Dysglycaemia in Ebola virus disease: a retrospective analysis from the 2018 to 2020 outbreak.

BACKGROUND: Ebola virus disease (EVD) is associated with multisystem organ failure and high mortality. Severe hypoglycaemia is common, life-threatening, and correctable in critically ill patients, but glucose monitoring may be limited in EVD treatment units. METHODS: We conducted a retrospective review of patients admitted to EVD treatment units in Butembo and Katwa, Eastern DRC. Glucose measurements were done using a handheld glucometer at the bedside or using the Piccolo xpress Chemistry Analyzer on venous samples. FINDINGS: 384 patients (median age 30 years (interquartile range, IQR, 20-45), 57% female) and 6422 glucose measurements (median 11 per patient, IQR 4-22) were included in the analysis. Severe hypoglycaemia (≤2.2 mmol/L) and hyperglycaemia (>10 mmol/L) were recorded at least once during the ETU admission in 97 (25%) and 225 (59%) patients, respectively. A total of 2004 infusions of glucose-containing intravenous solutions were administered to 302 patients (79%) with a median cumulative dose of 175g (IQR 100-411). The overall case fatality rate was 157/384 (41%) and was 2.2-fold higher (95% CI 1.3-3.8) in patients with severe hypoglycaemia than those without hypoglycaemia (p = 0.0042). In a multivariable Cox proportional hazards model, periods of severe hypoglycaemia (adjusted hazard ratio (aHR) 6.2, 95% CI 3.2-12, p < 0.0001) and moderate hypoglycaemia (aHR 3.0, 95% CI 1.9-4.8, p < 0.0001) were associated with elevated mortality. INTERPRETATION: Hypoglycaemia is common in EVD, requires repeated correction with intravenous dextrose solutions, and is associated with mortality. FUNDING: This study was not supported by any specific funding.

South Asia's unprotected poor: A systematic review of why social protection programs fail to reach their potential.

The incongruity between South Asia's economic growth and extreme poverty has led to a growing interest in social protection and subsequent implementation of anti-poverty initiatives. However, many programs have consistently fallen short of their full potential in reaching the poor. We reviewed the literature to understand the factors behind this failure. A search of EconLit, Global Health Database, MEDLINE and SocINDEX, supplemented by an external search, yielded 42 papers evaluating 23 programs. Inclusion criteria included social and political determinants of program outcomes. Articles were assessed for quality using the GRADE and GRADE CERQual criteria and analyzed using Thomas & Harding's thematic synthesis approach. We identified five themes: (1) structurally flawed program theories overlook the complexities of poverty and are rooted in simplistic cause-and-effect approaches; (2) elite capture through appropriation of benefits, powerful positioning in program implementation, and gatekeeping through relationships of patronage; (3) insufficient targeting strategies to reach the poorest; (4) neglect of gendered restrictions, hidden costs, lack of legal documentation, and physical and social exclusion; (5) active self-exclusion from social protection to maintain dignity, a perception that programs are substandard, and a lack of resources required. The review highlights the well-documented disconnect between South Asian social protection program designs and the ground realities of their 'ideal' beneficiaries. This stems from a dominance of Western-led poverty discourse that disregards the influence of caste, the challenge of effective engagement with a group whose identity remains unclear, and fast-paced funding calls that do not lend themselves to meaningful identification and collaboration with the invisible poor. We suggest this disconnect is intentional and reflects a broader power dynamic rooted in geopolitical interests and national priorities. Study limitations reflect the shortcomings of the existing literature, which largely uses quantitative research methods that fail to capture the multidimensional experiences of the poor.

Rhabdomyolysis, Acute Kidney Injury, and Mortality in Ebola Virus Disease: Retrospective Analysis of Cases From the Eastern Democratic Republic of the Congo, 2019.

