Variation of caesarean section rates in Palestinian governmental hospitals.

BACKGROUND: Globally, the increased use of cesarean sections has become prevalent in high-income and low and middle-income countries. In Palestine, the rate had risen from 20.3% in 2014 to 25.1% in 2018. We have rates as high as 35.8% in some governmental hospitals and some as low as 15%. This study aimed to understand better why there is a variation in cesarean rates in governmental hospitals that use the same guidelines. METHODS: A qualitative and quantitative research approach was used. In-depth interviews were conducted with 27 specialists, obstetrics and gynecologists, and midwives in five government hospitals. The hospitals were selected based on the 2017 Annual Health Report reported cesarean section rates. The interview guide was created with the support of specialists and researchers and was piloted. Questions focused mainly on adherence to the obstetric guidelines and barriers to the use, sources of information, training for healthcare providers, the hospital system, and the factors that affect decision-making. Each hospital's delivery records for one month were analyzed to determine the reason for each cesarean section. RESULTS: The results indicated that each governmental hospital at the system level had a different policy on cesarean sections. The National Guidelines were found to be interpreted differently among hospitals. One obstetrician-gynecologist decided on a cesarean section at high-rate hospitals, while low-rate hospitals used collective decision-making with empowered midwives. At the professional level, all hospitals urged the importance of a continuous training program to refresh the medical team knowledge, in-house training of new members joining the hospital, and discussion of cases subjective to obstetrician-gynecologists interpretations. CONCLUSION: Several institutional factors were identified to strengthen the implementation of the national obstetric guidelines. For example, encouraging collective decision-making between obstetrician-gynecologists and midwives, promoting the use of a second opinion, and mandatory training.

Post-traumatic stress disorder among victims of great march of return in the Gaza Strip, Palestine: A need for policy intervention.

This study aimed to assess the level of Post-Traumatic Stress Disorder (PSTD) and to examine the relationship between exposure to war stress and posttraumatic symptoms among people who were injured during the Great March of Return (GMR) in the Gaza Strip, Palestine. A sample of 264 adults who were injured during participation in the events of GMR completed the Impact Event Scale-Revised (IES-R). IES-R has three sub-scales; intrusion, avoidance, and hyper-arousal. Only 27.3% of the participants had two or more injuries and 38.4% of participants reported having disability due to their injuries. The results showed that 95.4% of the participants had severe posttraumatic symptoms. Total score of IES-R ranged between 29 and 88 (mean = 61.28). The most frequent symptoms of trauma subscales was "Intrusion" (mean = 2.90), followed by "Avoidance" (mean = 2.73), and then "Hyper-arousal" (mean = 2.70). Level of PTSD was affected by working status, need for hospitalization, need for a referral for treatment outside the Gaza Strip, disability and severity of injury. Such high level of PSTD will have negative consequences on participants' physical and mental status. Therefore, a need for special counseling programs is required to help them to survive with least consequences of PTSD on their wellbeing.

WHO/International Society of Hypertension risk prediction charts versus the UK Prospective Diabetes Study risk engine for cardiovascular risk assessment among patients with type 2 diabetes: a comparative study.

BACKGROUND: Patients with type 2 diabetes are at increased risk of developing cardiovascular diseases, and assessment of cardiac risk is important for preventive strategies. We compared the performance of two cardiac assessment tools to predict 10-year cardiovascular risk. METHODS: This was a retrospective study of patients with type 2 diabetes who attended two primary-health-care centres in the Gaza Strip from Sept 15 to Nov 15, 2019. We excluded patients who had any existing cardiovascular disease. 10-year cardiovascular risk assessment was done with two risk assessment tools: the WHO/International Society of Hypertension (WHO/ISH) risk prediction charts and the UK Prospective Diabetes Study (UKPDS) risk engine. We also assessed the need for prescribing statins based on the documented risk. FINDINGS: Of 350 patients assessed, 200 were eligible for the study. WHO/ISH charts classified 135 (68%) patients as being at low of cardiac events and the UKPDS risk engine classified 100 (50%). WHO/ISH assigned 40 (20%) people to the low to moderate 10-year risk category compared with 52 (26%) assigned by the UKPDS risk engine. Agreement between the two tools was poor (p=0·01). 12 (6%) patients who were classified as being at very low 10-year cardiac risk by WHO/ISH were classified as being at very high risk when assessed by the UKPDS risk engine. Furthermore, 150 (75%) of individuals who were categorised as having low cardiac risk by WHO/ISH had higher LDL-cholesterol concentrations than the therapeutic target of 100 mg/dL. Meanwhile, the UKPD risk engine, which uses a higher number of parameters for assessment, identified these individuals as having moderate to high risk. Based on risk documented in the medical records, 33 patients needed statin therapy of whom 12 (36%) patients were receiving this treatment. Among the remaining 167 patients who did not need statin therapy, treatment was prescribed for 57 (34%). INTERPRETATION: There is a significant discrepancy between the WHO/ISH risk charts and the UKPDS risk engine in assigning cardiac risk. Sensitivity in identifying patients with treatable levels of LDL cholesterol and diastolic blood pressure was low for both tools. Furthermore, a lack of clear local protocols led to incorrect or unnecessary prescribing. This study showed that there is a need to reconsider the use of assessment tools either by adding a new tool or by improving assessments with the current tools. FUNDING: None.