Clinical and nutritional correlates of bacterial diarrhoea aetiology in young children: a secondary cross-sectional analysis of the ABCD trial.

OBJECTIVE: The objective was to assess the association between nutritional and clinical characteristics and quantitative PCR (qPCR)-diagnosis of bacterial diarrhoea in a multicentre cohort of children under 2 years of age with moderate to severe diarrhoea (MSD). DESIGN: A secondary cross-sectional analysis of baseline data collected from the AntiBiotics for Children with Diarrhoea trial (NCT03130114). PATIENTS: Children with MSD (defined as >3 loose stools within 24 hours and presenting with at least one of the following: some/severe dehydration, moderate acute malnutrition (MAM) or severe stunting) enrolled in the ABCD trial and collected stool sample. STUDY PERIOD: June 2017-July 2019. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Likely bacterial aetiology of diarrhoea. Secondary outcomes included specific diarrhoea aetiology. RESULTS: A total of 6692 children with MSD had qPCR results available and 28% had likely bacterial diarrhoea aetiology. Compared with children with severe stunting, children with MAM (adjusted OR (aOR) (95% CI) 1.56 (1.18 to 2.08)), some/severe dehydration (aOR (95% CI) 1.66 (1.25 to 2.22)) or both (aOR (95% CI) 2.21 (1.61 to 3.06)), had higher odds of having likely bacterial diarrhoea aetiology. Similar trends were noted for stable toxin-enterotoxigenic Escherichia coli aetiology. Clinical correlates including fever and prolonged duration of diarrhoea were not associated with likely bacterial aetiology; children with more than six stools in the previous 24 hours had higher odds of likely bacterial diarrhoea (aOR (95% CI) 1.20 (1.05 to 1.36)) compared with those with fewer stools. CONCLUSION: The presence of MAM, dehydration or high stool frequency may be helpful in identifying children with MSD who might benefit from antibiotics.

Azithromycin for Bacterial Watery Diarrhea: A Reanalysis of the AntiBiotics for Children With Severe Diarrhea (ABCD) Trial Incorporating Molecular Diagnostics.

BACKGROUND: Bacterial pathogens cause substantial diarrhea morbidity and mortality among children living in endemic settings, yet antimicrobial treatment is only recommended for dysentery or suspected cholera. METHODS: AntiBiotics for Children with severe Diarrhea was a 7-country, placebo-controlled, double-blind efficacy trial of azithromycin in children 2-23 months of age with watery diarrhea accompanied by dehydration or malnutrition. We tested fecal samples for enteric pathogens utilizing quantitative polymerase chain reaction to identify likely and possible bacterial etiologies and employed pathogen-specific cutoffs based on genomic target quantity in previous case-control diarrhea etiology studies to identify likely and possible bacterial etiologies. RESULTS: Among 6692 children, the leading likely etiologies were rotavirus (21.1%), enterotoxigenic Escherichia coli encoding heat-stable toxin (13.3%), Shigella (12.6%), and Cryptosporidium (9.6%). More than one-quarter (1894 [28.3%]) had a likely and 1153 (17.3%) a possible bacterial etiology. Day 3 diarrhea was less common in those randomized to azithromycin versus placebo among children with a likely bacterial etiology (risk difference [RD]likely, -11.6 [95% confidence interval {CI}, -15.6 to -7.6]) and possible bacterial etiology (RDpossible, -8.7 [95% CI, -13.0 to -4.4]) but not in other children (RDunlikely, -0.3% [95% CI, -2.9% to 2.3%]). A similar association was observed for 90-day hospitalization or death (RDlikely, -3.1 [95% CI, -5.3 to -1.0]; RDpossible, -2.3 [95% CI, -4.5 to -.01]; RDunlikely, -0.6 [95% CI, -1.9 to .6]). The magnitude of risk differences was similar among specific likely bacterial etiologies, including Shigella. CONCLUSIONS: Acute watery diarrhea confirmed or presumed to be of bacterial etiology may benefit from azithromycin treatment. CLINICAL TRIALS REGISTRATION: NCT03130114.

National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis.

