Maternal Mortality in a Rural District of Pakistan and Contributing Factors

INTRODUCTION

Pakistan is among the ten countries that account for 60% of global maternal mortality. Lack of accurate data on maternal mortality and a complex interrelation of access and quality of healthcare services, healthcare delivery system, and socio-economic and demographic factors contribute significantly to inadequate progress in reducing maternal mortality.

MATERIAL AND METHODS

A population-based prospective cohort study was conducted in a rural district of Pakistan using data obtained from an enhanced surveillance system. A total of 7572 pregnancies and their outcomes were recorded by 273 Lady Health Workers and 73 Community Health Workers over 2016-2017. Logistic regression was used to calculate the unadjusted and adjusted odds ratios (OR) for maternal mortality for each risk factor. Population Attributable Fraction (PAF) was derived from the ORs and risk factor prevalence.

RESULTS

The study recorded 18 maternal deaths. The maternal mortality rate was estimated at 238/100,000 pregnancies (95% CI 141-376), and the maternal mortality ratio was 247/100,000 live births (95% CI 147-391). Half of the maternal deaths (9) were from obstetric hemorrhage, and 28% (5) from puerperal sepsis. Postpartum hemorrhage was associated with a 17-fold higher risk of maternal mortality (PAF = 40%) and puerperal sepsis with a 12-fold higher mortality risk (PAF = 29%) compared to women without these conditions. Women delivered by unskilled birth attendants had a three-fold (PAF = 21%), and women having prolonged labour had a fourfold risk of maternal mortality compared to those with these conditions. Women with leg swelling (47%) and pre-eclampsia (26%) are at seven times the risk of maternal mortality compared to those without these conditions. Mortality in women delivered by unskilled birth attendants was three times higher than with skilled attendants.

CONCLUSION

The study, among a few large-scale prospective cohort studies conducted at the community level in a rural district of Pakistan, provides a better understanding of the risk factors determining maternal mortality in Pakistan. Poverty emerged as a significant risk factor for maternal mortality in the study area and contributes to the underutilization of health facilities and skilled birth attendants. Incorporating poverty reduction strategies across all sectors, including health, is urgently required to address higher maternal mortality in Pakistan. A paradigm shift is required in Maternal and Child health related programs and interventions to include poverty estimation and measuring mortality through linking mortality surveillance with the Civil Registration and Vital Statistics system. Accelerated efforts to expand the coverage and completeness of mortality data with risk factors to address inequalities in access and utilization of health services.

Predictive Ability And Stakeholders' Perceptions Of The Selection Tools For Mbbs In Women Medical College: A Mixed Methods Study

BACKGROUND

The selection criteria for entry into the MBBS programme used by Women Medical College (WMC) includes previous academic achievements, namely Secondary School Certificate (SSC) and Higher Secondary Certificate (HSC), and the Medical and Dental College Admission Test (MDCAT). This study determined the predictive validity of these selection tools and explored the perceptions of stakeholders regarding the selection process and the use of selection tools in WMC.

METHODS

This study utilized both quantitative and qualitative methods. Quantitative methods involved a retrospective cohort study design to determine the statistical correlation between the performance of candidates in the selection tools and their subsequent academic achievements at medical college. This consisted of data collected from three cohorts (n=186) of students who graduated in 2014, 2015 and 2016. Qualitative methods of the study explored the perceptions of stakeholders through purposive sampling using face-to-face semi-structured interviews, which were analysed using thematic analysis.

RESULTS

The study showed very weak correlations of SSC with performance in the fourth professional examination undertaken by the students and HSC with performance in the first and second professional examinations. MDCAT did not correlate with any professional examination. Qualitative analysis identified three emerging themes; a) lack of standardization, b) fairness of selection criteria, and c) assessment of noncognitive attributes.

CONCLUSIONS

The selection tools showed poor predictive ability for the performance of students in the medical college. Standardizing the selection tools and including an assessment of non-cognitive attributes in the selection criteria is suggested.

Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan

Background

Reliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data.

Methods

An enhanced surveillance system was established that measured maternal, perinatal and neonatal mortality rates through more complete enumeration of births and deaths in a rural district of Pakistan. Data were collected over a period of 1 year (2015/16) from augmentation of the existing health information system covering public healthcare facilities (n = 19), and the community through 273 existing Lady Health Workers; and with the addition of private healthcare facilities (n = 10), and 73 additional Community Health Workers to cover a total study population of 368,454 consisting of 51,690 eligible women aged 18 to 49 years with 7580 pregnancies and 7273 live births over 1 year. Maternal, neonatal, perinatal and stillbirth rates and ratios were calculated, with comparisons to routine reporting from the previous period (2014–15).