BACKGROUND: Skeletal muscle injury in Ebola virus disease (EVD) has been reported, but its association with morbidity and mortality remains poorly defined. METHODS: This retrospective study included patients admitted to 2 EVD treatment units over an 8-month period in 2019 during an EVD epidemic in the Democratic Republic of the Congo. RESULTS: An overall 333 patients (median age, 30 years; 58% female) had at least 1 creatine kinase (CK) measurement (n = 2229; median, 5/patient [IQR, 1-11]). Among patients, 271 (81%) had an elevated CK level (>380 U/L); 202 (61%) had rhabdomyolysis (CK >1000 IU/L); and 45 (14%) had severe rhabdomyolysis (≥5000 U/L). Among survivors, the maximum CK level was a median 1600 (IQR, 550-3400), peaking 3.4 days after admission (IQR, 2.3-5.5) and decreasing thereafter. Among fatal cases, the CK rose monotonically until death, with a median maximum CK level of 2900 U/L (IQR, 1500-4900). Rhabdomyolysis at admission was an independent predictor of acute kidney injury (adjusted odds ratio, 2.2 [95% CI, 1.2-3.8]; P = .0065) and mortality (adjusted hazard ratio, 1.7 [95% CI, 1.03-2.9]; P = .037). CONCLUSIONS: Rhabdomyolysis is associated with acute kidney injury and mortality in patients with EVD. These findings may inform clinical practice by identifying laboratory monitoring priorities and highlighting the importance of fluid management.

Ultrasound imaging and the culture of pregnancy management in low-and middle-income countries: A systematic review.

BACKGROUND: Obstetric ultrasound imaging is a relatively new, but rapidly expanding, technology in low- and middle-income countries (LMICs). Given that new technologies modify practices, the influence of ultrasound on pregnancy management in LMICs is not comprehensively understood. OBJECTIVES: To map how ultrasound technology may be modulating the culture of pregnancy management in LMICs. SEARCH STRATEGY: A search of five databases up to November 18, 2022. SELECTION CRITERIA: Original, peer-reviewed articles from LMICs, published in English from 2000 to 2022. DATA COLLECTION AND ANALYSIS: All articles were assessed for quality using the GRADE approach. Data were analyzed thematically to generate new interpretive constructs and explanations. RESULTS: Forty articles involving 113 000 respondents suggests that obstetric ultrasound is becoming the preferred method of pregnancy surveillance, replacing clinically important components of prenatal care. Mothers overestimate ultrasound as an all-powerful diagnostic and "therapeutic" tool that can deliver the perfect baby. For-profit providers are driving medically unnecessary scans while the poor do not receive the recommended scans. CONCLUSION: Ultrasound technology has modified the culture of pregnancy management in LMICs in unintended and possibly harmful ways. Private health services are pushing the detrimental trends. Limitations include generalizability of qualitative studies and insufficient attention to inequities.

Scaling up the "24/7 BHU" strategy to provide round-the-clock maternity care in Punjab, Pakistan: a theory-driven, coproduced implementation study.

BACKGROUND: Pakistan's maternal mortality rate remains persistently high at 186/100,000 live births. The country's government-run first-level healthcare facilities, the basic health units (BHUs), are an important source of maternity care for rural women. However,BHUsonly operate on working days from 8:00 am to 2:00 pm. Recognizing that this severely constrains access to maternity services, the government is implementing the "24/7 BHU" initiative to upgrade BHUs to provide round-the-clock care. Although based on a successful pilot project, initial reports reveal challenges in scaling up the initiative. This implementation research project aims to address a key concern of the Government of Punjab: How can the 24/7 BHU initiative be successfully implemented at scale to provide high-quality, round-the-clock skilled maternity care in rural Punjab? METHODS: The project consists of two overlapping work packages (WP). WP1 includes three modules generating data at the directorate, district and BHU levels. Module 1 uses document analysis and policy-maker interviews to explicateprogrammetheory and begin to build a system model. Module 2 compares government-collected data with data generated from a survey of 1500 births to assess BHU performance. Module 3 uses institutional ethnographies in 4-5 BHUs in three districts to provide a detailed system for understanding and identifying processes that influence scale-up. WP2 includes two modules. First, two workshops and regular meetings with stakeholders integrate WP1 findings, identify feasible changes and establish priorities. Next, "change ideas" are selected for testing in one district and 2-3 BHUs through carefully documented pilots using the PDSA (plan-do-study-act) improvement approach. An integrated knowledge translation approach will engage key policy and practice stakeholders throughout the project. DISCUSSION: This theory-driven implementation research project willcoproducesignificant new understandings of the wider system in which the 24/7 BHU initiative is being implemented, and actionable knowledge that will highlight ways the implementation processes might be modified to enable BHUs to meet service provision goals. This study will also produce insights that will be relevant for other South Asian and low- and middle-income countries (LMICs) that experience similar challenges of programme scale-up and delivery of maternal health services to remote and marginalized communities.