BACKGROUND: Preterm birth is the leading cause of neonatal mortality and is associated with long-term physical, neurodevelopmental, and socioeconomic effects. This study updated national preterm birth rates and trends, plus novel estimates by gestational age subgroups, to inform progress towards global health goals and targets, and aimed to update country, regional, and global estimates of preterm birth for 2020 in addition to trends between 2010 and 2020. METHODS: We systematically searched population-based, nationally representative data on preterm birth from Jan 1, 2010, to Dec 31, 2020 and study data (26 March-14 April, 2021) for countries and areas with no national-level data. The analysis included 679 data points (86% nationally representative administrative data [582 of 679 data points]) from 103 countries and areas (62% of countries and areas having nationally representative administrative data [64 of 103 data points]). A Bayesian hierarchical regression was used for estimating country-level preterm rates, which incoporated country-specific intercepts, low birthweight as a covariate, non-linear time trends, and bias adjustments based on a data quality categorisation, and other indicators such as method of gestational age estimation. FINDINGS: An estimated 13·4 million (95% credible interval [CrI] 12·3-15·2 million) newborn babies were born preterm (<37 weeks) in 2020 (9·9% of all births [95% CrI 9·1-11·2]) compared with 13·8 million (12·7-15·5 million) in 2010 (9·8% of all births [9·0-11·0]) worldwide. The global annual rate of reduction was estimated at -0·14% from 2010 to 2020. In total, 55·6% of total livebirths are in southern Asia (26·8% [36 099 000 of 134 767 000]) and sub-Saharan Africa (28·7% [38 819 300 of 134 767 000]), yet these two regions accounted for approximately 65% (8 692 000 of 13 376 200) of all preterm births globally in 2020. Of the 33 countries and areas in the highest data quality category, none were in southern Asia or sub-Saharan Africa compared with 94% (30 of 32 countries) in high-income countries and areas. Worldwide from 2010 to 2020, approximately 15% of all preterm births occurred at less than 32 weeks of gestation, requiring more neonatal care (<28 weeks: 4·2%, 95% CI 3·1-5·0, 567 800 [410 200-663 200 newborn babies]); 28-32 weeks: 10·4% [9·5-10·6], 1 392 500 [1 274 800-1 422 600 newborn babies]). INTERPRETATION: There has been no measurable change in preterm birth rates over the last decade at global level. Despite increasing facility birth rates and substantial focus on routine health data systems, there remain many missed opportunities to improve preterm birth data. Gaps in national routine data for preterm birth are most marked in regions of southern Asia and sub-Saharan Africa, which also have the highest estimated burden of preterm births. Countries need to prioritise programmatic investments to prevent preterm birth and to ensure evidence-based quality care when preterm birth occurs. Investments in improving data quality are crucial so that preterm birth data can be improved and used for action and accountability processes. FUNDING: The Children's Investment Fund Foundation and the UNDP, United Nations Population Fund-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Systematic estimates of the global, regional and national under-5 mortality burden attributable to birth defects in 2000-2019: a summary of findings from the 2020 WHO estimates.

OBJECTIVES: To examine the potential for bias in the estimate of under-5 mortality due to birth defects recently produced by the WHO and the Maternal and Child Epidemiology Estimation research group. DESIGN: Systematic analysis. METHODS: We examined the estimated number of under-5 deaths due to birth defects, the birth defect specific under-5 mortality rate, and the per cent of under-5 mortality due to birth defects, by geographic region, national income and under-5 mortality rate for three age groups from 2000 to 2019. RESULTS: The under-5 deaths per 1000 live births from birth defects fell from 3.4 (95% uncertainty interval (UI) 3.1-3.8) in 2000 to 2.9 (UI 2.6-3.3) in 2019. The per cent of all under-5 mortality attributable to birth defects increased from 4.6% (UI 4.1%-5.1%) in 2000 to 7.6% (UI 6.9%-8.6%) in 2019. There is significant variability in mortality due to birth defects by national income level. In 2019, the under-5 mortality rate due to birth defects was less in high-income countries than in low-income and middle-income countries, 1.3 (UI 1.2-1.3) and 3.0 (UI 2.8-3.4) per 1000 live births, respectively. These mortality rates correspond to 27.7% (UI 26.6%-28.8%) of all under-5 mortality in high-income countries being due to birth defects, and 7.4% (UI 6.7%-8.2%) in low-income and middle-income countries. CONCLUSIONS: While the under-5 mortality due to birth defects is declining, the per cent of under-5 mortality attributable to birth defects has increased, with significant variability across regions globally. The estimates in low-income and middle-income countries are likely underestimated due to the nature of the WHO estimates, which are based in part on verbal autopsy studies and should be taken as a minimum estimate. Given these limitations, comprehensive and systematic estimates of the mortality burden due to birth defects are needed to estimate the actual burden.

