Accessibility of basic paediatric emergency care in Malawi: analysis of a national facility census.

BACKGROUND: Emergency care is among the weakest parts of health systems in low-income countries with both quality and accessibility constraints. Previous studies estimated accessibility to surgical or emergency care based on population travel times to nearest hospital with no assessment of hospital readiness to provide such care. We analysed a Malawi national facility census with comprehensive inventory audits and geocoded facility locations to identify hospitals equipped to provide basic paediatric emergency care with estimated travel times to these hospitals from non-equipped facilities and in relation to Malawi's population distribution. METHODS: We analysed a Malawi national facility census in 2013-2014 to identify hospitals equipped to manage critically ill children according to an extended version of WHO Emergency Triage, Assessment and Treatment (ETAT) guidelines. These guidelines include 25 components including staff, transport, equipment, diagnostics, medications, fluids, feeds and consumables that defined an emergency-equipped hospital in our study. We estimated travel times to emergency-equipped hospitals from non-equipped facilities and relative to population distributions using geocoded facility locations and an established accessibility mapping approach using global road network datasets from OpenStreetMap and Google. RESULTS: Four (3.5, 95% CI: 1.3-8.9) of 116 Malawi hospitals were emergency-equipped. Least available items were nasogastric tubes in 34.5% of hospitals (95% CI: 26.4-43.6), blood typing services (40.4, 95% CI: 31.9-49.6), micro nebulizers (50.9, 95% CI: 41.9-60.0), and radiology (54.2, 95% CI: 45.1-63.0). Nationally, the median travel time from non-equipped facilities to the nearest emergency-equipped hospital was 73 min (95% CI: 67-77) ranging 1-507 min. Approximately one-quarter (27%) of Malawians lived over 120 min from an emergency-equipped hospital with significantly better accessibility in Central than North and South regions (16% vs. 38 and 35%, p < 0.001). CONCLUSIONS: There are unacceptable deficiencies in accessibility of basic paediatric emergency care in Malawi. Reliable supply chains for essential drugs and commodities are needed, particularly nasogastric tubes, asthma drugs and blood, along with improved capacity for time-sensitive referral. Further child mortality reductions will require substantial investments to expand basic paediatric emergency care into all Malawi hospitals for better managing critically ill children at highest mortality risk.

Time trends and sociodemographic determinants of preterm births in pregnancy cohorts in Matlab, Bangladesh, 1990-2014.

INTRODUCTION: Preterm birth is the major cause of under-five mortality. Population-based data on determinants and proportions of children born preterm are limited, especially from low-income countries. This study aimed at assessing time trends and social, reproductive and environmental determinants of preterm births based on a population-based pregnancy cohort over 25 years in rural Bangladesh. METHODS: In this cohort study in Matlab, a rural area in Bangladesh, we used data from the Health and Demographic Surveillance System from 1990 to 2014. Gestational age at birth was based on the reported last menstrual period and verified by ultrasound assessments. Preterm birth proportions were assessed within strata of social and reproductive characteristics, and time series analysis was performed with decomposition for trend and seasonality. We also determined the prevented fractions of preterm birth reduction associated with social and demographic changes during the follow-up period. RESULTS: Analyses were based on 63 063 live births. Preterm birth decreased from 29% (95% CI 28.6 to 30.1) in 1990-1994 to 11% (95% CI 10.5 to 11.6) in 2010-2014. Low education, older age and multi-parity were associated with higher proportions of preterm births across the study period. Preterm births had a marked seasonal variation. A rapid increase in women's educational level and decrease in parity were associated with the decline in preterm births, and 27% of the reduction observed from 1990 to 2014 could be attributed to these educational and reproductive changes. CONCLUSION: The reduction in preterm birth was to a large extent associated with the sociodemographic transition, especially changes in maternal education and parity. The persistent seasonal variation in the proportion of preterm birth may reflect the environmental stressors for pregnant women across the study period. Continued investments in girls' education and family planning programmes may contribute to further reduction of preterm births in Bangladesh.

Assessing the Multiple Dimensions of Poverty. Data Mining Approaches to the 2004-14 Health and Demographic Surveillance System in Cuatro Santos, Nicaragua.