Caste in Muslim Pakistan: a structural determinant of inequities in the uptake of maternal health services.

The failure to reduce maternal mortality rates in high-burden countries has led to calls for a greater understanding of structural determinants of inequities in access to maternal health services. Caste is a socially constructed identity that imposes structural disadvantages on subordinate groups. Although a South Asian construct, the existence of caste as a structural social stratifier is actively rejected in Muslim Pakistan as a regressive symbol of Hinduism. In this inimical context, the possibility of caste as a driver of maternal health care inequities is not acknowledged and has, therefore, remained unexplored in Pakistan. The objective of the present study is to quantitatively assess the variation in the use of maternity services across different caste groups in Pakistan. The research also contributes to methodological innovation in modelling relationships between caste, mediating and/or confounding socio-economic factors and maternal health service indicators. A clustered, stratified survey sampled 1457 mothers in districts Jhelum and Layyah. Multivariable, multi-level (confounder-adjusted) logistic regression analysis showed "Low" caste mothers had higher odds of landlessness, no education, working in unskilled occupations, asset poverty, no antenatal care and a home-based birth with an unskilled attendant compared to "High" or "Middling" caste individuals. Despite the important role of caste in patterning socio-economic disadvantage, its indirect causal effect on maternal health care was predominantly mediated through mothers' education and household assets. Our findings suggest a need for group-specific policies, including constructing schools in low-caste dominant settlements, affirmative action with job quotas, redistributing agricultural lands and promoting industrial development in the poorer districts.

Violence and precarity: A neglected cause of large family sizes in Pakistan.

ABSTRACTA key objective of Pakistan's family planning program has been to increase awareness of the benefits of a small family. Despite five decades of effort, family size ideals of four children persist. Research suggests a preference for large families and many sons is driven by an economic and gender order that situates sons, and subsequent large families, as a form of financial and social capital. We argue an additional factor promoting large family size in Pakistan is precarity. Drawing upon 13 months' of ethnographic work from a village in Khyber Pakhtunkhwa, our data show our respondents' preference for large families with several sons was a rational response to precarity, created by economic insecurity and persistent conflict. While child mortality has reduced, the risk of an untimely conflict-related death of adult sons remains high and continues to play a crucial role in our respondents' family size calculations. Our research contributes to the body of literature listing the forces pushing large family sizes and provides an additional explanation for Pakistan's stagnating modern contraceptive prevalence rate. It also provides policy direction for reducing Pakistan's high fertility rate, suggesting a need to address the upstream factors that contribute to the continuing need for large families.

Culture's Place in Quality of Care in a Resource-Constrained Health System: Comparison Between Three Malawi Districts.

