BackgroundPeripartum mistreatment of women contributes to maternal mortality across the globe and disproportionately affects vulnerable populations. While traditionally recognized in low/low-middle-income countries, the extent of research on respectful maternity care and the types of mistreatment occurring in high-income countries is not well understood. We conducted a scoping review to 1) map existing respectful maternity care research by location, country income level, and approach, 2) determine if high-income countries have been studied equally when compared to low/low-middle-income countries, and 3) analyze the types of disrespectful care found in high-income countries.MethodsA systematic search for published literature up to April 2021 using PubMed/MEDLINE, EMBASE, CINAHL Complete, and the Maternity & Infant Care Database was performed. Studies were included if they were full-length journal articles, published in any language, reporting original data on disrespectful maternal care received from healthcare providers during childbirth. Study location, country income level, types of mistreatment reported, and treatment interventions were extracted. This study was registered on PROSPERO, number CRD42021255337.ResultsA total of 346 included studies were categorized by research approach, including direct labor observation, surveys, interviews, and focus groups. Interviews and surveys were the most common research approaches utilized (47% and 29% of all articles, respectively). Only 61 (17.6%) of these studies were conducted in high-income countries. The most common forms of mistreatment reported in high-income countries were lack of informed consent, emotional mistreatment, and stigma/discrimination.ConclusionsMapping existing research on respectful maternity care by location and country income level reveals limited research in high-income countries and identifies a need for a more global approach. Furthermore, studies of respectful maternity care in high-income countries identify the occurrence of all forms of mistreatment, clashing with biases that suggest respectful maternity care is only an issue in low-income countries and calling for additional research to identify interventions that embrace an equitable, patient-centric empowerment model of maternity care.

Abstract

The 2019 Pakistan Maternal Mortality Survey (2019 PMMS) was the first stand-alone maternal mortality survey conducted in Pakistan. A nationally representative sample of 1,396 primary sampling units were randomly selected. The survey was expected to result in about 14,000 interviews with ever-married women age 15-49.

The primary objective of the 2019 PMMS is to provide up-to-date estimates of basic demographic and health indicators. Specifically, the survey was designed and carried out with the purpose of assessing where Pakistan stands on maternal health indicators and how well the country is moving toward these targets. Overall aims of the 2019 PMMS were as follows: - To estimate national and regional levels of maternal mortality for the 3 years preceding the survey and determine whether the MMR has declined substantially since 2006-07 - To identify medical causes of maternal deaths and the biological and sociodemographic risk factors associated with maternal mortality - To assess the impact of maternal and newborn health services, including antenatal and postnatal care and skilled birth attendance, on prevention of maternal mortality and morbidity - To estimate the prevalence and determinants of common obstetric complications and morbidities among women of reproductive age during the 3 years preceding the survey

Geographic coverage

National coverage

Analysis unit

• Household
• Individual
• Woman age 15-49
• Community

Kind of data

Sample survey data [ssd]

Sampling procedure

The 2019 PMMS used a multistage and multiphase cluster sampling methodology based on updated sampling frames derived from the 6th Population and Housing Census, which was conducted in 2017 by the Pakistan Bureau of Statistics (PBS). The sampling universe consisted of urban and rural areas of the four provinces of Pakistan (Punjab, Sindh, Khyber Pakhtunkhwa, and Balochistan), Azad Jammu and Kashmir (AJK), Gilgit Baltistan (GB), Federally Administered Tribal Areas (FATA), and the Islamabad Capital Territory (ICT). A total of 153,560 households (81,400 rural and 72,160 urban) were selected using a two-stage and two-phase stratified systematic sampling approach. The survey was designed to provide representative results for most of the survey indicators in 11 domains: four provinces (by urban and rural areas with Islamabad combined with Punjab and FATA combined with Khyber Pakhtunkhwa), Azad Jammu and Kashmir (urban and rural), and Gilgit Baltistan. Restricted military and protected areas were excluded from the sample.

The sampled households were randomly selected from 1,396 primary sampling units (PSUs) (740 rural and 656 urban) after a complete household listing. In each PSU, 110 randomly selected households were administered the various questionnaires included in the survey. All 110 households in each PSU were asked about births and deaths during the previous 3 years, including deaths among women of reproductive age (15-49 years). Households that reported at least one death of a woman of reproductive age were then visited, and detailed verbal autopsies were conducted to determine the causes and circumstances of these deaths to help identify maternal deaths. In the second phase, 10 households in each PSU were randomly selected from the 110 households selected in the first phase to gather detailed information on women of reproductive age. All eligible ever-married women age 15-49 residing in these 10 households were interviewed to gather detailed information, including a complete pregnancy history.

Note: A detailed description of the sample design is provided in Appendix A of the final report.

Mode of data collection

Face-to-face [f2f]

Research instrument

Six questionnaires were used in the 2019 PMMS: the Short Household Questionnaire, the Long Household Questionnaire, the Woman’s Questionnaire, the Verbal Autopsy Questionnaire, the Community Questionnaire, and the Fieldworker Questionnaire. A Technical Advisory Committee was established to solicit comments on the questionnaires from various stakeholders, including representatives of government ministries and agencies, nongovernmental organisations, and international donors. The survey protocol was reviewed and approved by the National Bioethics Committee, the Pakistan Health Research Council, and the ICF Institutional Review Board. After being finalised in English, the questionnaires were translated into Urdu and Sindhi. The 2019 PMMS used paper-based questionnaires for data collection, while computer-assisted field editing (CAFE) was used to edit questionnaires in the field.

Cleaning operations

The processing of the 2019 PMMS data began simultaneously with the fieldwork. As soon as data collection was completed in each cluster, all electronic data files were transferred via the Internet File Streaming System (IFSS) to the NIPS central office in Islamabad. These data files were registered and checked for inconsistencies, incompleteness, and outliers. A double entry procedure was adopted by NIPS to ensure data accuracy. The field teams were alerted about any inconsistencies and errors. Secondary editing of completed questionnaires, which involved resolving inconsistencies and coding open-ended questions, was carried out in the central office. The survey core team members assisted with secondary editing, and the NIPS data processing manager coordinated the work at the central office. Data entry and editing were carried out using the CSPro software package. The concurrent processing of the data offered a distinct advantage because it maximised the likelihood of the data being error-free and accurate.

Response rate

In the four provinces, the sample contained a total of 116,169 households. All households were visited by the field teams, and 110,483 households were found to be occupied. Of these households, 108,766 were successfully interviewed, yielding a household response rate of 98%. The subsample selected for the Long Household Questionnaire comprised 11,080 households, and interviews were carried out in 10,479 of these households. A total of 12,217 ever-married women age 15-49 were eligible to be interviewed based on the Long Household Questionnaire, and 11,859 of these women were successfully interviewed (a response rate of 97%).