We identified clusters of multiple dimensions of poverty according to the capability approach theory by applying data mining approaches to the Cuatro Santos Health and Demographic Surveillance database, Nicaragua. Four municipalities in northern Nicaragua constitute the Cuatro Santos area, with 25,893 inhabitants in 5,966 households (2014). A local process analyzing poverty-related problems, prioritizing suggested actions, was initiated in 1997 and generated a community action plan 2002-2015. Interventions were school breakfasts, environmental protection, water and sanitation, preventive healthcare, home gardening, microcredit, technical training, university education stipends, and use of the Internet. In 2004, a survey of basic health and demographic information was performed in the whole population, followed by surveillance updates in 2007, 2009, and 2014 linking households and individuals. Information included the house material (floor, walls) and services (water, sanitation, electricity) as well as demographic data (birth, deaths, migration). Data on participation in interventions, food security, household assets, and women's self-rated health were collected in 2014. A K-means algorithm was used to cluster the household data (56 variables) in six clusters. The poverty ranking of household clusters using the unsatisfied basic needs index variables changed when including variables describing basic capabilities. The households in the fairly rich cluster with assets such as motorbikes and computers were described as modern. Those in the fairly poor cluster, having different degrees of food insecurity, were labeled vulnerable. Poor and poorest clusters of households were traditional, e.g., in using horses for transport. Results displayed a society transforming from traditional to modern, where the forerunners were not the richest but educated, had more working members in household, had fewer children, and were food secure. Those lagging were the poor, traditional, and food insecure. The approach may be useful for an improved understanding of poverty and to direct local policy and interventions.

Can malaria rapid diagnostic tests by drug sellers under field conditions classify children 5 years old or less with or without Plasmodium falciparum malaria? Comparison with nested PCR analysis.

BACKGROUND: Malaria rapid diagnostic tests (RDTs) available as dipsticks or strips, are simple to perform, easily interpretable and do not require electricity nor infrastructural investment. Correct interpretation of and compliance with the RDT results is a challenge to drug sellers. Thus, drug seller interpretation of RDT strips was compared with laboratory scientist re-reading, and PCR analysis of Plasmodium DNA extracted from RDT nitrocellulose strips and fast transient analysis (FTA) cards. Malaria RDT cassettes were also assessed as a potential source of Plasmodium DNA. METHODS: A total of 212 children aged between 2 and 60 months, 199 of whom had complete records at two study drug shops in south western Uganda participated in the study. Duplicate 5 µL samples of capillary blood were picked from the 212 children, dispensed onto the sample well of the CareStart™ Pf-HRP2 RDT cassette and a FTA, Whatman™ 3MM filter paper in parallel. The RDT strip was interpreted by the drug seller within 15-20 min, visually re-read centrally by laboratory scientist and from it; Plasmodium DNA was recovered and detected by PCR, and compared with FTA recovered P. falciparum DNA PCR detection. RESULTS: Malaria positive samples were 62/199 (31.2%, 95% CI 24.9, 38.3) by drug seller interpretation of RDT strip, 59/212 (27.8%, 95% CI 22.2, 34.3) by laboratory scientist, 55/212 (25.9%, 95% CI 20.0, 32.6) by RDT nitrocellulose strip PCR and 64/212 (30.2%, 95% CI 24.4, 37.7). The overall agreement between the drug seller interpretation and laboratory scientist re-reading of the RDT strip was 93.0% with kappa value of 0.84 (95% CI 0.75, 0.92). The drug seller compliance with the reported RDT results was 92.5%. The performance of the three diagnostic strategies compared with FTA-PCR as the gold standard had sensitivity between 76.6 and 86.9%, specificity above 90%, positive predictive values ranging from 79.0 to 89.8% and negative predictive values above 90%. CONCLUSION: Drug sellers can use RDTs in field conditions and achieve acceptable accuracy for malaria diagnosis, and they comply with the RDT results. Plasmodium DNA can be recovered from RDT nitrocellulose strips even in the context of drug shops. Future malaria surveillance and diagnostic quality control studies with RDT cassette as a source of Plasmodium DNA are recommended.

Secular trend, seasonality and effects of a community-based intervention on neonatal mortality: follow-up of a cluster-randomised trial in Quang Ninh province, Vietnam.