Antenatal corticosteroids for early preterm birth: implementation strategy lessons from the WHO ACTION-I trial.

The WHO ACTION-I trial, the largest placebo-controlled trial on antenatal corticosteroids (ACS) efficacy and safety to date, reaffirmed the benefits of ACS on mortality reduction among early preterm newborns in low-income settings. We discuss here lessons learned from ACTION-I trial that are relevant to a strategy for ACS implementation to optimize impact. Key elements included (i) gestational age dating by ultrasound (ii) application of appropriate selection criteria by trained obstetric physicians to identify women with a likelihood of preterm birth for ACS administration; and (iii) provision of a minimum package of care for preterm newborns in facilities. This strategy accurately identified a large proportion of women who eventually gave birth preterm, and resulted in a 16% reduction in neonatal mortality from ACS use. Policy-makers, programme managers and clinicians are encouraged to consider this implementation strategy to effectively scale and harness the benefits of ACS in saving preterm newborn lives.

Preconception and periconception interventions to prevent low birth weight, small for gestational age and preterm birth: a systematic review and meta-analysis.

BACKGROUND: Low birth weight (LBW), including preterm birth (PTB) and small for gestational age (SGA), contributes a significant global health burden. We aimed to summarise current evidence on the effect of preconception and periconception interventions on LBW, SGA and PTB. METHODS: In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library and WHO Global Index Medicus for randomised controlled trials and quasi-experimental studies published by 28 November 2020, which assessed interventions delivered in preconception and periconception or preconception and pregnancy. Primary outcomes were LBW, SGA and PTB. Studies were categorised by intervention type and delivery during preconception and periconception or during preconception and pregnancy. Estimates were pooled using fixed-effects or random-effects restricted maximum likelihood method meta-analyses. Quality of evidence for primary outcomes was assessed using the Grades of Recommendations, Assessment, Development and Evaluation approach. RESULTS: We included 58 studies. Twenty-eight studies examined nutrition interventions (primarily micronutrient or food supplementation). Thirty studies (including one reporting a nutrition intervention) provided health interventions (general preconception health, early adverse pregnancy outcome prevention, non-communicable disease and infectious disease prevention and management). One study assessed a social intervention (reproductive planning). Studies varied in terms of specific interventions, including delivery across preconception or pregnancy, resulting in few studies for any single comparison. Overall, the evidence was generally very uncertain regarding the impact of any intervention on LBW, SGA and PTB. Additionally, preconception and periconception nutritional supplementation containing folic acid was associated with reduced risk of birth defects (10 studies, N=3 13 312, risk ratio: 0.37 (95% CI: 0.24 to 0.55), I2: 74.33%). CONCLUSION: We found a paucity of evidence regarding the impact of preconception and periconception interventions on LBW, SGA and PTB. Further research on a wider range of interventions is required to clearly ascertain their potential effectiveness. TRIAL REGISTRATION NUMBER: This review was prospectively registered with PROSPERO (CRD42020220915).

Study protocol for WHO and UNICEF estimates of global, regional, and national preterm birth rates for 2010 to 2019.

BACKGROUND: Preterm birth is a leading cause of death among children under five years. Previous estimates indicated global preterm birth rate of 10.6% (14.8 million neonates) in 2014. We aim to update preterm birth estimates at global, regional, and national levels for the period 2010 to 2019. METHODS: Preterm birth is defined as a live birth occurring before 37 completed gestational weeks, or <259 days since a woman's last menstrual period. National administrative data sources for WHO Member States with facility birth rates of ≥80% in the most recent year for which data is available will be searched. Administrative data identified for these countries will be considered if ≥80% of UN estimated live births include gestational age information to define preterm birth. For countries without eligible administrative data, a systematic review of studies will be conducted. Research studies will be eligible if the reported outcome is derived from an observational or intervention study conducted at national or sub-national level in population- or facility-based settings. Risk of bias assessments will focus on gestational age measurement method and coverage, and inclusion of special subgroups in published estimates. Covariates for inclusion will be selected a priori based on a conceptual framework of plausible associations with preterm birth, data availability, and quality of covariate data across many countries and years. Global, regional and national preterm birth rates will be estimated using a Bayesian multilevel-mixed regression model. DISCUSSION: Accurate measurement of preterm birth is challenging in many countries given incomplete or unavailable data from national administrative sources, compounded by limited gestational age assessment during pregnancy to define preterm birth. Up-to-date modelled estimates will be an important resource to measure the global burden of preterm birth and to inform policies and programs especially in settings with a high burden of neonatal mortality. TRIAL REGISTRATION: PROSPERO registration: CRD42021237861.