In Azad Jammu and Kashmir, 16,755 households were occupied, and interviews were successfully carried out in 16,588 of these households (99%). A total of 1,707 ever-married women were eligible for individual interviews, of whom 1,666 were successfully interviewed (98%). In Gilgit Baltistan, 11,005 households were occupied, and interviews were conducted in 10,872 households (99%). A total of 1,219 ever-married women were eligible for interviews, of whom 1,178 were successfully interviewed (97%).

A total of 944 verbal autopsy interviews were conducted in Pakistan overall, 150 in Azad Jammu and Kashmir, and 88 in Gilgit Baltistan. The Verbal Autopsy Questionnaire was used in almost all of the interviews, and response rates were nearly 100%.

Sampling error estimates

The estimates from a sample survey are affected by two types of errors: nonsampling errors and sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2019 Pakistan Maternal Mortality Survey (2019 PMMS) to minimise this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically.

Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2019 PMMS is only one of many samples that could have been selected from the same population, using the same design and sample size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability among all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results.

Sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95% of all possible samples of identical size and design.

If the sample of respondents had been selected by simple random sampling, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2019 PMMS sample was the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulas. Sampling errors are computed using SAS programmes developed by ICF. These programmes use the Taylor linearisation method to estimate variances for survey estimates that are means, proportions, or ratios and use the Jackknife repeated replication method for variance estimation of more complex statistics such as fertility and mortality rates.

A more detailed description of estimates of sampling errors are presented in Appendix B of the survey report.

Data appraisal

Data Quality Tables

- Household age distribution

Dataset Description: This dataset contains materials from the Smart Discharges for Mom & Baby parent study within the Smart Discharges program of research. Materials include the parent study ethics protocol and associated documents. See the Metadata section below for links to related publications and datasets. Background: In low-income country settings, the first six weeks after birth remain a critical period of vulnerability for both mother and newborn. Despite recommendations for routine post-discharge follow-up, few mothers and newborns receive guideline recommended care during this period. Prediction modelling of post-delivery outcomes has the potential to improve outcomes for both mother and newborn by identifying high-risk dyads, improving risk communication, and facilitating a patient-centered approach to postnatal care. Methods: This is a mixed-methods study to explore and map the current postnatal discharge processes in Uganda.We will conduct an observational cohort study (Phase I) to develop and internally validate our risk score and aim to recruit 7,000 mother and newborn dyads from Jinja Regional Referral Hospital and Mbarara Regional Referral Hospital. We will also engage with patients, families, and health workers through patient journey mapping and focus group discussions (Phases II-IV) to identify barriers and facilitators to inform the development of an evidence- and risk-based bundle of interventions to improve postnatal care (PNC) for dyads. The primary outcome is maternal and/or neonatal death or need for re-admission within six weeks of birth. Secondary outcomes include: 1. Post-natal care visits during the 6-week post-discharge period 2. Post-discharge health seeking practices for mothers/newborns during the 6-week post-discharge period 3. Causes of readmission/mortality among those who experience such outcomes, based on verbal autopsies and admission symptom/diagnosis questionnaires. Data Collection Methods: All data will be collected at the point of care using encrypted study tablets. These data will be uploaded to a Research Electronic Data Capture (REDCap) database hosted at the BC Children’s Hospital Research Institute (Vancouver, Canada). At admission, trained study nurses will systematically collect data on clinical, social and demographic variables. Following discharge, field officers will contact mothers at 6-weeks post-discharge, to determine vital status, post-discharge health-seeking, and readmission details. Verbal autopsies were conducted for participants who had died following discharge. Direct observation and interviews will be conducted on a sub-set of participants to collect process outcomes and barriers and facilitators to the patient's journey. FGDs will be digitally recorded, transcribed verbatim in the language spoken during the recording and analyzed for emerging themes. Ethics Declaration: Ethics approvals have been obtained from the Makerere University School of Public Health (MakSPH) Institutional Review Board (SPH-2021-177), the Uganda National Council of Science and Technology (UNCST) in Uganda (HS2174ES) and the University of British Columbia in Canada (H21-03709). This study has been registered at clinicaltrials.gov (NCT05730387). Associated datasets: Pending publication NOTE for restricted files: If you are not yet a CoLab member, please complete our membership application survey to gain access to restricted files within 2 business days. Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator on this page under "collaborate with the pediatric sepsis colab."

Reliable statistics on maternal morbidity and mortality are scarce in low and middle-income countries, especially in rural areas. This is the case in Mozambique where many births happen at home. Furthermore, a sizeable number of facility births have inadequate registration. Such information is crucial for developing effective national and global health policies for maternal and child health. The aim of this study was to generate reliable baseline socio-demographic information on women of reproductive age as well as to establish a demographic surveillance platform to support the planning and implementation of the Community Level Intervention for Pre-eclampsia (CLIP) study, a cluster randomized controlled trial. This study represents a census of all women of reproductive age (12–49 years) in twelve rural communities in Maputo and Gaza provinces of Mozambique. The data were collected through electronic forms implemented in Open Data Kit (ODK) (an app for android based tablets) and household and individual characteristics. Verbal autopsies were conducted on all reported maternal deaths to determine the underlying cause of death. Between March and October 2014, 50,493 households and 80,483 women of reproductive age (mean age 26.9 years) were surveyed. A total of 14,617 pregnancies were reported in the twelve months prior to the census, resulting in 9,029 completed pregnancies. Of completed pregnancies, 8,796 resulted in live births, 466 resulted in stillbirths and 288 resulted in miscarriages. The remaining pregnancies had not yet been completed during the time of the survey (5,588 pregnancies). The age specific fertility indicates that highest rate (188 live births per 1,000 women) occurs in the age 20–24 years old. The estimated stillbirth rate was 50.3/1,000 live and stillbirths; neonatal mortality rate was 13.3/1,000 live births and maternal mortality ratio was 204.6/100,000 live births. The most common direct cause of maternal death was eclampsia and tuberculosis was the most common indirect cause of death. This study found that fertility rate is high at age 20–24 years old. Pregnancy in the advanced age (>35 years of age) in this study was associated with higher poor outcomes such as miscarriage and stillbirth. The study also found high stillbirth rate indicating a need for increased attention to maternal health in southern Mozambique. Tuberculosis and HIV/AIDS are prominent indirect causes of maternal death, while eclampsia represents the number one direct obstetric cause of maternal deaths in these communities. Additional efforts to promote safe motherhood and improve child survival are crucial in these communities.