BACKGROUND: Little is know about whether the effects of community engagement interventions for child survival in low-income and middle-income settings are sustained. Seasonal variation and secular trend may blur the data. Neonatal mortality was reduced in a cluster-randomised trial in Vietnam where laywomen facilitated groups composed of local stakeholders employing a problem-solving approach for 3 years. In this analysis, we aim at disentangling the secular trend, the seasonal variation and the effect of the intervention on neonatal mortality during and after the trial. METHODS: In Quang Ninh province, 44 communes were allocated to intervention and 46 to control. Births and neonatal deaths were assessed in a baseline survey in 2005, monitored during the trial in 2008-2011 and followed up by a survey in 2014. Time series analyses were performed on monthly neonatal mortality data. RESULTS: There were 30 187 live births and 480 neonatal deaths. The intervention reduced the neonatal mortality from 19.1 to 11.6 per 1000 live births. The reduction was sustained 3 years after the trial. The control areas reached a similar level at the time of follow-up. Time series decomposition analysis revealed a downward trend in the intervention areas during the trial that was not found in the control areas. Neonatal mortality peaked in the hot and wet summers. CONCLUSIONS: A community engagement intervention resulted in a lower neonatal mortality rate that was sustained but not further reduced after the end of the trial. When decomposing time series of neonatal mortality, a clear downward trend was demonstrated in intervention but not in control areas. TRIAL REGISTRATION NUMBER: ISRCTN44599712, Post-results.

Cost-effectiveness of prenatal food and micronutrient interventions on under-five mortality and stunting: Analysis of data from the MINIMat randomized trial, Bangladesh.

INTRODUCTION: Nutrition interventions may have favourable as well as unfavourable effects. The Maternal and Infant Nutrition Interventions in Matlab (MINIMat), with early prenatal food and micronutrient supplementation, reduced infant mortality and were reported to be very cost-effective. However, the multiple micronutrients (MMS) supplement was associated with an increased risk of stunted growth in infancy and early childhood. This unfavourable outcome was not included in the previous cost-effectiveness analysis. The aim of this study is to evaluate whether the MINIMat interventions remain cost-effective in view of both favourable (decreased under-five-years mortality) and unfavourable (increased stunting) outcomes. METHOD: Pregnant women in rural Bangladesh, where food insecurity still is prevalent, were randomized to early (E) or usual (U) invitation to be given food supplementation and daily doses of 30 mg, or 60 mg iron with 400 µg of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 µg of folic acid. E reduced stunting at 4.5 years compared with U, MMS increased stunting at 4.5 years compared with Fe60, while the combination EMMS reduced infant mortality compared with UFe60. The outcome measure used was disability adjusted life years (DALYs), a measure of overall disease burden that combines years of life lost due to premature mortality (under five-year mortality) and years lived with disability (stunting). Incremental cost effectiveness ratios were calculated using cost data from already published studies. RESULTS: By incrementing UFe60 (standard practice) to EMMS, one DALY could be averted at a cost of US$24. CONCLUSION: When both favourable and unfavourable outcomes were included in the analysis, early prenatal food and multiple micronutrient interventions remained highly cost effective and seem to be meaningful from a public health perspective.

Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda: a quasi-experimental study.

BACKGROUND: Fever case management is a major challenge for improved child health globally, despite existence of cheap and effective child survival health technologies. The integrated Community Case Management (iCCM) intervention of paediatric febrile illnesses though adopted by Uganda's Ministry of Health to be implemented by community health workers, has not addressed the inaccess to life-saving medicines and diagnostics. Therefore, the iCCM intervention was implemented in private drug shops and evaluated for its effect on appropriate treatment of paediatric fever in a low malaria transmission setting in South Western Uganda. METHODS: From June 2013 to September 2015, the effect of the iCCM intervention on drug seller paediatric fever management and adherence to iCCM guidelines was assessed in a quasi-experimental study in South Western Uganda. A total of 212 care-seeker exit interviews were done before and 285 after in the intervention arm as compared to 216 before and 268 care-seeker interviews at the end of the study period in the comparison arm. The intervention effect was assessed by difference-in-difference analysis of drug seller treatment practices against national treatment recommendations between the intervention and comparison arms. Observed proportions among care-seeker interviews were compared with corresponding proportions from 5795 child visits recorded in patient registries and 49 direct observations of drug seller-care-seeker encounters in intervention drug shops. RESULTS: The iCCM intervention increased the appropriate treatment of uncomplicated malaria, pneumonia symptoms and non-bloody diarrhoea by 80.2% (95% CI 53.2-107.2), 65.5% (95% CI 51.6-79.4) and 31.4% (95% CI 1.6-61.2), respectively. Within the intervention arm, drug seller scores on appropriate treatment for pneumonia symptoms and diagnostic test use were the same among care-seeker exit interviews and direct observation. A linear trend (negative slope, - 0.009 p value < 0.001) was observed for proportions of child cases prescribed any antimicrobial medicine in the intervention arm drug shops. CONCLUSIONS: The iCCM intervention improved appropriate treatment for uncomplicated malaria, pneumonia symptoms and diarrhoea. Drug seller adherence to iCCM guidelines was high, without causing excessive prescription of antimicrobial medicines in this study. Further research should assess whether this effect is sustained over time and under routine supervision models.