Results

Higher maternal mortality, perinatal mortality and neonatal mortality rates were observed through enhanced surveillance compared to mortality rates in the previous 1.5 years from the routine monitoring system from increased completeness and coverage. Maternal mortality was 247 compared to 180 per 100, 000 live births (p = 0.36), neonatal mortality 40 compared to 20 per 1, 000 live births (p < 0.001), and perinatal mortality 60 compared to 47 per 1000 live births (p < 0.001). All the mortality rates were higher than provincial and national estimates proffered by international agencies based on successive Pakistan Demographic and Health Surveys and projections.

Conclusion

Extension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level.

Human Thiel-Embalmed Cadaveric Aortic Model with Perfusion for Endovascular Intervention Training and Medical Device Evaluation

Purpose

The purpose of this investigation was to evaluate human Thiel-embalmed cadavers with the addition of extracorporeal driven ante-grade pulsatile flow in the aorta as a model for simulation training in interventional techniques and endovascular device testing.

Materials and Methods

Three human cadavers embalmed according to the method of Thiel were selected. Extracorporeal pulsatile ante-grade flow of 2.5 L per min was delivered directly into the aorta of the cadavers via a surgically placed connection. During perfusion, aortic pressure and temperature were recorded and optimized for physiologically similar parameters. Pre- and post-procedure CT imaging was conducted to plan and follow up thoracic and abdominal endovascular aortic repair as it would be in a clinical scenario. Thoracic endovascular aortic repair (TEVAR) and endovascular abdominal repair (EVAR) procedures were conducted in simulation of a clinical case, under fluoroscopic guidance with a multidisciplinary team present.

Results

The Thiel cadaveric aortic perfusion model provided pulsatile ante-grade flow, with pressure and temperature, sufficient to conduct a realistic simulation of TEVAR and EVAR procedures. Fluoroscopic imaging provided guidance during the intervention. Pre- and post-procedure CT imaging facilitated planning and follow-up evaluation of the procedure.

Conclusion

The human Thiel-embalmed cadavers with the addition of extracorporeal flow within the aorta offer an anatomically appropriate, physiologically similar robust model to simulate aortic endovascular procedures, with potential applications in interventional radiology training and medical device testing as a pre-clinical model.

Electronic supplementary material

The online version of this article (doi:10.1007/s00270-017-1643-z) contains supplementary material, which is available to authorized users.

Development and evaluation of a secondary reference panel for BCR-ABL1 quantification on the International Scale

Molecular monitoring of chronic myeloid leukemia patients using robust BCR-ABL1 tests standardized to the International Scale (IS) is key to proper disease management, especially when treatment cessation is considered. Most laboratories currently use a time-consuming sample exchange process with reference laboratories for IS calibration. A World Health Organization (WHO) BCR-ABL1 reference panel was developed (MR¹–MR⁴), but access to the material is limited. In this study, we describe the development of the first cell-based secondary reference panel that is traceable to and faithfully replicates the WHO panel, with an additional MR^4.5 level. The secondary panel was calibrated to IS using digital PCR with ABL1, BCR and GUSB as reference genes and evaluated by 44 laboratories worldwide. Interestingly, we found that >40% of BCR-ABL1 assays showed signs of inadequate optimization such as poor linearity and suboptimal PCR efficiency. Nonetheless, when optimized sample inputs were used, >60% demonstrated satisfactory IS accuracy, precision and/or MR^4.5 sensitivity, and 58% obtained IS conversion factors from the secondary reference concordant with their current values. Correlation analysis indicated no significant alterations in %BCR-ABL1 results caused by different assay configurations. More assays achieved good precision and/or sensitivity than IS accuracy, indicating the need for better IS calibration mechanisms.

Reproductive health and access to healthcare facilities: risk factors for depression and anxiety in women with an earthquake experience

Background

The reproductive and mental health of women contributes significantly to their overall well-being. Three of the eight Millennium Development Goals are directly related to reproductive and sexual health while mental disorders make up three of the ten leading causes of disease burden in low and middle-income countries. Among mental disorders, depression and anxiety are two of the most prevalent. In the context of slower progress in achieving Millennium Development Goals in developing countries and the ever-increasing man-made and natural disasters in these areas, it is important to understand the association between reproductive health and mental health among women with post-disaster experiences.

