Postpartum Care Model for Mother-Baby Dyads

Objective

To evaluate the efficacy, safety, and maternal satisfaction of a newly established integrative postpartum community-based clinic providing comprehensive support for mothers during the first month after discharge from the hospital. Our primary interests were breastfeeding rates, readmission and patient satisfaction.

Methods

A randomized controlled trial was conducted in Ottawa, Canada, where 472 mothers were randomized via a 1:2 ratio to either receive standard of care (n = 157) or to attend the postpartum breastfeeding clinic (n = 315). Outcome data were captured through questionnaires completed by the participants at 2, 4, 12 and 24 weeks postpartum. Unadjusted and adjusted logistic regression models were conducted to determine the effect of the intervention on exclusive breastfeeding at 12 weeks (primary outcome). Secondary outcomes included breastfeeding rate at 2, 4 and 24 weeks, breastfeeding self-efficacy scale, readmission rate, and satisfaction score.

Results

More mothers in the intervention group (n = 195, 66.1%) were exclusively breastfeeding at 12 weeks compared to mothers in the control group (n = 81, 60.5%), however no statistically significant difference was observed (OR = 1.28; 95% CI:0.84–1.95)). The rate of emergency room visits at 2 weeks for the intervention group was 11.4% compared to the standard of care group (15.2%) (OR = 0.69; 95% CI: 0.39–1.23). The intervention group was significantly more satisfied with the overall care they received for breastfeeding compared to the control group (OR = 1.96; 95% CI: 3.50–6.88)).

Conclusion

This new model of care did not significantly increase exclusive breastfeeding at 12 weeks. However, there were clinically meaningful improvements in the rate of postnatal problems and satisfaction that support this new service delivery model for postpartum care. A community-based multidisciplinary postpartum clinic is feasible to implement and can provide appropriate and highly satisfactory care to mother-baby dyads. This model of care may be more beneficial in a population that is not already predisposed to breastfeed.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT02043119","term_id":"NCT02043119"}}NCT02043119     

Did Equity of Reproductive and Maternal Health Service Coverage Increase during the MDG Era? An Analysis of Trends and Determinants across 74 Low- and Middle-Income Countries

Introduction

Despite widespread gains toward the 5^th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. As countries enter the post-MDG era and strive toward UHC, it will be important to monitor the extent to which countries are achieving equity of RH and MH service coverage. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country’s progress, or lack thereof, toward more equitable RH and MH service coverage.

Methods

We used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014. We examined trends in both relative and absolute equity, and measured relative equity using a concentration index of coverage data grouped by wealth quintile. Through multivariate analysis we examined the relative importance of policy factors, such as political commitment to health, governance, and the level of prepayment, in determining countries’ progress toward greater equity in RH and MH service coverage.

Results

Relative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity.

Conclusion

Equity in RH and MH service coverage has improved but varies considerably across countries and over time. Even among the subset of countries that are close to achieving the MDGs, progress made on equity varies considerably across countries. Enduring disparities in access and outcomes underpin mounting support for targeted reforms within the broader context of universal health coverage (UHC).     

Is Spousal Violence Being “Vertically Transmitted” through Victims? Findings from the Pakistan Demographic and Health Survey 2012-13

Introduction

Violence against women is regarded as a major violation of human rights, and several socio-behavioral aspects among victims have been identified as important determinants of spousal violence experience. Pakistani nationally representative contextual evidence is scarce in this regard. We aimed to estimate prevalence of spousal violence, and explore its association with intergenerational transfer, and attitudinal acceptance of violence, among Pakistani ever-married women.

Materials and Methods

Data of 3,687 ever-married women from Pakistan Demographic and Health Survey, 2012-13 was used to perform secondary analysis. Logistic regression analyses were conducted. Association between the different forms of spousal violence and the independent variables: intergenerational transfer of spousal violence (mother also beaten up by father); and attitudinal acceptance of spousal violence (beating is justifies if wife argues with husband) were reported as Odds ratios with 95% confidence intervals (CI).

Results

Overall, more than a third (n=1344, 37.9%)of ever-married women reported that they experienced spousal violence. Almost 68% (n=539) of the women who reported that their mothers were also beaten up by their fathers, were victims of spousal violence; and almost 47% (n=603) of the women who agreed that beating was justified if the wife argues with her husband, also suffered spousal violence. Intergenerational transfer (OR =5.71, 95%CI 4.40-7.41, p-value <0.01), and attitudinal acceptance (OR =1.66, 95%CI 1.27-2.15, p-value <0.01) were significantly associated with experience of physical violence even after adjusting for respondents’ age at marriage, education level, wealth index, parity, employment status, and empowerment status.

Conclusions

Spousal violence continues to haunt the lives of women in Pakistan, and is being transmitted as a learned behavior from mothers to daughters who tend to accept such violation of human rights. Girl children from such unfortunate homes may continue to transmit such behaviors, and thus may be targeted for future anti-domestic violence efforts.     

Facility Delivery,Postnatal Care and Neonatal Deaths in India: Nationally-Representative Case-Control Studies

Objective

Clinical studies demonstrate the efficacy of interventions to reduce neonatal deaths, but there are fewer studies of their real-life effectiveness. In India, women often seek facility delivery after complications arise, rather than to avoid complications. Our objective was to quantify the association of facility delivery and postnatal checkups with neonatal mortality while examining the “reverse causality” in which the mothers deliver at a health facility due to adverse perinatal events.