Prenatal early food and multiple micronutrient supplementation trial reduced infant mortality in Bangladesh, but did not influence morbidity.

AIM: A previous maternal and infant nutrition intervention in rural Matlab, Bangladesh, showed that prenatal nutrient supplements improved child survival, but had no effect on size at birth. This secondary analysis examined whether prenatal multiple micronutrient supplements (MMS), on their own or combined with an early invitation to receive prenatal food supplements, affected child morbidity. METHODS: This randomised trial enrolled 4436 pregnant women from November 2001 to October 2003 and allocated them to early or standard invitations to food supplements, in the ninth and 20th weeks of pregnancy, respectively, and supplements of either the standard 60 mg iron with 400 µg folic acid, 30 mg iron with 400 µg folic acid or MMS. Quasi-Poisson regression was used to analyse morbidity. RESULTS: There were 3560 single live births and 3516 had morbidity data. The incidence rates of fever, diarrhoea and acute lower respiratory tract infection were 15.3, 3.6 and 2.3 episodes per person-year, respectively. The separate or combined interventions had no effect on morbidity up to 24 months. CONCLUSION: Early invitations to prenatal food supplements or prenatal MMS had no effect on common infections in rural Bangladesh, suggesting that earlier findings on improved child survival were not mediated by an effect on child morbidity.

Baseline data from a planned RCT on attitudes to female genital cutting after migration: when are interventions justified?

OBJECTIVES: To present the primary outcomes from a baseline study on attitudes towards female genital cutting (FGC) after migration. DESIGN: Baseline data from a planned cluster randomised, controlled trial. Face-to-face interviews were used to collect questionnaire data in 2015. Based on our hypothesis that established Somalis could be used as facilitators of change among those newly arrived, data were stratified into years of residency in Sweden. SETTING: Sweden. PARTICIPANTS: 372 Somali men and women, 206 newly arrived (0-4 years), 166 established (>4 years). PRIMARY OUTCOME MEASURES: Whether FGC is acceptable, preferred for daughter and should continue, specified on anatomical extent. RESULTS: The support for anatomical change of girls and women's genitals ranged from 0% to 2% among established and from 4% to 8% among newly arrived. Among those supporting no anatomical change, 75%-83% among established and 53%-67% among newly arrived opposed all forms of FGC, with the remaining supporting pricking of the skin with no removal of tissue. Among newly arrived, 37% stated that pricking was acceptable, 39% said they wanted their daughter to be pricked and 26% reported they wanted pricking to continue being practised. Those who had lived in Sweden ≤ 2 years had highest odds of supporting FGC; thereafter, the opposition towards FGC increased over time after migration. CONCLUSION: A majority of Somali immigrants, including those newly arrived, opposed all forms of FGC with increased opposition over time after migration. The majority of proponents of FGC supported pricking. We argue that it would have been unethical to proceed with the intervention as it, with this baseline, would have been difficult to detect a change in attitudes given that a majority opposed all forms of FGC together with the evidence that a strong attitude change is already happening. Therefore, we decided not to implement the planned intervention. TRIAL REGISTRATION NUMBER: Trial registration number NCT02335697;Pre-results.

Integrated paediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census.