The MOSEXY trial: mobile phone intervention for sexual health in youth-a pragmatic randomised controlled trial to evaluate the effect of a smartphone application on sexual health in youth in Stockholm, Sweden.

An estimated 350 million cases of STIs occur globally each year. In Sweden, Chlamydia is the most common STI with approximately 30 000 cases annually, disproportionally affecting youth. National surveys report low condom use among youth. Smartphone coverage is high among this tech-savvy group. In collaboration with youth, we developed an interactive smartphone application comprising games, peer experiences and information snippets to promote condom use. OBJECTIVES: To evaluate in a randomised controlled trial, the effectiveness of this smartphone application to improve condom use among youth in Stockholm, Sweden. METHODS: This two-arm, individually randomised controlled trial was implemented through the Youth Health Clinics (YHC) in Stockholm, Sweden. Youth aged 18-23 years, who owned a smartphone and had ≥2 sexual partners during the past 6 months were eligible. The intervention delivered the interactive elements described above over 180 days. The control group received a 'dummy' application. Both groups received standard of care at the YHC. The primary outcome was proportion of consistent (100%) self-reported condom use at 6 months. Secondary outcomes included self-reported number of partners, occurrence of STIs/pregnancy and STI tests during the study period. An intention-to-treat approach was used. RESULTS: 214 and 219 youth were randomised to the intervention and control groups, respectively. Consistent condom use was reported for 32/214 (15.0%) in the intervention group and for 35/219 (16.0%) in the control group (OR 0.9, 95% CI 0.5 to 1.6). No significant differences in secondary outcomes were seen. CONCLUSION: We were unable to detect an effect of the intervention. Future research should focus on targeting different subgroups within the overall risk group, with tailored mHealth interventions. The potential for such interventions in settings where sexual health services are unavailable should be evaluated. TRIAL REGISTRATION NUMBER: ISRCTN13212899.

Perceptions of quality of care during birth at private Chiranjeevi facilities in Gujarat: lessons for Universal Health Coverage.

The Indian national health policy encourages partnerships with private providers as a means to achieve universal health coverage. One of these was the Chiranjeevi Yojana (CY), a partnership since 2006 with private obstetricians to increase access to institutional births in the state of Gujarat. More than a million births have occurred under this programme. We studied women's perceptions of quality of care in the private CY facilities, conducting 30 narrative interviews between June 2012 and April 2013 with mothers who had birthed in 10 CY facilities within the last month. The commonly agreed upon characteristics of a "good (sari) delivery" were: giving birth vaginally, to a male child, with the shortest period of pain, and preferably free of charge. But all this mattered only after the primary outcome of being "saved" was satisfied. Women ensured this by choosing a competent provider, a "good doctor". They wanted a quick delivery by manipulating "heat" (intensifying contractions) through oxytocics. There were instances of inadequate clinical care for serious morbidities although the few women who experienced poor quality of care still expressed satisfaction with their overall care. Mothers' experiences during birth are more accurate indicators of the quality of care received by them, than the satisfaction they report at discharge. Improving health literacy of communities regarding the common causes of severe maternal morbidity and mortality must be addressed urgently. It is essential that cashless CY services be ensured to achieve the goal of 100% institutional births.

Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries.

BACKGROUND: The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain. METHODS: We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale. RESULTS: A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P = 0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P = 0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events. CONCLUSIONS: Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection. (Funded by the Bill and Melinda Gates Foundation and the World Health Organization; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000476336; Clinical Trials Registry-India number, CTRI/2017/04/008326.).

'Repeat testing without having 'the talk' is not meaningful'-healthcare providers' perceptions on finding a balance between Chlamydia trachomatis testing and primary prevention strategies. A qualitative study in Stockholm, Sweden.