Public health scholars describe "culture of quality" in terms of desired values, attitudes, and practices, but this literature rarely includes explicitly stated theories of culture formation. In this article, we apply Fredrik Barth's transactional model to demonstrate how taking a theory-centered approach can help to identify what would be necessary to foster "cultures of quality" outlined in the public health literature. We draw on data from a study of the Republic of Malawi's Performance and Quality Improvement for Reproductive Health initiative. These data were generated in 2017-2018 through a 6-month organizational ethnography in three facilities selected to represent a range of districts with differing social and economic contexts. Our analysis revealed facility-level organizational cultures in which staff valued providing care, but responded to structural constraints by normalizing divergence from quality-of-care protocols. These findings indicate that sustaining a quality-oriented organizational culture requires addressing underlying conditions that generate routine experiences and practices.

Midwives providing maternal health services to poor women in the private sector: is it a financially feasible model?

Governments in many low- and middle-income countries have increasingly turned to the private sector to address the gap in skilled birth attendance in rural areas. They draw on limited, but emerging evidence that the poor also seek private healthcare services. A question not addressed in this policy and strategy is: Can poor women pay the fees required for private-sector maternity care providers to financially sustain their practices? This article examined the financial viability of private-sector midwifery practices established to provide skilled birth services to Afghan refugee women in Baluchistan, Pakistan. An international non-governmental organization established 45 midwifery practices as part of a poverty alleviation project aimed at providing market-based solutions for female poverty. A retrospective micro-cost analysis was conducted on a sample of 11 practices. In-depth interviews were conducted with 33 stakeholders to explore the midwives' experiences of operating private practices, and the facilitators and barriers they experienced. The single midwife-practices saw a mean of 8.7 ANC patients (range 1-19), attended 2.9 births (range 0-10) and provided care to 1.6 postnatal patients (range 0-7). The average net income of the 11 practices in May 2014 was US$81, but the median was just US$12. To contextualize these incomes, the midwives earned, on average, 25% of Pakistan's minimum monthly living wage. The financial analysis showed only 3 out of 11 sampled practices could be considered financially viable. The qualitative data revealed that even in practices with reasonable client volumes, the patients' inability to pay was the critical factor in the midwife practices' low net incomes. The research provides empirical evidence of a potential pitfall of private funding models in resource-poor settings where providers rely on impoverished clients to pay user-fees. Such financial models essentially shift the government's responsibility to provide safe childbirth services onto providers who can least afford to offer such care.

Needles Don't Agree with Me, Pills Don't Agree with Me: Experiences of Contraceptive Use among Pakhtun Women in Pakistan.

The sixth most populous country, Pakistan's modern contraceptive use rate is just 25%. Of the multiple reasons for avoiding contraceptives, women cite side effects as a significant deterrent to contraceptive uptake. Efforts to understand these side effects are limited by overreliance on the biomedical framework, which typically dismisses some of women's negative experiences and explanatory models as misperceptions. Drawing on 13 months of ethnographic data from a village in Khyber Pakhtunkhwa, Pakistan, our study sought to provide an emic description of contraceptive side effects. Respondents' described what we call "spiritual" and "somatic" side effects. While the latter included experiences such as irregular bleeding and leg pain, spiritual side effects had more severe implications ranging from job loss, birth defects, to child death. In a context of a firm belief that family planning was a sin, contraceptives were believed to negatively impact spiritual well-being and invite God's wrath. Our data suggest these perceptions and experiences played a crucial role in contraceptive decision-making. The spiritual and somatic experiences of contraceptive use described by respondents also demonstrate the importance of broadening dominant biomedical approaches to holistically understand contraceptive side effects and usage.

Women's voices and medical abortions: A review of the literature.