The 2008 National Demographic and Health Survey (2008 NDHS) is a nationally representative survey of 13,594 women age 15-49 from 12,469 households successfully interviewed, covering 794 enumeration areas (clusters) throughout the Philippines. This survey is the ninth in a series of demographic and health surveys conducted to assess the demographic and health situation in the country. The survey obtained detailed information on fertility levels, marriage, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood mortality, maternal and child health, and knowledge and attitudes regarding HIV/AIDS and tuberculosis. Also, for the first time, the Philippines NDHS gathered information on violence against women. The 2008 NDHS was conducted by the Philippine National Statistics Office (NSO). Technical assistance was provided by ICF Macro through the MEASURE DHS program. Funding for the survey was mainly provided by the Government of the Philippines. Financial support for some preparatory and processing phases of the survey was provided by the U.S. Agency for International Development (USAID). Like previous Demographic and Health Surveys (DHS) conducted in the Philippines, the 2008 National Demographic and Health Survey (NDHS) was primarily designed to provide information on population, family planning, and health to be used in evaluating and designing policies, programs, and strategies for improving health and family planning services in the country. The 2008 NDHS also included questions on domestic violence. Specifically, the 2008 NDHS had the following objectives: Collect data at the national level that will allow the estimation of demographic rates, particularly, fertility rates by urban-rural residence and region, and under-five mortality rates at the national level. Analyze the direct and indirect factors which determine the levels and patterns of fertility. Measure the level of contraceptive knowledge and practice by method, urban-rural residence, and region. Collect data on family health: immunizations, prenatal and postnatal checkups, assistance at delivery, breastfeeding, and prevalence and treatment of diarrhea, fever, and acute respiratory infections among children under five years. Collect data on environmental health, utilization of health facilities, prevalence of common noncommunicable and infectious diseases, and membership in health insurance plans. Collect data on awareness of tuberculosis. Determine women's knowledge about HIV/AIDS and access to HIV testing. Determine the extent of violence against women. MAIN RESULTS FERTILITY Fertility Levels and Trends. There has been a steady decline in fertility in the Philippines in the past 36 years. From 6.0 children per woman in 1970, the total fertility rate (TFR) in the Philippines declined to 3.3 children per woman in 2006. The current fertility level in the country is relatively high compared with other countries in Southeast Asia, such as Thailand, Singapore and Indonesia, where the TFR is below 2 children per woman. Fertility Differentials. Fertility varies substantially across subgroups of women. Urban women have, on average, 2.8 children compared with 3.8 children per woman in rural areas. The level of fertility has a negative relationship with education; the fertility rate of women who have attended college (2.3 children per woman) is about half that of women who have been to elementary school (4.5 children per woman). Fertility also decreases with household wealth: women in wealthier households have fewer children than those in poorer households. FAMILY PLANNING Knowledge of Contraception. Knowledge of family planning is universal in the Philippines- almost all women know at least one method of fam-ily planning. At least 90 percent of currently married women have heard of the pill, male condoms, injectables, and female sterilization, while 87 percent know about the IUD and 68 percent know about male sterilization. On average, currently married women know eight methods of family planning. Unmet Need for Family Planning. Unmet need for family planning is defined as the percentage of currently married women who either do not want any more children or want to wait before having their next birth, but are not using any method of family planning. The 2008 NDHS data show that the total unmet need for family planning in the Philippines is 22 percent, of which 13 percent is limiting and 9 percent is for spacing. The level of unmet need has increased from 17 percent in 2003. Overall, the total demand for family planning in the Philippines is 73 percent, of which 69 percent has been satisfied. If all of need were satisfied, a contraceptive prevalence rate of about 73 percent could, theoretically, be expected. Comparison with the 2003 NDHS indicates that the percentage of demand satisfied has declined from 75 percent. MATERNAL HEALTH Antenatal Care. Nine in ten Filipino mothers received some antenatal care (ANC) from a medical professional, either a nurse or midwife (52 percent) or a doctor (39 percent). Most women have at least four antenatal care visits. More than half (54 percent) of women had an antenatal care visit during the first trimester of pregnancy, as recommended. While more than 90 percent of women who received antenatal care had their blood pressure monitored and weight measured, only 54 percent had their urine sample taken and 47 percent had their blood sample taken. About seven in ten women were informed of pregnancy complications. Three in four births in the Philippines are protected against neonatal tetanus. Delivery and Postnatal Care. Only 44 percent of births in the Philippines occur in health facilities-27 percent in a public facility and 18 percent in a private facility. More than half (56 percent) of births are still delivered at home. Sixty-two percent of births are assisted by a health professional-35 percent by a doctor and 27 percent by a midwife or nurse. Thirty-six percent are assisted by a traditional birth attendant or hilot. About 10 percent of births are delivered by C-section. The Department of Health (DOH) recommends that mothers receive a postpartum check within 48 hours of delivery. A majority of women (77 percent) had a postnatal checkup within two days of delivery; 14 percent had a postnatal checkup 3 to 41 days after delivery. CHILD HEALTH Childhood Mortality. Childhood mortality continues to decline in the Philippines. Currently, about one in every 30 children in the Philippines dies before his or her fifth birthday. The infant mortality rate for the five years before the survey (roughly 2004-2008) is 25 deaths per 1,000 live births and the under-five mortality rate is 34 deaths per 1,000 live births. This is lower than the rates of 29 and 40 reported in 2003, respectively. The neonatal mortality rate, representing death in the first month of life, is 16 deaths per 1,000 live births. Under-five mortality decreases as household wealth increases; children from the poorest families are three times more likely to die before the age of five as those from the wealthiest families. There is a strong association between under-five mortality and mother's education. It ranges from 47 deaths per 1,000 live births among children of women with elementary education to 18 deaths per 1,000 live births among children of women who attended college. As in the 2003 NDHS, the highest level of under-five mortality is observed in ARMM (94 deaths per 1,000 live births), while the lowest is observed in NCR (24 deaths per 1,000 live births). NUTRITION Breastfeeding Practices. Eighty-eight percent of children born in the Philippines are breastfed. There has been no change in this practice since 1993. In addition, the median durations of any breastfeeding and of exclusive breastfeeding have remained at 14 months and less than one month, respectively. Although it is recommended that infants should not be given anything other than breast milk until six months of age, only one-third of Filipino children under six months are exclusively breastfed. Complementary foods should be introduced when a child is six months old to reduce the risk of malnutrition. More than half of children ages 6-9 months are eating complementary foods in addition to being breastfed. The Infant and Young Child Feeding (IYCF) guidelines contain specific recommendations for the number of times that young children in various age groups should be fed each day as well as the number of food groups from which they should be fed. NDHS data indicate that just over half of children age 6-23 months (55 percent) were fed according to the IYCF guidelines. HIV/AIDS Awareness of HIV/AIDS. While over 94 percent of women have heard of AIDS, only 53 percent know the two major methods for preventing transmission of HIV (using condoms and limiting sex to one uninfected partner). Only 45 percent of young women age 15-49 know these two methods for preventing HIV transmission. Knowledge of prevention methods is higher in urban areas than in rural areas and increases dramatically with education and wealth. For example, only 16 percent of women with no education know that using condoms limits the risk of HIV infection compared with 69 percent of those who have attended college. TUBERCULOSIS Knowledge of TB. While awareness of tuberculosis (TB) is high, knowledge of its causes and symptoms is less common. Only 1 in 4 women know that TB is caused by microbes, germs or bacteria. Instead, respondents tend to say that TB is caused by smoking or drinking alcohol, or that it is inherited. Symptoms associated with TB are better recognized. Over half of the respondents cited coughing, while 39 percent mentioned weight loss, 35 percent mentioned blood in sputum, and 30 percent cited coughing with sputum. WOMEN'S STATUS Women's Status and Employment.