OBJECTIVES: Chlamydia trachomatis is a public health problem. Widespread testing and re-testing after a sexually transmitted infection (STI) is recommended to contain the epidemic and has been adopted by many countries. A recent study in Stockholm found that serial testing was used as a substitute for condom use by youth presenting at the Youth Health Clinics (YHC). The objectives of this study are to explore frontline healthcare provider's perception of youth testing repeatedly for C. trachomatis as a substitute for condom use and their views on how this might be addressed. DESIGN: Qualitative study, in-depth interviews and analysed using content analysis. SETTING: YHC in Stockholm County, Sweden. PARTICIPANTS: Healthcare providers (HCPs) working at the YHC. FINDINGS: Testing used as a method of prevention of STIs by youth has been a well-known phenomenon observed by HCPs at the YHC. Despite frustration regarding this behaviour, attitudes towards youth visiting the clinics repeatedly were overall positive. It is seen as an opportunity to reach youth with primary prevention strategies. Time for in-depth conversations with the youth is considered essential to understand the various reasons behind sexual risk-taking and to tailor counselling accordingly. Introducing concepts of self-compassion and self-respect in relation to sex is thought of as an effective intervention to improve sexual health among youth. CONCLUSION: HCPs' views on testing repeatedly for C. trachomatis as means of prevention, range widely from seeing this as 'a positive strategy for C. trachomatis prevention' to 'a waste of healthcare resources'. There was a more unified view on how this should be addressed. Testing without having time to problematise sexual risk-taking was seen as meaningless. In depth, one-on-one counselling was deemed important. While scaling up accessibility to testing services, primary prevention strategies must not be neglected.

Development of a Mobile Phone App to Promote Safe Sex Practice Among Youth in Stockholm, Sweden: Qualitative Study.

BACKGROUND: Mobile health (mHealth) has been shown to be effective in increasing knowledge of sexual health among youth. To date, evaluations mostly refer to interventions delivered via computer, email, and text messages. The possibility of downloading apps on mobile devices has opened up opportunities to develop engaging interventions on safe sexual health promotion. To attract young users and have them engage with a sexual health app, it is important to involve youth in intervention development. OBJECTIVE: This study aimed to obtain input from youth on the content of a mobile phone app intended to promote safe sex and increase condom use among youth in Stockholm. METHODS: This study was conducted at the Youth Health Clinics (YHC) in Stockholm County, Sweden. A total of 15 individual in-depth interviews and 2 focus group discussions (with youth aged 18-23 years) were conducted at the YHC in Stockholm. Areas explored were: (1) youth perceptions of condom use (advantages and obstacles), (2) perceptions of mHealth to promote safe sexual practices, and (3) content development for a mobile phone app to promote safe sex. RESULTS: The smartphone app was developed based on the categories that emerged from the data. With regard to content, youth requested sex education, including information on sexually transmitted infections. In addition, condom-specific information, including practical usage technique, advice on how to have the condom talk, and how to decrease shame related to condom use, was requested. Youth suggested different modes to deliver the content, including text messages, movie clips, and push notifications. It was suggested that the tone of the messages delivered should be fun, entertaining, and supportive. The inputs from youth influenced the development of the following sections of the app: Condom Obstacles and Solutions; Quiz; Games; Self-Refection; Challenges; Stories by Peers (stories from peers and information from a doctor); Condom Tips, Pep Talk, and Boosting; and Random Facts. CONCLUSIONS: It is important to use input from youth when developing a smartphone intervention since the success of the intervention largely depends on the level of engagement and usage by youth. Furthermore, if proven efficient in increasing condom use, it is important that the development, including content and mode, is thoroughly described so that the intervention can be replicated. Likewise, if proven inefficient, it is important to learn from mistakes to improve and adjust the intervention. The effect of this smartphone app on safe sexual practices among youth is being evaluated in a pragmatic randomized controlled trial in Stockholm (ISRCTN13212899) and will be reported separately.

Participation in the state led 'Janani Sahayogi Yojana' public private partnership program to promote facility births in Madhya Pradesh, India: views from private obstetrician partners.