BACKGROUND: There are growing concerns about irrational antibiotic prescription practices in the era of test-based malaria case management. This study assessed integrated paediatric fever management using malaria rapid diagnostic tests (RDT) and Integrated Management of Childhood Illness (IMCI) guidelines, including the relationship between RDT-negative results and antibiotic over-treatment in Malawi health facilities in 2013-2014. METHODS: A Malawi national facility census included 1981 observed sick children aged 2-59 months with fever complaints. Weighted frequencies were tabulated for other complaints, assessments and prescriptions for RDT-confirmed malaria, IMCI-classified non-severe pneumonia, and clinical diarrhoea. Classification trees using model-based recursive partitioning estimated the association between RDT results and antibiotic over-treatment and learned the influence of 38 other input variables at patient-, provider- and facility-levels. RESULTS: Among 1981 clients, 72 % were tested or referred for malaria diagnosis and 85 % with RDT-confirmed malaria were prescribed first-line anti-malarials. Twenty-eight percent with IMCI-pneumonia were not prescribed antibiotics (under-treatment) and 59 % 'without antibiotic need' were prescribed antibiotics (over-treatment). Few clients had respiratory rates counted to identify antibiotic need for IMCI-pneumonia (18 %). RDT-negative children had 16.8 (95 % CI 8.6-32.7) times higher antibiotic over-treatment odds compared to RDT-positive cases conditioned by cough or difficult breathing complaints. CONCLUSIONS: Integrated paediatric fever management was sub-optimal for completed assessments and antibiotic targeting despite common compliance to malaria treatment guidelines. RDT-negative results were strongly associated with antibiotic over-treatment conditioned by cough or difficult breathing complaints. A shift from malaria-focused 'test and treat' strategies toward 'IMCI with testing' is needed to improve quality fever care and rational use of both anti-malarials and antibiotics in line with recent global commitments to combat resistance.

Effect of diagnostic testing on medicines used by febrile children less than five years in 12 malaria-endemic African countries: a mixed-methods study.

BACKGROUND: In 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age. METHODS: Data were compiled from 12 Demographic and Health Surveys in 2010-2012 that reported fever prevalence, diagnostic test and medicine use, and socio-economic covariates (n=16,323 febrile under-fives taken to care). Mixed-effects logistic regression models quantified the influence of diagnostic testing on three outcomes (artemisinin combination therapy (ACT), any anti-malarial or any antibiotic use) after adjusting for data clustering and confounding covariates. For each outcome, interactions between diagnostic testing and the following covariates were separately tested: malaria risk, season, source of care, symptoms, and age. A multiple case study design was used to understand varying results across selected countries and sub-national groups, which drew on programme documents, published research and expert consultations. A descriptive typology of plausible explanations for quantitative results was derived from a cross-case synthesis. RESULTS: Significant variability was found in the effect of diagnostic testing on ACT use across countries (e.g., Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes emerged to explain results: available diagnostics and medicines; quality of care; care-seeking behaviour; and, malaria epidemiology. CONCLUSIONS: Significant country variation was found in the effect of diagnostic testing on paediatric fever treatment at the population level, and qualitative results suggest the impact of diagnostic scale-up on treatment practices may not be straightforward in routine conditions given contextual factors (e.g., access to care, treatment-seeking behaviour or supply stock-outs). Despite limitations, quantitative results could help identify countries (e.g., Mozambique) or issues (e.g., malaria risk) where facility-based research or programme attention may be warranted. The mixed-methods approach triangulates different evidence to potentially provide a standard framework to assess routine programmes across countries or over time to fill critical evidence gaps.

Trends and social differentials in child mortality in Rwanda 1990-2010: results from three demographic and health surveys.

BACKGROUND: Rwanda has embarked on ambitious programmes to provide equitable health services and reduce mortality in childhood. Evidence from other countries indicates that advances in child survival often have come at the expense of increasing inequity. Our aims were to analyse trends and social differentials in mortality before the age of 5 years in Rwanda from 1990 to 2010. METHODS: We performed secondary analyses of data from three Demographic and Health Surveys conducted in 2000, 2005 and 2010 in Rwanda. These surveys included 34 790 children born between 1990 and 2010 to women aged 15-49 years. The main outcome measures were neonatal mortality rates (NMR) and under-5 mortality rates (U5MR) over time, and in relation to mother's educational level, urban or rural residence and household wealth. Generalised linear mixed effects models and a mixed effects Cox model (frailty model) were used, with adjustments for confounders and cluster sampling method. RESULTS: Mortality rates in Rwanda peaked in 1994 at the time of the genocide (NMR 60/1000 live births, 95% CI 51 to 65; U5MR 238/1000 live births, 95% CI 226 to 251). The 1990s and the first half of the 2000s were characterised by a marked rural/urban divide and inequity in child survival between maternal groups with different levels of education. Towards the end of the study period (2005-2010) NMR had been reduced to 26/1000 (95% CI 23 to 29) and U5MR to 65/1000 (95% CI 61 to 70), with little or no difference between urban and rural areas, and household wealth groups, while children of women with no education still had significantly higher U5MR. CONCLUSIONS: Recent reductions in child mortality in Rwanda have concurred with improved social equity in child survival. Current challenges include the prevention of newborn deaths.