BackgroundMaternal immunization has gained traction as a strategy to diminish maternal and young infant mortality attributable to infectious diseases. Background rates of adverse pregnancy outcomes are crucial to interpret results of clinical trials in Sub-Saharan Africa. MethodsWe developed a mathematical model that calculates a clinical trial's expected number of neonatal and maternal deaths at an interim safety assessment based on the person-time observed during different risk windows. This model was compared to crude multiplication of the maternal mortality ratio and neonatal mortality rate by the number of live births. Systematic reviews of severe acute maternal morbidity (SAMM), low birth weight (LBW), prematurity, and major congenital malformations (MCM) in Sub-Saharan African countries were also performed. FindingsAccounting for the person-time observed during different risk periods yields lower, more conservative estimates of expected maternal and neonatal deaths, particularly at an interim safety evaluation soon after a large number of deliveries. Median incidence of SAMM in 16 reports was 40.7 (IQR: 10.6–73.3) per 1,000 total births, and the most common causes were hemorrhage (34%), dystocia (22%), and severe hypertensive disorders of pregnancy (22%). Proportions of liveborn infants who were LBW (median 13.3%, IQR: 9.9–16.4) or premature (median 15.4%, IQR: 10.6–19.1) were similar across geographic region, study design, and institutional setting. The median incidence of MCM per 1,000 live births was 14.4 (IQR: 5.5–17.6), with the musculoskeletal system comprising 30%. InterpretationSome clinical trials assessing whether maternal immunization can improve pregnancy and young infant outcomes in the developing world have made ethics-based decisions not to use a pure placebo control. Consequently, reliable background rates of adverse pregnancy outcomes are necessary to distinguish between vaccine benefits and safety concerns. Local studies that quantify population-based background rates of adverse pregnancy outcomes will improve safety assessment of interventions during pregnancy.

IntroductionHypertension is the common disorder encountered during pregnancy, complicating 5% to 10% of all pregnancies. Hypertensive disorders in pregnancy (HDP) are also a leading cause of maternal and perinatal morbidity and mortality. The majority of feto-maternal complications due to HPD have occurred in the low- and middle-income countries. However, few studies have been done to assess the feto-maternal outcomes and the predictors of adverse perinatal outcome among women with HDP in these countries.MethodsA prospective cohort study was conducted on women with HDP who were delivered at National Hospital of Obstetrics and Gynecology, Vietnam from March 2023 to July 2023. Socio-demographic and obstetrics characteristics, and feto-maternal outcomes were obtained by trained study staff from interviews and medical records. Statistical analysis was performed using SPSS version 26.0. Bivariate and multiple logistic regressions were done to determine factors associated with adverse perinatal outcome. A 95% confidence interval not including 1 was considered statically significant.ResultsA total of 255 women with HDP were enrolled. Regarding adverse maternal outcomes, HELLP syndrome (3.9%), placental abruption (1.6%), and eclampsia (1.2%) were three most common complications. There was no maternal death associated with HDP. The most common perinatal complication was preterm delivery developed in 160 (62.7%) of neonates. Eight stillbirths (3.1%) were recorded whereas the perinatal mortality was 6.3%. On bivariate logistic regression, variables such as residence, type of HDP, highest systolic BP, highest diastolic BP, platelet count, severity symptoms, and birth weight were found to be associated with adverse perinatal outcome. On multiple logistic regression, highest diastolic BP, severity symptoms, and birth weight were found to be independent predictors of adverse perinatal outcome.ConclusionOur study showed lower prevalence of stillbirth, perinatal mortality, and maternal complication compared to some previous studies. Regular antenatal care and early detection of abnormal signs during pregnancy help to devise an appropriate monitoring and treatment strategies for each women with HDP.