BACKGROUND: In Madhya Pradesh, India, the government invited private obstetric hospitals for partnership to provide intrapartum care to poor women, paid for by the state. This statewide program, the Janani Sahayogi Yojana (JShY or maternal support scheme), ran from 2006 to 2012. The partnership was an uneasy one with many private obstetricians choosing to leave the partnership. This paper explores the motives of private obstetricians in the state for participating in the JShY, their experiences within the partnership, their interactions with the state and motives for withdrawal among those who withdrew from the scheme. This study sheds light on the dynamics of a public-private partnership for obstetric care from the perspective of private sector obstetricians. METHOD: Fifteen in-depth interviews were conducted with private obstetricians and hospital administrators from eight districts of Madhya Pradesh who had participated in the JShY. A Framework approach was used to analyze the data. RESULTS: Private obstetricians reported entering the JShY partnership for altruistic reasons but also as way of expanding their practices and reputations. They perceived that although their facilities provided better quality of care than state facilities, participation was risky because beneficiaries were often unbooked and seen as 'high risk' cases. The need to arrange for blood transfusions for these high risk women was perceived as particularly difficult. Cumbersome paper work and delays in receiving payments from the state also dissuaded participation. Some participants felt that there was inadequate engagement by the state, and better monitoring and supervision would have helped. The state changed the financial reimbursement arrangements due to a high proportion of Cesarean births in the early years of the partnership, as these were perversely incentivized. This change resulted in a large exodus of private obstetricians from the partnership. CONCLUSION: This study highlights the contribution of cumbersome processes, trust deficits and a lack of dialogue between public and private partners. Input from both public and private sectors into the design of a carefully thought through financial reimbursement package for private partners was highlighted as a necessary component for future success of such schemes.

Mobile Health for Tuberculosis Management in South India: Is Video-Based Directly Observed Treatment an Acceptable Alternative?

BACKGROUND: With the availability of low-cost mobile devices and the ease of internet access, mobile health (mHealth) is digitally revolutionizing the health sector even in resource-constrained settings. It is however necessary to assess end-user perceptions before deploying potential interventions. OBJECTIVE: This study aimed to assess the mobile phone usage patterns and the acceptability of mobile phone support during care and treatment in patients with tuberculosis (TB) in South India. METHODS: This exploratory study was conducted at an urban private tertiary care teaching hospital and nearby public primary-level health care facilities in Bangalore, South India. We recruited 185 patients with TB through consecutive sampling. Subsequent to written informed consent, participants responded to an interviewer-administered pretested questionnaire. The questionnaire included questions on demographics, phone usage patterns, and the benefits of using of mobile phone technology to improve health outcomes and treatment adherence. Frequency, mean, median, and SD or interquartile range were used to describe the data. Bivariate associations were assessed between demographics, clinical details, phone usage, and mHealth communication preferences using the chi-square test and odds ratios. Associations with a P value ≤.20 were included in a logistic regression model. A P value of <.05 was considered significant. RESULTS: Of the 185 participants, 151 (81.6%) used a mobile phone, and half of them owned a smartphone. The primary use of the mobile phone was to communicate over voice calls (147/151, 97.4%). The short message service (SMS) text messaging feature was used by only 66/151 (43.7%) mobile phone users. A total of 87 of the 151 mobile phone users (57.6%) knew how to use the camera. Only 41/151 (27.2%) mobile phone users had used their mobile phones to communicate with their health care providers. Although receiving medication reminders via mobile phones was acceptable to all participants, 2 participants considered repeated reminders as an intrusion of their privacy. A majority of the participants (137/185, 74.1%) preferred health communications via voice calls. Of the total participants, 123/185 (66.5%) requested reminders to be sent only at specific times during the day, 22/185 (11.9%) suggested reminders should synchronize with their prescribed medication schedule, whereas 40/185 (21.6%) did not have any time preferences. English literacy was associated with a preference for SMS in comparison with voice calls. Most participants (142/185, 76.8%) preferred video-based directly observed treatment when compared with in-person directly observed treatment. CONCLUSIONS: Although mobile phones for supporting health and treatment adherence were acceptable to patients with TB, mHealth interventions should consider language, mode of communication, and preferred timing for communication to improve uptake.

Caesarean sections in the in the context of the Chiranjeevi Yojana public private partnership program to promote institutional birth in Gujarat, India; does the embedded disincentive for caesarean section work?