Methods

This was a cross-sectional study with a sample of 387 women of reproductive age (15-49 years) randomly selected from the October 2005 earthquake affected areas of Pakistan. Data on reproductive health was collected using the Centers for Disease Control reproductive health assessment toolkit. Depression and anxiety were measured using the Hopkins Symptom Checklist-25, while earthquake experiences were captured using the Harvard Trauma Questionnaire. The association of either depression or anxiety with socio-demographic variables, earthquake experiences, reproductive health and access to health facilities was estimated using multivariate logistic regression.

Results

Post-earthquake reproductive health events together with economic deprivation, lower family support and poorer access to health care facilities explained a significant proportion of differences in the experiencing of clinical levels of depression and anxiety. For instance, women losing resources for subsistence, separation from family and experiencing reproductive health events such as having a stillbirth, having had an abortion, having had abnormal vaginal discharge or having had genital ulcers, were at significant risk of depression and anxiety.

Conclusion

The relationship between women's post-earthquake mental health and reproductive health, socio-economic status, and health care access is complex and explained largely by the socio-cultural role of women. It is suggested that interventions that consider gender differences and that are culturally appropriate are likely to reduce the incidence.

Micro-determination of iron in pharmaceutical preparations by image scanning and computational quantification

Iron has been quantified in pharmaceutical preparations by developing red spots pursuant to interaction of Fe(II) ions in the sample with 1, 10-phenanthroline on TLC plate. Soon after, TLC was scanned on a flatbed scanner and the image was transferred to the computer. Color intensity of the spot was computationally quantified with the help of native software developed for this purpose. The conditions were optimized and the results were compared with a reference method.

External dose assessment from the measured radioactivity in soil samples collected from the Islamabad capital territory, Pakistan

It is a well known fact that natural radionuclides are the major contributors towards the gamma ray exposure received by the general public. In this context, soil samples were collected from the Islamabad capital territory and activities due to (226)Ra, (232)Th, (40)K and (137)Cs were measured using gamma ray spectrometry: activities ranged from 41.5-106.2 Bq kg(-1), 4.0-193.8 Bq kg(-1), 325.3-657.4 Bq kg(-1) and 1.6-9.45 Bq kg(-1), respectively. From the measured activities, the external hazard index, internal hazard index, absorbed dose rate and mean annual effective dose were calculated. External and internal hazard indices were calculated as 0.76 and 0.95, respectively. The mean absorbed dose rate was found to be 130.97 nGy h(-1). The mean effective dose was estimated as 0.16 mSv y(-1), which is less than the maximum permissible dose of 1 mSv y(-1).

Assessment of the dose received by students and staff in schools in the Rawalpindi region of Pakistan due to indoor radon

Studies concerning measurements of indoor radon levels were carried out in 60 schools in the Rawalpindi region of Pakistan. In each school, six CR-39 based NRPB type radon detectors were installed and exposed to the indoor radon in two cycles (each of six months' duration). After exposure, the detectors were removed, etched in 6 M NaOH for 16 h at 80 degrees C, and the tracks were counted under an optical microscope. The measured track densities were then related to radon concentrations, from which the radiation doses were calculated. The observed radon concentrations varied from 15 to 140 Bq m(-3), with an average activity concentration of 42.75 +/- 9.28 Bq m(-3). The mean annual radon effective dose equivalent was found to be 0.40 +/- 0.09 mSv using an occupancy factor of 8 h day(-1). Our results show that the indoor radon concentrations in the schools surveyed are within the permissible limits.

Presentation of typhoid fever patients in Hazara Division and response to different treatment regimens

BACKGROUND

Response to treatment can vary in patients with typhoid fever. This study was carried out on a group of typhoid patients who were treated in Medical B ward of Ayub Teaching Hospital. Resistance to antibiotic is commonly acquired by Salmonella typhi and is widely reported. Objective of study was to identify such resistance in patients coming from parts of Hazara Division.

METHODS

All patients who presented with typhoid fever and admitted to Medical B Unit from 1st July to 30th September 2002 were included in study. Out of 76 patients 46 (60%) were male. Epidemiological date, presenting symptoms, finding on physical examination, laboratory investigation and radiological examination were recorded. Then one of six commonly used treatment regimens were started. Response to treatment was studied.

RESULTS

Common presenting symptoms and signs were recorded. Headache and fever were seen in 100% of patients. Cough and hypotension were among presenting features in 65% of patients. Leucocyte count of Less than 4 x 10(3)/dl was seen in 11% of samples. Liver functions and Renal function were found altered in 30% of patients. Study of response pattern to different regimens suggested relatively poor response to flouroquinolones. Fever of those patients who were treated with chloamphenicol and cefexime, settled early as compared to patients on other regimens.