The 1993 National Demographic Survey (NDS) is a nationally representative sample survey of women age 15-49 designed to collect information on fertility; family planning; infant, child and maternal mortality; and maternal and child health. The survey was conducted between April and June 1993. The 1993 NDS was carried out by the National Statistics Office in collaboration with the Department of Health, the University of the Philippines Population Institute, and other agencies concerned with population, health and family planning issues. Funding for the 1993 NDS was provided by the U.S. Agency for International Development through the Demographic and Health Surveys Program. Close to 13,000 households throughout the country were visited during the survey and more than 15,000 women age 15-49 were interviewed. The results show that fertility in the Philippines continues its gradual decline. At current levels, Filipino women will give birth on average to 4.1 children during their reproductive years, 0.2 children less than that recorded in 1988. However, the total fertility rate in the Philippines remains high in comparison to the level achieved in the neighboring Southeast Asian countries. The primary objective of the 1993 NDS is to provide up-to-date inform ation on fertility and mortality levels; nuptiality; fertility preferences; awareness, approval, and use of family planning methods; breastfeeding practices; and maternal and child health. This information is intended to assist policymakers and administrators in evaluating and designing programs and strategies for improving health and family planning services in 'the country. MAIN RESULTS Fertility varies significantly by region and socioeconomic characteristics. Urban women have on average 1.3 children less than rural women, and uneducated women have one child more than women with college education. Women in Bicol have on average 3 more children than women living in Metropolitan Manila. Virtually all women know of a family planning method; the pill, female sterilization, IUD and condom are known to over 90 percent of women. Four in 10 married women are currently using contraception. The most popular method is female sterilization ( 12 percent), followed by the piU (9 percent), and natural family planning and withdrawal, both used by 7 percent of married women. Contraceptive use is highest in Northern Mindanao, Central Visayas and Southern Mindanao, in urban areas, and among women with higher than secondary education. The contraceptive prevalence rate in the Philippines is markedly lower than in the neighboring Southeast Asian countries; the percentage of married women who were using family planning in Thailand was 66 percent in 1987, and 50 percent in Indonesia in 199l. The majority of contraceptive users obtain their methods from a public service provider (70 percent). Government health facilities mainly provide permanent methods, while barangay health stations or health centers are the main sources for the pill, IUD and condom. Although Filipino women already marry at a relatively higher age, they continue to delay the age at which they first married. Half of Filipino women marry at age 21.6. Most women have their first sexual intercourse after marriage. Half of married women say that they want no more children, and 12 percent have been sterilized. An additional 19 percent want to wait at least two years before having another child. Almost two thirds of women in the Philippines express a preference for having 3 or less children. Results from the survey indicate that if all unwanted births were avoided, the total fertility rate would be 2.9 children, which is almost 30 percent less than the observed rate, More than one quarter of married women in the Philippines are not using any contraceptive method, but want to delay their next birth for two years or more (12 percent), or want to stop childbearing (14 percent). If the potential demand for family planning is satisfied, the contraceptive prevalence rate could increase to 69 percent. The demand for stopping childbearing is about twice the level for spacing (45 and 23 percent, respectively). Information on various aspects of maternal and child health-antenatal care, vaccination, breastfeeding and food supplementation, and illness was collected in the 1993 NDS on births in the five years preceding the survey. The findings show that 8 in 10 children under five were bom to mothers who received antenatal care from either midwives or nurses (45 percent) or doctors (38 percent). Delivery by a medical personnel is received by more than half of children born in the five years preceding the survey. However, the majority of deliveries occurred at home. Tetanus, a leading cause of infant deaths, can be prevented by immunization of the mother during pregnancy. In the Philippines, two thirds of bitlhs in the five years preceding the survey were to mothers who received a tetanus toxoid injection during pregnancy. Based on reports of mothers and information obtained from health cards, 90 percent of children aged 12-23 months have received shots of the BCG as well as the first doses of DPT and polio, and 81 percent have received immunization from measles. Immunization coverage declines with doses; the drop out rate is 3 to 5 percent for children receiving the full dose series of DPT and polio. Overall, 7 in 10 children age 12-23 months have received immunization against the six principal childhood diseases-polio, diphtheria, ~rtussis, tetanus, measles and tuberculosis. During the two weeks preceding the survey, 1 in 10 children under 5 had diarrhea. Four in ten of these children were not treated. Among those who were treated, 27 percent were given oral rehydration salts, 36 percent were given recommended home solution or increased fluids. Breasffeeding is less common in the Philippines than in many other developing countries. Overall, a total of 13 percent of children born in the 5 years preceding the survey were not breastfed at all. On the other hand, bottle feeding, a widely discouraged practice, is relatively common in the Philippines. Children are weaned at an early age; one in four children age 2-3 months were exclusively breastfed, and the mean duration of breastfeeding is less than 3 months. Infant and child mortality in the Philippines have declined significantly in the past two decades. For every 1,000 live births, 34 infants died before their first birthday. Childhood mortality varies significantly by mother's residence and education. The mortality of urban infants is about 40 percent lower than that of rural infants. The probability of dying among infants whose mother had no formal schooling is twice as high as infants whose mother have secondary or higher education. Children of mothers who are too young or too old when they give birth, have too many prior births, or give birth at short intervals have an elevated mortality risk. Mortality risk is highest for children born to mothers under age 19. The 1993 NDS also collected information necessary for the calculation of adult and maternal mortality using the sisterhood method. For both males and females, at all ages, male mortality is higher than that of females. Matemal mortality ratio for the 1980-1986 is estimated at 213 per 100,000 births, and for the 1987-1993 period 209 per 100,000 births. However, due to the small number of sibling deaths reported in the survey, age-specific rates should be used with caution. Information on health and family planning services available to the residents of the 1993 NDS barangay was collected from a group of respondents in each location. Distance and time to reach a family planning service provider has insignificant association with whether a woman uses contraception or the choice of contraception being used. On the other hand, being close to a hospital increases the likelihood that antenatal care and births are to respondents who receive ANC and are delivered by a medical personnel or delivered in a health facility.

Background - We have previously estimated that respiratory syncytial virus (RSV) was associated with 22% of all episodes of (severe) acute lower respiratory infection (ALRI) resulting in 55000 to 199000 deaths in children younger than 5 years in 2005. In the past 5 years, major research activity on RSV has yielded substantial new data from developing countries. With a considerably expanded dataset from a large international collaboration, we aimed to estimate the global incidence, hospital admission rate, and mortality from RSV-ALRI episodes in young children in 2015. Methods - We estimated the incidence and hospital admission rate of RSV-associated ALRI (RSV-ALRI) in children younger than 5 years stratified by age and World Bank income regions from a systematic review of studies published between Jan 1, 1995, and Dec 31, 2016, and unpublished data from 76 high quality population-based studies. We estimated the RSV-ALRI incidence for 132 developing countries using a risk factor-based model and 2015 population estimates. We estimated the in-hospital RSV-ALRI mortality by combining in-hospital case fatality ratios with hospital admission estimates from hospital-based (published and unpublished) studies. We also estimated overall RSV-ALRI mortality by identifying studies reporting monthly data for ALRI mortality in the community and RSV activity. Findings - We estimated that globally in 2015, 33*1 million (uncertainty range [UR] 21*6-50*3) episodes of RSV-ALRI, resulted in about 3*2 million (2*7-3*8) hospital admissions, and 59 600 (48 000-74 500) in-hospital deaths in children younger than 5 years. In children younger than 6 months, 1*4 million (UR 1*2-1*7) hospital admissions, and 27 300 (UR 20 700-36 200) in-hospital deaths were due to RSV-ALRI. We also estimated that the overall RSV-ALRI mortality could be as high as 118 200 (UR 94 600-149 400). Incidence and mortality varied substantially from year to year in any given population. Interpretation Globally, RSV is a common cause of childhood ALRI and a major cause of hospital admissions in young children, resulting in a substantial burden on health-care services. About 45% of hospital admissions and in- hospital deaths due to RSV-ALRI occur in children younger than 6 months. An effective maternal RSV vaccine or monoclonal antibody could have a substantial effect on disease burden in this age group.

Abstract

The Tanzania Demographic and Health Survey (TDHS) is part of the worldwide Demographic and Health Surveys (DHS) programme, which is designed to collect data on fertility, family planning, and maternal and child health.

The primary objective of the 1999 TRCHS was to collect data at the national level (with breakdowns by urban-rural and Mainland-Zanzibar residence wherever warranted) on fertility levels and preferences, family planning use, maternal and child health, breastfeeding practices, nutritional status of young children, childhood mortality levels, knowledge and behaviour regarding HIV/AIDS, and the availability of specific health services within the community.1 Related objectives were to produce these results in a timely manner and to ensure that the data were disseminated to a wide audience of potential users in governmental and nongovernmental organisations within and outside Tanzania. The ultimate intent is to use the information to evaluate current programmes and to design new strategies for improving health and family planning services for the people of Tanzania.

Geographic coverage

National. The sample was designed to provide estimates for the whole country, for urban and rural areas separately, and for Zanzibar and, in some cases, Unguja and Pemba separately.