BACKGROUND: The government of Gujarat, India runs a large public private partnership program to widen access to emergency obstetric care (EmOC). The program include a disincentive for Cesareans section (CS) which are capped at seven per 100 women. In this paper, we study if the disincentive works by comparing CS rates among similar groups of women who deliver within and outside the program. METHODS: Community-based panel study in three districts of Gujarat, India. SAMPLE SIZE: 2123 women. Data was analyzed using multivariable logistic regression. RESULTS: Overall seven point seven % (164/2123) of the all women in the study had a CS. After adjusting for confounding factors women within the program had 62% (AOR 0.38, 95% CI 0.22-0.44) lower odds of having a CS than to non-beneficiaries. In a separate model of predictors of CS among women giving birth only in program accredited hospitals, we found that CY program beneficiaries had lower odds of having a CS birth than non-beneficiary women (paying clients) (AOR 0.40, 95% CI 0.24-0.67). CONCLUSIONS: The Gujarat government is trying to ensure access to EmOC (including CS) for its vulnerable population through CY. The embedded disincentive to prevent unnecessary cesareans by private obstetricians is a novel one, and appears to work, though one could argue it works 'over-efficiently' by depriving some women who need CS from receiving one under the program. The state needs to revisit and review what is happening in the program periodically, and have oversight over whether women who need CS under the program actually receive the care that they need.

Postpartum quality of life in Indian women after vaginal birth and cesarean section: a pilot study using the EQ-5D-5L descriptive system.

BACKGROUND: There has been little evaluation of the postpartum quality of life (QOL) of women in India and its association with the mode of birth. This study piloted the use of the generic EQ-5D-5L questionnaire to assess postpartum QOL experienced by rural Indian women. METHODS: A convenience sample of rural women who gave birth in a health facility in Gujarat or Madhya Pradesh was recruited into this pilot study. QOL was measured during three interviews within 30 days of birth using the EQ-5D-5L questionnaire. Patient-level quality-adjusted life days (QALDs) were estimated. Multivariate regression was used to adjust for selected baseline characteristics. RESULTS: Forty-six women with cesarean section and 178 with vaginal birth from 17 public and private health facilities were studied. Postpartum QOL in both groups improved between interviews 1 and 3. Comparing between vaginal and cesarean births indicated that the vaginal birth group had a higher QOL (0-3 days postpartum: 0.28 vs. 0.57, 3-7 days postpartum: 0.59 vs. 0.81; P < 0.001) and was more likely to report no or slight problems in 4 of 5 health dimensions (mobility, self-care, usual activities, pain or discomfort; P ≤ 0.04) during interviews 1 and 2. Postpartum QOL converged, but still differed between groups by the time of interview 3 (21-30 days postpartum: 0.85 vs. 0.93; P < 0.001). While most women reported no problems by the end of the first postpartum month, the difference in the ability to perform usual activities persisted (P = 0.001). In result, fewer QALDs were attained by women in the cesarean section group between day 1 and day 21 postpartum (13.1 vs. 16.6 QALDs; P < 0.001). Subgroup analysis showed that having had an episiotomy during vaginal birth was also associated with reduced QOL postpartum, but to a lesser extent than cesarean section. Similar results were obtained when adjusting for socioeconomic, pregnancy and birth characteristics, but postpartum QOL already ceased to be statistically different between groups before interview 3. CONCLUSIONS: Vaginal births, even with episiotomy, were associated with a higher postpartum QOL than cesarean births among the Indian women in our pilot study. Finding these expected results suggests that the EQ-5D-5L questionnaire is a suitable instrument to assess postpartum QOL in Indian women.

Bypassing health facilities for childbirth in the context of the JSY cash transfer program to promote institutional birth: A cross-sectional study from Madhya Pradesh, India.