Globally, a growing proportion of induced abortions are medical abortions. The procedure has been hailed as a revolutionary technology, which, according to experts, has the potential to transform women's experiences of abortion and the way abortion services are accessed. Noticeably absent in the discourse, however, are women's voices. More specifically, there is a lack of understanding about what shapes women's preferences for medical abortion and the challenges they experience in accessing the drugs for the procedure. We conducted a systematic review of the literature to draw attention to these important issues which exist, but are often embedded within research highlighting other dominating aspects of medical abortions. A comprehensive search of four databases - supplemented by searching reference sections of selected articles, tracking their citations, and hand searching special editions on medical abortion - was conducted. A total of 45 peer-reviewed studies met our inclusion criteria. The studies were assessed for quality and analyzed using a critical interpretive synthesis approach. The findings revealed significant variations in women's preferences for surgical versus medical abortions. Country-specific abortion laws, implementing protocols, side-effects, rates of failures, and the need to verify the abortion shaped women's preference for abortion methods. Overall, women who preferred medical abortions did so because they perceived it as a 'natural' and safe procedure that can be self-conducted at home, thereby reducing their dependency on the health system. However, women face significant barriers to medical abortion care. These include legal requirements around type of provider, site of service, need for follow-up, providers' limited knowledge of the procedure, and preferences for surgical abortions. Borderless internet-based services have enabled some women to circumvent these barriers. Our review suggests that medical abortions are used by women either in countries where the health system is fully supportive or where the health system is completely disengaged, usually due to restricted abortion laws. In those countries where abortions are legal but often difficult to access due to health system barriers, women tend to prefer surgical abortions.

Challenges to achieving appropriate and equitable access to Caesarean section: ethnographic insights from rural Pakistan.

Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan - Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient-provider power differentials and financial constraints. They considered C-section an expensive and risky procedure, which often lacked medical justification, and was instead driven by profit motive. Physicians saw C-section as symbolizing obstetric skill and status and a source of legitimate income. Physician views and practices were also shaped by the wider health care system characterized by private practice, competition between providers and a lack of regulation and supervision. These multi-layered factors have resulted in both unnecessary intervention, and missed opportunities for appropriate C-sections. The data indicate a need for synergistic action at patient, provider and system levels. Recommendations include: improving physician communication with patients and family so that the need for C-section is better understood as a life-saving procedure, challenging negative attitudes and promoting informed decision-making by mothers and their families, holding physicians accountable for their practice and introducing price caps and regulations to limit financial incentives associated with C-sections. The current push for privatization of health care in low-income countries also needs scrutiny given its potential to encourage unnecessary intervention.

"How can we leave the traditions of our Baab Daada" socio-cultural structures and values driving menstrual hygiene management challenges in schools in Pakistan.

INTRODUCTION: Despite the growing attention to the relationship between menstruation and girls schooling, there remain many challenges to addressing the issue. Current interventions, which mostly focus on developing WASH infrastructure and sanitary hygiene management products, while necessary, may not be sufficient. This paper aimed to identify the root causes of poorly maintained WASH infrastructure, and understand the deeply embedded socio-cultural values around menstrual hygiene management that need to be addressed in order to provide truly supportive school environments for menstruating girls. METHODS: Qualitative data were collected in rural and urban sites in three provinces in Pakistan using participatory activities with 312 girls aged 16-19 years, observations of 7 School WASH facilities, 42 key informant interviews and a document review. RESULTS: Three key themes emerged from our data: (1) a poorly maintained, girls-unfriendly School WASH infrastructure was a result of gender-insensitive design, a cultural devaluation of toilet cleaners and inadequate governing practices; (2) the design of WASH facilities did not align with traditionally-determined modes of disposal of rag-pads, the most common used absorbents; (3) traditional menstrual management practices situate girls in an 'alternate space' characterised by withdrawal from many daily routines. These three socio-culturally determined practices interacted in a complex manner, often leading to interrupted class engagement and attendance. CONCLUSIONS: To be truly effective, current menstrual hygiene management strategies need to address the root causes of poor WASH infrastructure and ensure facility design is sensitive to the gendered and deeply embedded local socio-cultural values and beliefs around menstrual hygiene management.

Family planning in Pakistan: A site of resistance.