Analysis unit

Households, individuals

Universe

Men and women 15-49, children under 5

Kind of data

Sample survey data

Sampling procedure

The TRCHS used a three-stage sample design. Overall, 176 census enumeration areas were selected (146 on the Mainland and 30 in Zanzibar) with probability proportional to size on an approximately self-weighting basis on the Mainland, but with oversampling of urban areas and Zanzibar. To reduce costs and maximise the ability to identify trends over time, these enumeration areas were selected from the 357 sample points that were used in the 1996 TDHS, which in turn were selected from the 1988 census frame of enumeration in a two-stage process (first wards/branches and then enumeration areas within wards/branches). Before the data collection, fieldwork teams visited the selected enumeration areas to list all the households. From these lists, households were selected to be interviewed. The sample was designed to provide estimates for the whole country, for urban and rural areas separately, and for Zanzibar and, in some cases, Unguja and Pemba separately. The health facilities component of the TRCHS involved visiting hospitals, health centres, and pharmacies located in areas around the households interviewed. In this way, the data from the two components can be linked and a richer dataset produced.

See detailed sample implementation in the APPENDIX A of the final report.

Mode of data collection

Face-to-face

Research instrument

The household survey component of the TRCHS involved three questionnaires: 1) a Household Questionnaire, 2) a Women’s Questionnaire for all individual women age 15-49 in the selected households, and 3) a Men’s Questionnaire for all men age 15-59.

The health facilities survey involved six questionnaires: 1) a Community Questionnaire administered to men and women in each selected enumeration area; 2) a Facility Questionnaire; 3) a Facility Inventory; 4) a Service Provider Questionnaire; 5) a Pharmacy Inventory Questionnaire; and 6) a questionnaire for the District Medical Officers.

All these instruments were based on model questionnaires developed for the MEASURE programme, as well as on the questionnaires used in the 1991-92 TDHS, the 1994 TKAP, and the 1996 TDHS. These model questionnaires were adapted for use in Tanzania during meetings with representatives from the Ministry of Health, the University of Dar es Salaam, the Tanzania Food and Nutrition Centre, USAID/Tanzania, UNICEF/Tanzania, UNFPA/Tanzania, and other potential data users. The questionnaires and manual were developed in English and then translated into and printed in Kiswahili.

The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including his/her age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for individual interview and children under five who were to be weighed and measured. Information was also collected about the dwelling itself, such as the source of water, type of toilet facilities, materials used to construct the house, ownership of various consumer goods, and use of iodised salt. Finally, the Household Questionnaire was used to collect some rudimentary information about the extent of child labour.

The Women’s Questionnaire was used to collect information from women age 15-49. These women were asked questions on the following topics: · Background characteristics (age, education, religion, type of employment) · Birth history · Knowledge and use of family planning methods · Antenatal, delivery, and postnatal care · Breastfeeding and weaning practices · Vaccinations, birth registration, and health of children under age five · Marriage and recent sexual activity · Fertility preferences · Knowledge and behaviour concerning HIV/AIDS.

The Men’s Questionnaire covered most of these same issues, except that it omitted the sections on the detailed reproductive history, maternal health, and child health. The final versions of the English questionnaires are provided in Appendix E.

Before the questionnaires could be finalised, a pretest was done in July 1999 in Kibaha District to assess the viability of the questions, the flow and logical sequence of the skip pattern, and the field organisation. Modifications to the questionnaires, including wording and translations, were made based on lessons drawn from the exercise.

Response rate

In all, 3,826 households were selected for the sample, out of which 3,677 were occupied. Of the households found, 3,615 were interviewed, representing a response rate of 98 percent. The shortfall is primarily due to dwellings that were vacant or in which the inhabitants were not at home despite of several callbacks.

In the interviewed households, a total of 4,118 eligible women (i.e., women age 15-49) were identified for the individual interview, and 4,029 women were actually interviewed, yielding a response rate of 98 percent. A total of 3,792 eligible men (i.e., men age 15-59), were identified for the individual interview, of whom 3,542 were interviewed, representing a response rate of 93 percent. The principal reason for nonresponse among both eligible men and women was the failure to find them at home despite repeated visits to the household. The lower response rate among men than women was due to the more frequent and longer absences of men.

The response rates are lower in urban areas due to longer absence of respondents from their homes. One-member households are more common in urban areas and are more difficult to interview because they keep their houses locked most of the time. In urban settings, neighbours often do not know the whereabouts of such people.

Sampling error estimates

The estimates from a sample survey are affected by two types of errors: (1) non-sampling errors, and (2) sampling errors. Non-sampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the TRCHS to minimise this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically.

Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the TRCHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results.

A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design.

If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the TRCHS sample is the result of a two-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the TRCHS is the ISSA Sampling Error Module (SAMPERR). This module used the Taylor linearisation method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rate

Note: See detailed sampling error

BackgroundPostpartum hemorrhage (PPH) is a leading cause of maternal mortality in Nigeria and in most low- and middle-income countries. The World Health Organization (WHO) strongly recommends oxytocin as effective, affordable, and the safest drug of first choice in the prevention and treatment of PPH in the third stage of labor. However, there are concerns about its quality. Very high prevalence of poor-quality oxytocin, especially in Africa and Asia, has been reported in literature. Excessive and inappropriate use of oxytocin is also common in low-resource settings.ObjectiveTo assess clinical experiences with quality of oxytocin used by healthcare providers in Lagos State, Nigeria.MethodsThis was a descriptive cross-sectional study conducted in 2017, with 705 respondents (doctors and nurses) who use oxytocin for obstetrics and gynecological services recruited from 195 health facilities (public and registered private) across Lagos State. Data collection was quantitative, using a pretested self-administered questionnaire. Data analysis was performed with IBM SPSS version 21. Statistical significance was set at 5 percent (p

Abstract

This study examines various dimensions of primary health care delivery in Uganda, using a baseline survey of public and private dispensaries, the most common lower level health facilities in the country.

The survey was designed and implemented by the World Bank in collaboration with the Makerere Institute for Social Research and the Ugandan Ministries of Health and of Finance, Planning and Economic Development. It was carried out in October - December 2000 and covered 155 local health facilities and seven district administrations in ten districts. In addition, 1617 patients exiting health facilities were interviewed. Three types of dispensaries (both with and without maternity units) were included: those run by the government, by private for-profit providers, and by private nonprofit providers, mainly religious.

This research is a Quantitative Service Delivery Survey (QSDS). It collected microlevel data on service provision and analyzed health service delivery from a public expenditure perspective with a view to informing expenditure and budget decision-making, as well as sector policy.