Bypassing health facilities for childbirth can be costly both for women and health systems. There have been some reports on this from Sub-Saharan African and from Nepal but none from India. India has implemented the Janani Suraksha Yojana (JSY), a large national conditional cash transfer program which has successfully increased the number of institutional births in India. This paper aims to study the extent of bypassing the nearest health facility offering intrapartum care in three districts of Madhya Pradesh, India, and to identify individual and facility determinants of bypassing in the context of the JSY program. Our results provide information to support the optimal utilization of facilities at different levels of the healthcare system for childbirth. Data was collected from 96 facilities (74 public) and 720 rural mothers who delivered at these facilities were interviewed. Multilevel logistic regression was used to analyze the data. Facility obstetric care functionality was assessed by the number of emergency obstetric care (EmOC) signal functions performed in the last three months. Thirty eighth percent of the mothers bypassed the nearest public facility for their current delivery. Primiparity, higher education, arriving by hired transport and a longer distance from home to the nearest facility increased the odds of bypassing a public facility for childbirth. The variance partition coefficient showed that 37% of the variation in bypassing the nearest public facility can be attributed to difference between facilities. The number of basic emergency obstetric care signal functions (AOR = 0.59, 95% CI 0.37-0.93), and the availability of free transportation at the nearest facility (AOR = 0.11, 95% CI 0.03-0.31) were protective factors against bypassing. The variation between facilities (MOR = 3.85) was more important than an individual's characteristics to explain bypassing in MP. This multilevel study indicates that in this setting, a focus on increasing the level of emergency obstetric care functionality in public obstetric care facilities will allow more optimal utilization of facilities for childbirth under the JSY program thereby leading to better outcomes for mothers.

Trial protocol: a parallel group, individually randomized clinical trial to evaluate the effect of a mobile phone application to improve sexual health among youth in Stockholm County.

BACKGROUND: Genital Chlamydia trachomatis infection is a major public health problem worldwide affecting mostly youth. Sweden introduced an opportunistic screening approach in 1982 accompanied by treatment, partner notification and case reporting. After an initial decline in infection rate till the mid-90s, the number of reported cases has increased over the last two decades and has now stabilized at a high level of 37,000 reported cases in Sweden per year (85% of cases in youth). Sexual risk-taking among youth is also reported to have significantly increased over the last 20 years. Mobile health (mHealth) interventions could be particularly suitable for youth and sexual health promotion as the intervention is delivered in a familiar and discrete way to a tech savvy at-risk population. This paper presents a protocol for a randomized trial to study the effect of an interactive mHealth application (app) on condom use among the youth of Stockholm. METHODS: 446 youth resident in Stockholm, will be recruited in this two arm parallel group individually randomized trial. Recruitment will be from Youth Health Clinics or via the trial website. Participants will be randomized to receive either the intervention (which comprises an interactive app on safe sexual health that will be installed on their smart phones) or a control group (standard of care). Youth will be followed up for 6 months, with questionnaire responses submitted periodically via the app. Self-reported condom use over 6 months will be the primary outcome. Secondary outcomes will include presence of an infection, Chlamydia tests during the study period and proxy markers of safe sex. Analysis is by intention to treat. DISCUSSION: This trial exploits the high mobile phone usage among youth to provide a phone app intervention in the area of sexual health. If successful, the results will have implications for health service delivery and health promotion among the youth. From a methodological perspective, this trial is expected to provide information on the strength and challenges of implementing a partially app (internet) based trial in this context. TRIAL REGISTRATION: ISRCTN 13212899, date of registration June 22, 2017.

Repeat testing for chlamydia trachomatis, a "safe approach" to unsafe sex? a qualitative exploration among youth in Stockholm.

BACKGROUND: Chlamydia trachomatis testing is offered to youth in Sweden, through a network of Youth Health Clinics, free at the point of care, in an attempt to bring down the prevalence and incidence of the infection. Nevertheless, infections rates have continued to rise during the past two decades and re-testing rates among youth for Chlamydia trachomatis has been reported to be high in Stockholm County. A few literature reports suggest that testing for sexually transmitted infections and the test result itself can have an undesirable impact on the sexual behaviour for the individual, i.e. increase sexual risk-taking. METHODS: This qualitative study aimed to explore the motives for repeated testing for Chlamydia trachomatis among youth using the services of the Youth Health Clinics in Stockholm, and how testing affects their subsequent risk-taking. We interviewed 15 repeat testers aging 18-22 years. RESULTS: Our main findings were that the fear of social stigma related to infecting a peer was a major driver of the re-testing process. The repetitive testing process, the test result, and the encounter with personnel did not decrease sexual risk-taking among this group. CONCLUSIONS: While testing and treatment services are an important part of Chlamydia trachomatis prevention it must not take the focus away from primary prevention strategies. Testing should be encouraged, but not to the exclusion of risk reduction measures. The testing services must be complemented with stronger emphasis on safe sex, especially for those who attend the clinics repeatedly, otherwise the easy accessible testing services risk counteracting its own purpose. Future research should focus on developing and evaluating youth appropriate interventions to increase condom use, taking into consideration factors which youth perceive as important to drive this behaviour change.