As the population of Pakistan has increased beyond 200 million, it is evident that the country's family planning program has been unable to sufficiently expand contraceptive use. To understand the obstacles, researchers have tended to focus on service delivery failures, 'cultural' barriers and varying political support. However, a small body of literature documents citizen's suspicions of an ulterior motive underlying Pakistan's family planning program. Often dismissed as unfounded conspiracies, a gap in our knowledge is the role these beliefs might be playing in the failure of the program. Using a critical ethnographic approach, we conduced 242 observations of daily life, 109 informal and 197 in-depth interviews with 41 women and 35 men living in a village in Khyber Pakhtunkhwa. Data were collected between September 2013 and April 2015 and analysed using latent content analysis. Our respondents viewed Western support for family planning as confirmation of their suspicions of the program's hidden agenda. Western military intervention in the region complicated their beliefs about the potential altruistic nature of foreign support for the family planning program. Awareness of rampant corruption among Pakistani government officials had fractured their trust in the state while contributing to the notion that the government was complicit with foreign interference. These considerations coupled with the fact that the priorities of Pakistani Family Planning program did not align with the reality of their lives contributed to the skepticism of family planning. For our respondents, resisting family planning and its ideology was a means to resist the perceived violence inflicted by the West and the complicity of the Pakistani government. These findings signal how geopolitics influence the use of family planning services. By demonstrating the importance of embedding perceptions of family planning programs in their local and global contexts, these findings suggest potential areas for future research in the field.

Family planning, Islam and sin: Understandings of moral actions in Khyber Pakhtunkhwa, Pakistan.

Pakistan, with a population of over 207 million, is the sixth most populous country in the world. Yet, only 25% of eligible couples' report using a modern contraceptive method. A large body of literature indicates the existence of a widely-held perception among Pakistanis that family planning use is a sin, which is then often cited as evidence that Islamic beliefs impede contraceptive use (see Agha, 2010; Ali and Ushijima, 2005; Azmat, 2011; Zafar et al., 2003). We argue that this body of literature, which has relied primarily on quantitative measures and survey methodology, is highly reductive. Missing from this discourse is a nuanced analysis of how individuals engage with their Islamic beliefs to make fertility decisions. Drawing on 13 months of ethnographic data, our findings demonstrate that despite most of our respondents overwhelmingly believing that family planning use was a sin, many had, at some stage, tried to control their fertility. Our findings evidenced that respondents' beliefs surrounding the morality of fertility control was informed by multiple moral registers beyond Islam. For our respondents, moral action was informed by interpretations of Islamic teachings, economic insecurity, socioeconomic inequities, community/public discourse, and geopolitics. We argue there is a need to complicate our understanding of how Islam shapes reproductive strategies in Pakistan, and its relative importance in contraceptive decisions.

Perspectives of Immigrant Women on the Gender of Provider During Childbirth.

OBJECTIVE: This study sought to gain an understanding of the importance and effect of provider gender for immigrant women accessing obstetrical care. METHODS: A focused ethnography was conducted using purposive sampling of 38 immigrant women from one hospital in Edmonton, Alberta. Data collection consisted of semistructured interviews conducted antenatally (n = 38); an attempt was made to conduct interviews postpartum (n = 21), and intrapartum observations were made (n = 17). Interviews were audio-recorded and transcribed verbatim. Data were managed using qualitative data analysis software and analyzed through thematic analysis. RESULTS: Study participants came from varied educational and ethnic backgrounds (predominately North/East African, Middle Eastern, and South Asian), but most were Muslim (n = 30) and married (n = 36), with a mean age of 27.7. All of the women stated that they preferred a female provider, which they explained in terms of the high value they placed on modesty, often as part of the Muslim faith. The women deemed provider competency and having safe childbirth more important, however, and said that they would accept intrapartum care from a male provider. A small minority of the women reported experiencing psychological stress as a consequence of having received care from a male provider. CONCLUSION: As a whole, our study population accepted care from male providers, yet for some women this compromise came at a price, and a small minority of women perceived it as profoundly detrimental. There is a need to identify those women for whom gender of provider is a substantial barrier, so that optimal support can be provided.