Social equity in perinatal survival: a case-control study at hospitals in Kigali, Rwanda.

AIM: Rwanda has invested heavily in improving maternal and child health, but knowledge is limited regarding social equity in perinatal survival. We analysed whether perinatal mortality risks differed between social groups in hospitals in the country's capital. METHODS: A case-control study was carried out on singleton births aged at least 22 weeks of gestation and born in district or tertiary referral hospitals in Kigali from July 2013 to May 2014. Perinatal deaths were recorded as they occurred, with the next two surviving neonates born in the same hospital selected as controls. Conditional logistic regression was used to determine social determinants of perinatal death after adjustments for potential confounders. RESULTS: We analysed 234 perinatal deaths and 468 controls. Rural residence was linked to an increased risk of perinatal death (OR = 3.31, 95% CI 1.43-7.61), but maternal education or household asset score levels were not. Having no health insurance (OR = 2.11, 95% CI 0.91-4.89) was associated with an increased risk of perinatal death, compared to having community health insurance. CONCLUSION: Living in a rural area and having no health insurance were associated with an increased risk of perinatal mortality rates in the Rwandan capital, but maternal education and household assets were not.

Diagnostic testing of pediatric fevers: meta-analysis of 13 national surveys assessing influences of malaria endemicity and source of care on test uptake for febrile children under five years.

BACKGROUND: In 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation. METHODS AND FINDINGS: We compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009-2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2-10<5%), moderate (PfPR2-10 5-40%), high (PfPR2-10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%-21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56-0.69) and community health workers (OR: 0.31, 95% CI: 0.23-0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42-0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39-1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16-1.54). CONCLUSIONS: Diagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers.

Attitudes towards cesarean section in a nationwide sample of obstetricians and gynecologists.

OBJECTIVE: The Swedish cesarean section (CS) rate has increased dramatically over the last decades, but remains relatively low compared to several other countries in the Western world. The reasons for this continuous increase are multifactorial and difficult to investigate. That pregnant women are demanding CS more frequently does not appear to be the major explanatory factor for the increasing CS rate. Since Swedish CS rates are relatively low, it is important to study attitudes to CS in a nationwide population of Swedish obstetricians and gynecologists in order to determine the possible concerns of this group. METHODS: In 2006, a study-specific questionnaire was created and posted to Swedish obstetricians and gynecologists. In total, 1,280 obstetricians and gynecologists received a questionnaire and replied with a response rate of 66%. RESULTS: In general, older and longer work experience physicians had a more positive attitude towards providing CS on maternal request or elective CS for women who fear vaginal delivery. In addition, these colleagues were more positive in expressing their belief that elective CS is as safe as vaginal delivery for the mother and her child. The main difference between female and male physicians was that males were more positive toward providing CS on maternal request (p<0.001). CONCLUSION: We have shown that female physicians differ from their male colleagues in their attitudes toward providing CS on maternal request. Female physicians were more reluctant than males to provide CS on maternal request.

Hospitalizations in adolescence and early adulthood among Swedish men and women born preterm or small for gestational age.

BACKGROUND: Preterm birth and reduced intrauterine growth appear to be related to morbidity in childhood and later adulthood. We studied whether the risk of all-cause hospitalization in adolescence and early adulthood differed between individuals who were born preterm or small for gestational age (SGA) compared with those born at term and appropriate for gestational age. METHODS: Using Swedish registries, we followed 304,275 men and women born in 1973-1975 for any hospitalizations occurring in 1987-1996. Preterm birth was defined as <37 weeks of gestation and SGA as babies smaller than 2 standard deviations below the mean weight for gestational length, according to Swedish standards. We created 3 mutually exclusive categories: "preterm" (<37 weeks and not SGA), "SGA" (SGA and not preterm), and "both preterm and SGA." The comparison group was all term births not SGA. Childhood socioeconomic characteristics were accounted for in the analyses. RESULTS: The overall risk of hospitalization was higher for men and women born SGA (adjusted odds ratio = 1.16; 95% confidence interval = 1.12-1.21), for those born preterm (1.06; 1.02-1.10), and for those born both preterm and SGA (1.42; 1.26-1.59). In addition to higher risks for previously reported adverse health outcomes, such as neurodevelopment sequelae and congenital anomalies, men and women born SGA or preterm were more likely to be hospitalized due to unspecified symptoms. SGA also appeared to be associated with genitourinary diseases and drug use. CONCLUSIONS: Men and women born SGA or preterm were at higher risk for hospitalization during adolescence and early adulthood, with men and women born SGA more at risk than those born preterm.