Objectives of the study included: 1) Measuring and explaining the variation in cost-efficiency across health units in Uganda, with a focus on the flow and use of resources at the facility level; 2) Diagnosing problems with facility performance, including the extent of drug leakage, as well as staff performance and availability;
3) Providing information on pricing and user fee policies and assessing the types of service actually provided; 4) Shedding light on the quality of service across the three categories of service provider - government, for-profit, and nonprofit; 5) Examining the patterns of remuneration, pay structure, and oversight and monitoring and their effects on health unit performance; 6) Assessing the private-public partnership, particularly the program of financial aid to nonprofits.

Geographic coverage

The study districts were Mpigi, Mukono, and Masaka in the central region; Mbale, Iganga, and Soroti in the east; Arua and Apac in the north; and Mbarara and Bushenyi in the west.

Analysis unit

• local dispensary with or without maternity unit

Universe

The survey covered government, for-profit and nonprofit private dispensaries with or without maternity units in ten Ugandan districts.

Kind of data

Sample survey data [ssd]

Sampling procedure

The survey covered government, for-profit and nonprofit private dispensaries with or without maternity units in ten Ugandan districts.

The sample design was governed by three principles. First, to ensure a degree of homogeneity across sampled facilities, attention was restricted to dispensaries, with and without maternity units (that is, to the health center III level). Second, subject to security constraints, the sample was intended to capture regional differences. Finally, the sample had to include facilities in the main ownership categories: government, private for-profit, and private nonprofit (religious organizations and NGOs). The sample of government and nonprofit facilities was based on the Ministry of Health facility register for 1999. Since no nationwide census of for-profit facilities was available, these facilities were chosen by asking sampled government facilities to identify the closest private dispensary.

Of the 155 health facilities surveyed, 81 were government facilities, 30 were private for-profit facilities, and 44 were nonprofit facilities. An exit poll of clients covered 1,617 individuals.

The final sample consisted of 155 primary health care facilities drawn from ten districts in the central, eastern, northern, and western regions of the country. It included government, private for-profit, and private nonprofit facilities. The nonprofit sector includes facilities owned and operated by religious organizations and NGOs. Approximately one third of the surveyed facilities were dispensaries without maternity units; the rest provided maternity care. The facilities varied considerably in size, from units run by a single individual to facilities with as many as 19 staff members.

Ministry of Health facility register for 1999 was used to design the sampling frame. Ten districts were randomly selected. From the selected districts, a sample of government and private nonprofit facilities and a reserve list of replacement facilities were randomly drawn. Because of the unreliability of the register for private for-profit facilities, it was decided that for-profit facilities would be identified on the basis of information from the government facilities sampled. The administrative records for facilities in the original sample were first reviewed at the district headquarters, where some facilities that did not meet selection criteria and data collection requirements were dropped from the sample. These were replaced by facilities from the reserve list. Overall, 30 facilities were replaced.

The sample was designed in such a way that the proportion of facilities drawn from different regions and ownership categories broadly mirrors that of the universe of facilities. Because no nationwide census of for-profit health facilities is available, it is difficult to assess the extent to which the sample is representative of this category. A census of health care facilities in selected districts, carried out in the context of the Delivery of Improved Services for Health (DISH) project supported by the U.S. Agency for International Development (USAID), suggests that about 63 percent of all facilities operate on a for-profit basis, while government and nonprofit providers run 26 and 11 percent of facilities, respectively. This would suggest an undersampling of private providers in the survey. It is not clear, however, whether the DISH districts are representative of other districts in Uganda in terms of the market for health care.

For the exit poll, 10 interviews per facility were carried out in approximately 85 percent of the facilities. In the remaining facilities the target of 10 interviews was not met, as a result of low activity levels.

Sampling deviation

In the first stage in the sampling process, eight districts (out of 45) had to be dropped from the sample frame due to security concerns. These districts were Bundibugyo, Gulu, Kabarole, Kasese, Kibaale, Kitgum, Kotido, and Moroto.

Mode of data collection

Face-to-face [f2f]

Research instrument

The following survey instruments are available:

• District Health Team Questionnaire;
• District Facility Data Sheets;
• Uganda Health Facility Survey Questionnaire;
• Facility Data Sheets;
• Facility Patient Exit Poll Questionnaire.

The survey collected data at three levels: district administration, health facility, and client. In this way it was possible to capture central elements of the relationships between the provider organization, the frontline facility, and the user. In addition, comparison of data from different levels (triangulation) permitted cross-validation of information.

At the district level, a District Health Team Questionnaire was administered to the district director of health services (DDHS), who was interviewed on the role of the DDHS office in health service delivery. Specifically, the questionnaire collected data on health infrastructure, staff training, support and supervision arrangements, and sources of financing.

The District Facility Data Sheet was used at the district level to collect more detailed information on the sampled health units for fiscal 1999-2000, including data on staffing and the related salary structures, vaccine supplies and immunization activity, and basic and supplementary supplies of drugs to the facilities. In addition, patient data, including monthly returns from facilities on total numbers of outpatients, inpatients, immunizations, and deliveries, were reviewed for the period April-June 2000.

At the facility level, the Uganda Health Facility Survey Questionnaire collected a broad range of information related to the facility and its activities. The questionnaire, which was administered to the in-charge, covered characteristics of the facility (location, type, level, ownership, catchment area, organization, and services); inputs (staff, drugs, vaccines, medical and nonmedical consumables, and capital inputs); outputs (facility utilization and referrals); financing (user charges, cost of services by category, expenditures, and financial and in-kind support); and institutional support (supervision, reporting, performance assessment, and procurement). Each health facility questionnaire was supplemented by a Facility Data Sheet (FDS). The FDS was designed to obtain data from the health unit records on staffing and the related salary structure; daily patient records for fiscal 1999-2000; the type of patients using the facility; vaccinations offered; and drug supply and use at the facility.

Finally, at the facility level, an exit poll was used to interview about 10 patients per facility on the cost of treatment, drugs received, perceived quality of services, and reasons for using that unit instead of alternative sources of health care.

Cleaning operations

Detailed information about data editing procedures is available in "Data Cleaning Guide for PETS/QSDS Surveys" in external resources.

STATA cleaning do-files and the data quality reports on the datasets can also be found in external resources.