Methods

We conducted nationally representative case-control studies of about 300,000 live births and 4,000 neonatal deaths to examine the effect of, place of delivery and postnatal checkup on neonatal mortality. We compared neonatal deaths to all live births and to a subset of live births reporting excessive bleeding or obstructed labour that were more comparable to cases in seeking care.

Findings

In the larger study of 2004–8 births, facility delivery without postnatal checkup was associated with an increased odds of neonatal death (Odds ratio = 2.5; 99% CI 2.2–2.9), especially for early versus late neonatal deaths. However, use of more comparable controls showed marked attenuation (Odds ratio = 0.5; 0.4–0.5). Facility delivery with postnatal checkup was associated with reduced odds of neonatal death. Excess risks were attenuated in the earlier study of 2001–4 births.

Conclusion

The combined effect of facility deliveries with postnatal checks ups is substantially higher than just facility delivery alone. Evaluation of the real-life effectiveness of interventions to reduce child and maternal deaths need to consider reverse causality. If these associations are causal, facility delivery with postnatal check up could avoid about 1/3 of all neonatal deaths in India (~100,000/year).     

Association between Maternal Smoking during Pregnancy and Low Birthweight: Effects by Maternal Age

Background

Maternal smoking during pregnancy has been consistently related to low birthweight. However, older mothers, who are already at risk of giving birth to low birthweight infants, might be even more susceptible to the effects of maternal smoking. Therefore, this study aimed to examine the modified association between maternal smoking and low birthweight by maternal age.

Methods

Data were obtained from a questionnaire survey of all mothers of children born between 2004 and 2010 in Okinawa, Japan who underwent medical check-ups at age 3 months. Variables assessed were maternal smoking during pregnancy, maternal age, gestational age, parity, birth year, and complications during pregnancy. Stratified analyses were performed using a logistic regression model.

Results

In total, 92641 participants provided complete information on all variables. Over the 7 years studied, the proportion of mothers smoking during pregnancy decreased from 10.6% to 5.0%, while the prevalence of low birthweight did not change remarkably (around 10%). Maternal smoking was significantly associated with low birthweight in all age groups. The strength of the association increased with maternal age, both in crude and adjusted models.

Conclusions

Consistent with previous studies conducted in Western countries, this study demonstrates that maternal age has a modifying effect on the association between maternal smoking and birthweight. This finding suggests that specific education and health care programs for older smoking mothers are important to improve their foetal growth.     

Sporadic Retinoblastoma and Parental Smoking and Alcohol Consumption before and after Conception: A Report from the Children’s Oncology Group

Background

Retinoblastoma is the most frequent tumor of the eye in children and very little is known about the etiology of non-familial (sporadic) retinoblastoma. In this study we examined whether parental tobacco smoking or alcohol consumption (pre- or post-conception) contribute to the two phenotypes (bilateral or unilateral) of sporadic retinoblastoma.

Methods

Two large multicenter case-control studies identified 488 cases through eye referral centers in the United States and Canada or through the Children’s Oncology Group. Controls (n = 424) were selected from among friends and relatives of cases and matched by age. Risk factor information was obtained via telephone interview. We employed multivariable logistic regression to estimate the effects of parental tobacco smoking and alcohol consumption on retinoblastoma.

Findings

Maternal smoking before and during pregnancy contributed to unilateral retinoblastoma risk in the child: year before pregnancy conditional Odds Ratio (OR), 8.9; 95% confidence interval (CI) 1.5–51, and unconditional OR, 2.4; 95% CI, 1.3–4.7; month before or during pregnancy, conditional OR, 3.3; 95% CI, 0.5–20.8, and unconditional OR, 2.8; 95% CI, 1.1–7.0. No association was found for maternal or paternal alcohol consumption.

Conclusion

The results of this study indicate that maternal active smoking during pregnancy may be a risk factor for sporadic retinoblastoma. Our study supports a role for tobacco exposures in embryonal tumors.     

Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh,India and Nepal

Background

Globally, puerperal sepsis accounts for an estimated 8–12% of maternal deaths, but evidence is lacking on the extent to which clean delivery practices could improve maternal survival. We used data from the control arms of four cluster-randomised controlled trials conducted in rural India, Bangladesh and Nepal, to examine associations between clean delivery kit use and hand washing by the birth attendant with maternal mortality among home deliveries.

Methods

We tested associations between clean delivery practices and maternal deaths, using a pooled dataset for 40,602 home births across sites in the three countries. Cross-sectional data were analysed by fitting logistic regression models with and without multiple imputation, and confounders were selected a priori using causal directed acyclic graphs. The robustness of estimates was investigated through sensitivity analyses.

Results

Hand washing was associated with a 49% reduction in the odds of maternal mortality after adjusting for confounding factors (adjusted odds ratio (AOR) 0.51, 95% CI 0.28–0.93). The sensitivity analysis testing the missing at random assumption for the multiple imputation, as well as the sensitivity analysis accounting for possible misclassification bias in the use of clean delivery practices, indicated that the association between hand washing and maternal death had been over estimated. Clean delivery kit use was not associated with a maternal death (AOR 1.26, 95% CI 0.62–2.56).

Conclusions

Our evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, although the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings. Our findings indicating kit use does not improve maternal survival, suggests that the soap is not being used in all instances that kit use is being reported.