CONCLUSIONS

In addition to well known presenting features of typhoid like headache, fever, cough, hypotension and leucopenia abnormalities of renal and liver functions were commonly seen. Response to quinolone was poor suggesting emergence of resistance of salmonella typhi in this area.

Dielectric analysis of phosphorylcholine head group mobility in egg lecithin liposomes

PURPOSE

A knowledge of the interfacial properties of lecithin underpins our understanding of many of the physicochemical characteristics of drug delivery systems such as liposomes and lecithin stabilized microemulsions. In order to further this understanding, a high frequency dielectric study of the interfacial properties of egg lecithin liposomes was undertaken.

METHODS

The effect of temperature, lecithin concentration and probe sonication on the interfacial dielectric properties of liposomal suspensions was investigated by high frequency dielectric relaxation spectroscopy between 0.2-6 GHz.

RESULTS

The frequency dependent permittivity of each suspension exhibited a dielectric dispersion centred around 100 MHz, corresponding to the relaxation of zwitterionic head groups. The activation energy for head group reorientation was estimated as delta H = 6.3 kJ mol-1. There was an increase in extent of inter-head group interactions on increasing the liposome volume fraction, whereas the effect of probe sonication showed that: (i) head groups in both the outer and inner lamellae contribute to the dielectric response; (ii) the head groups may be less restricted in liposomes of high surface curvature with few lamellae; (iii) the high frequency permittivity of the suspension increased on sonication, as a result of a reduction in the amount of (depolarized) interlamellar water following a reduction in the number of lamellae per liposome.

CONCLUSIONS

Dielectric analysis of the zwitterionic head groups of lecithin therefore provides a means for investigating the surface of lecithin liposomes, and may be used to investigate the effect of drugs and other solutes on membranes.

Computer simulation of crystal-liquid interface: application to wettability of solids

PURPOSE

This study describes the development and application of a molecular simulation technique for investigating the solid-liquid interface. It attempts to relate the molecular and crystal structure to the observed wettability of solids.

METHODS

Molecular simulations have been carried out for the crystal-water interface of a series of N-n-alkyl-D-gluconamide crystals using the Monte Carlo technique. The molecular system simulated consisted of a layer of water bounded by two crystal slabs. The interfacial potential energies were calculated for the crystal-water interactions and compared with experimental enthalpy values obtained from contact angle measurements.

RESULTS

The simulations clearly reveal the distinct hydrophilic and hydrophobic nature of the respective (010) and (010) faces of these compounds. The distribution of water at the interface observed in the simulations is in accord with the nature of the crystal faces. The calculated interfacial potential energies are in the right ball park, but consistently higher than the experimental values. The disparity, however, is justifiable, resulting from the highly simplified model simulated.

CONCLUSIONS

Using the developed molecular simulation technique one can calculate the wettability of a solid given the crystal structure. This approach represents an important step towards the goal of engineering crystals with desired wettability characteristics.

Determination of chloride at picogram levels by molecular fluorescence in a graphite furnace

Chloride was determined at nanogram levels by adding excess of indium to the sample introduced into a graphite furnace and measuring the laser induced molecular fluorescence of indium chloride. The diatomic molecules of indium chloride were excited by a pulsed dye laser at 267 nm and fluorescence was measured at 359 nm. The effects of various parameters including amount of indium added, furnace thermal conditions and presence of concomitants were also studied. A linear calibration in the range of 0.025-1.25 ng and a detection limit of 17 pg of chloride were obtained under optimum conditions. The analytical usefulness of the method was checked by determining the chloride content in National Institute of Standards and Technology, Standard Reference Materials 1571a and 1571b Orchard Leaves.

Polymorphism of sulfathiazole

The polymorphism of sulfathiazole has been reexamined. The issue of the separate existence of two of the forms, forms III and IV, has now been definitively resolved: both forms exist. Single crystals were used to generate X-ray diffraction patterns, equivalent to those normally obtained from polycrystalline samples, using the ingenious Gandolfi camera. The patterns obtained were distinct and in agreement with the theoretical powder patterns calculated from the reported structures of the two forms, thus confirming the separate existence. Disagreement between the results of previous workers has been traced to two main causes: characterization techniques are not very discriminating for the two forms (III and IV), and the samples examined have invariably been mixtures of III and IV, since the two forms usually crystallize together. Furthermore, crystals of form III exhibit marked preferred orientation, which complicates powder X-ray diffraction (PXRD) analysis. The IR, Raman, and 13C NMR spectra, and PXRD patterns are reported for all four forms. These distinct fingerprints should now enable one to isolate pure samples and to study the properties and the relationships between these forms with full confidence.