BackgroundSeveral studies have shown that the impact of maternal mental health disorders on newborns’ well-being in low and middle-income countries (LMIC) are underreported, multi-dimensional and varies over time and differs from what is reported in high-income countries. We present the prevalence and risk factors associated with common mental disorders (CMDs) among breastfeeding mothers whose infants were admitted to Nigerian tertiary care facilities.MethodsThis was a national cross-sectional study involving mothers of hospitalised babies from eleven Nigerian tertiary hospitals. We used the WHO self-reporting Questionnaire 20 and an adapted WHO/UNICEF ten-step breastfeeding support package to assess mothers’ mental health and breastfeeding support.ResultsOnly 895 of the 1,120 mothers recruited from eleven tertiary healthcare nurseries in six geopolitical zones of Nigeria had complete datasets for analysis. The participants’ mean age was 29.9 ± 6.2 years. One in four had CMDs; 24.0% (95% CI: 21.235, 26.937%). The ages of mothers, parity, gestational age at delivery, and length of hospital stay were comparable between mothers with and those without CMDs. Antenatal care at primary healthcare facilities (adjusted odds ratio [aOR:13], primary education [aOR:3.255] living in the south-southern region of the country [aOR 2.207], poor breastfeeding support [aOR:1.467], polygamous family settings [aOR:2.182], and a previous history of mental health disorders [aOR:4.684] were significantly associated with CMDs. In contrast, those from the middle and lower socioeconomic classes were less likely to develop CMDs, with [aOR:0.532] and [aOR:0.493], respectively.ConclusionIn Nigeria, the prevalence of CMDs is relatively high among breastfeeding mothers with infants admitted to a tertiary care facility. Prior history of mental illness, polygamous households, mothers living in the southern region and low or no educational attainment have a greater risk of developing CMDs. This study provides evidence for assessing and tailoring interventions to CMDs among breastfeeding mothers in neonatal nurseries in LMIC.

BackgroundOf the total 56 million deaths worldwide during 2012, 38 million (68%) were due to noncommunicable diseases (NCDs), particularly cardiovascular diseases (17.5 million deaths) cancers (8.2 million) which represents46.2% and 21.7% of NCD deaths, respectively). Nearly 80 percent of the global CVD deaths occur in low- and middle-income countries. Some of the major CVDs such as ischemic heart disease (IHD) and stroke and CVD risk conditions, namely, hypertension and dyslipidaemia share common modifiable risk factors including smoking, unhealthy diets, harmful use of alcohol and physical inactivity. The CVDs are now putting a heavy strain of the health systems at both national and local levels, which have previously largely focused on infectious diseases and appalling maternal and child health. We set out to estimate district-level co-occurrence of two cardiovascular diseases (CVDs), namely, ischemic heart disease (IHD) and stroke; and two major risk conditions for CVD, namely, hypertension and dyslipidaemia in South Africa.MethodThe analyses were based on adults health collected as part of the 2012 South African National Health and Nutrition Examination Survey (SANHANES). We used joint disease mapping models to estimate and map the spatial distributions of risks of hypertension, self-report of ischaemic heart disease (IHD), stroke and dyslipidaemia at the district level in South Africa. The analyses were adjusted for known individual social demographic and lifestyle factors, household and district level poverty measurements using binary spatial models.ResultsThe estimated prevalence of IHD, stroke, hypertension and dyslipidaemia revealed high inequality at the district level (median value (range): 5.4 (0–17.8%); 1.7 (0–18.2%); 32.0 (12.5–48.2%) and 52.2 (0–71.7%), respectively). The adjusted risks of stroke, hypertension and IHD were mostly high in districts in the South-Eastern parts of the country, while that of dyslipidaemia, was high in Central and top North-Eastern corridor of the country.ConclusionsThe study has confirmed common modifiable risk factors of two cardiovascular diseases (CVDs), namely, ischemic heart disease (IHD) and stroke; and two major risk conditions for CVD, namely, hypertension and dyslipidaemia. Accordingly, an integrated intervention approach addressing cardiovascular diseases and associated risk factors and conditions would be more cost effective and provide stronger impacts than individual tailored interventions only. Findings of excess district-level variations in the CVDs and their risk factor profiles might be useful for developing effective public health policies and interventions aimed at reducing behavioural risk factors including harmful use of alcohol, physical inactivity and high salt intake.

BackgroundPerinatal mortality and morbidity continue to be major global health challenges strongly associated with prematurity and reduced fetal growth, an issue of further interest given the mounting evidence that fetal growth in general is linked to degrees of risk of common noncommunicable diseases in adulthood. Against this background, WHO made it a high priority to provide the present fetal growth charts for estimated fetal weight (EFW) and common ultrasound biometric measurements intended for worldwide use.Methods and FindingsWe conducted a multinational prospective observational longitudinal study of fetal growth in low-risk singleton pregnancies of women of high or middle socioeconomic status and without known environmental constraints on fetal growth. Centers in ten countries (Argentina, Brazil, Democratic Republic of the Congo, Denmark, Egypt, France, Germany, India, Norway, and Thailand) recruited participants who had reliable information on last menstrual period and gestational age confirmed by crown–rump length measured at 8–13 wk of gestation. Participants had anthropometric and nutritional assessments and seven scheduled ultrasound examinations during pregnancy. Fifty-two participants withdrew consent, and 1,387 participated in the study.At study entry, median maternal age was 28 y (interquartile range [IQR] 25–31), median height was 162 cm (IQR 157–168), median weight was 61 kg (IQR 55–68), 58% of the women were nulliparous, and median daily caloric intake was 1,840 cal (IQR 1,487–2,222).The median pregnancy duration was 39 wk (IQR 38–40) although there were significant differences between countries, the largest difference being 12 d (95% CI 8–16). The median birthweight was 3,300 g (IQR 2,980–3,615). There were differences in birthweight between countries, e.g., India had significantly smaller neonates than the other countries, even after adjusting for gestational age. Thirty-one women had a miscarriage, and three fetuses had intrauterine death.The 8,203 sets of ultrasound measurements were scrutinized for outliers and leverage points, and those measurements taken at 14 to 40 wk were selected for analysis. A total of 7,924 sets of ultrasound measurements were analyzed by quantile regression to establish longitudinal reference intervals for fetal head circumference, biparietal diameter, humerus length, abdominal circumference, femur length and its ratio with head circumference and with biparietal diameter, and EFW. There was asymmetric distribution of growth of EFW: a slightly wider distribution among the lower percentiles during early weeks shifted to a notably expanded distribution of the higher percentiles in late pregnancy.Male fetuses were larger than female fetuses as measured by EFW, but the disparity was smaller in the lower quantiles of the distribution (3.5%) and larger in the upper quantiles (4.5%). Maternal age and maternal height were associated with a positive effect on EFW, particularly in the lower tail of the distribution, of the order of 2% to 3% for each additional 10 y of age of the mother and 1% to 2% for each additional 10 cm of height. Maternal weight was associated with a small positive effect on EFW, especially in the higher tail of the distribution, of the order of 1.0% to 1.5% for each additional 10 kg of bodyweight of the mother. Parous women had heavier fetuses than nulliparous women, with the disparity being greater in the lower quantiles of the distribution, of the order of 1% to 1.5%, and diminishing in the upper quantiles. There were also significant differences in growth of EFW between countries. In spite of the multinational nature of the study, sample size is a limiting factor for generalization of the charts.ConclusionsThis study provides WHO fetal growth charts for EFW and common ultrasound biometric measurements, and shows variation between different parts of the world.