Relationship and parenthood in IVF couples with twin and singleton pregnancies compared with spontaneous singleton primiparous couples--a prospective 5-year follow-up study.

OBJECTIVE: To analyze relationship and parenthood in IVF twin couples, IVF singleton couples, and spontaneously pregnant primiparous couples. SETTING: Southeast region of Sweden. DESIGN: Prospective case-control study. PATIENT(S): In total, 24 women and men who became pregnant with twins, consecutively, and expected their first child in 1997-98 were studied. A control IVF group of 94 singleton primiparous IVF couples were used. A group of spontaneous primiparous pregnant women were selected out of the total pregnant population as a control group. MAIN OUTCOME MEASURE(S): Relationship and parenthood measured by questionnaires and interviews. RESULT(S): The IVF singleton couples were most stable in their relationship during the whole study period, and the IVF twin parents also seemed more stable and satisfied compared with the control group of spontaneous conception couples. In the control group, 88% had a second child during the study period. In the singleton IVF group the corresponding number was 9%, and none of the twin parents had another child during the study period. CONCLUSION(S): We conclude that the stresses associated with IVF treatment and becoming first-time parents of twins did not have a negative impact on the couples' appreciation of their relationship and parenthood as stated by both men and women.

Knowledge of reproduction in teenagers and young adults in Sweden.

OBJECTIVE: To investigate the knowledge of reproductive physiology and anatomy among adolescents and young adults in Sweden, and to evaluate the education obtained on these issues. METHODS: Two hundred and nine study specific questionnaires were distributed, of which 206 were answered by students in primary school, upper secondary school and at first year of university. A total knowledge score based on 21 out of the 35 questions in the questionnaire was calculated. As only 44 of the 206 respondents answered all the questions a revised score was also calculated, in which partial dropouts were interpreted as wrong answers. RESULTS: The mean of the total knowledge score was 28.7 out of 54 among the 44 respondents answering all questions, and the revised knowledge score was 24.0. The level of knowledge tended to be higher in older age groups, among women, as well as among respondents who had visited a Youth clinic. The time of ovulation was known by 21.4% of men compared to 63.4% of women. Almost 50% of the students knew one mechanism whereby oral contraceptives act to protect against pregnancy. Of the respondents, 77.2% knew of Chlamydia trachomatis but the knowledge of other STIs, like condyloma, was poorer (16.5%). Reasons for infertility were relatively well known among the respondents. Of the respondents, 57.5% stated that they had not received enough information on reproductive issues. CONCLUSIONS: The students have not achieved sufficient knowledge concerning sexual and reproductive matters that they, according to the national curriculum, should have attained by the end of the 9th grade. An improvement of the quality of the education, adapted to the students' age and pre-existing knowledge, and a review of the contents of the education is therefore needed.

Influence of rest during pregnancy on birth weight in working women.

OBJECTIVE: Birth weight in Sweden has increased during the past decades. We investigated whether rest provided by the combination of time off from work and social benefits among working pregnant women contributed to the observed changes. METHOD: A total of 7,459 consecutively delivered women in 1978, 1986, 1992, and 1997 at 2 delivery wards in southeastern Sweden were studied. RESULTS: Between 1978 and 1997, the average birth weight among the children of the women studied increased from 3,484 to 3,566 grams (P < .001). The in-crease in weight was most evident among infants born to women who were employed during pregnancy. The use of social benefits and increased rest during pregnancy did not significantly influence birth weight (P = .107), even after adjustment for gestational length, parity, smoking, age, and occupation. CONCLUSION: The continuous increase in infants' birth weight among pregnant women in this study did not correlate with rest periods in the form of leave supported by social benefit programs. The effects of social benefit programs on pregnancy outcome may thus be overrated and merits further research.