Status and drivers of maternal, newborn, child and adolescent health in the Islamic world: a comparative analysis.

BACKGROUND: The Millennium Development Goal (MDG) period saw dramatic gains in health goals MDG 4 and MDG 5 for improving child and maternal health. However, many Muslim countries in the south Asian, Middle Eastern, and African regions lagged behind. In this study, we aimed to evaluate the status of, progress in, and key determinants of reproductive, maternal, newborn, child, and adolescent health in Muslim majority countries (MMCs). The specific objectives were to understand the current status and progress in reproductive, maternal, newborn, child, and adolescent health in MMCs, and the determinants of child survival among the least developed countries among the MMCs; to explore differences in outcomes and the key contextual determinants of health between MMCs and non-MMCs; and to understand the health service coverage and contextual determinants that differ between best and poor or moderate performing MMCs. METHODS: In this country-level ecological study, we examined data from between 1990 and 2015 from multiple publicly available data repositories. We examined 47 MMCs, of which 26 were among the 75 high-burden Countdown to 2015 countries. These 26 MMCs were compared with 48 non-Muslim Countdown countries. We also examined characteristics of the eight best performing MMCs that had accelerated improvement in child survival (ie, that reached their MDG 4 targets). We estimated adolescent, maternal, under-5, and newborn mortality, and stillbirths, and the causes of death, essential interventions coverage, and contextual determinants for all MMCs and comparative groups using standardised methods. We also did a hierarchical multivariable analysis of determinants of under-5 mortality and newborn mortality in low-income and middle-income MMCs. FINDINGS: Despite notable reductions between 1990 and 2015, MMCs compared with a global esimate of all countries including MMCs had higher mortality rates, and MMCs relative to non-MMCs within Countdown countries also performed worse. Coverage of essential interventions across the continuum of care was on average lower among MMCs, especially for indicators of reproductive health, prenatal care, delivery, and labour, and childhood vaccines. Outcomes within MMCs for mortality and many reproductive, maternal, newborn, child, and adolescent health indicators varied considerably. Structural and contextual factors, especially state governance, conflict, and women and girl's empowerment indicators, were significantly worse in MMCs compared with non-MMCs within the high-burden Countdown countries, and were shown to be strongly associated with child and newborn mortality within low-income and middle-income MMCs. In adjusted hierarchical models, among other factors, under-5 mortality in MMCs increased with more refugees originating from a country (ß=23·67, p=0·0116), and decreased with better political stability or absence of terrorism (ß=-0·99, p=0·0285), greater political rights or government effectiveness (ß=-1·17, p<0·0001), improvements in log gross national income per capita (ß=-4·44, p<0·0001), higher total adult literacy (ß=-1·69, p<0·0001), higher female adult literacy (ß=-0·97, p<0·0001), and greater female to male enrolment in secondary school (ß=-16·1, p<0·0001). The best performing MMCs were Azerbaijan, Bangladesh, Egypt, Indonesia, Kyrgyzstan, Morocco, Niger, and Senegal, which had higher coverage of family planning interventions and newborn or child vaccinations, and excelled in many of the above contextual determinants when compared with moderate or poorly performing MMCs. INTERPRETATION: The status and progress in reproductive, maternal, newborn, child, and adolescent health is heterogeneous among MMCs, with little indication that religion and its practice affects outcomes systemically. Some Islamic countries such as Niger and Bangladesh have made great progress, despite poverty. Key findings from this study have policy and programmatic implications that could be prioritised by national heads of state and policy makers, development partners, funders, and the Organization of the Islamic Cooperation to scale up and improve these health outcomes in Muslim countries in the post-2015 era. FUNDING: US Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn, and Child Survival, the Centre for Global Child Health, Hospital for Sick Children, and the Aga Khan University.

Improving pediatric procedural skills and EPA assessments through an acute care procedural skills curriculum.

INTRODUCTION: Acute procedural skill competence is expected by the end of pediatric residency training; however, the extent to which residents are actually competent is not clear. Therefore, a cross-sectional observational study was performed to examine the competency of pediatric residents in acute care procedures in emergency medicine. MATERIALS AND METHODS: Pediatric residents underwent didactic/hands-on "Acute Procedure Day" where they performed procedures with direct supervision and received entrustable professional activity (EPA) assessments (scores from 1-5) for each attempt. Procedures included: bag-valve mask (BVM) ventilation, intubation, intraosseous (IO) line insertion, chest tube insertion, and cardiopulmonary resuscitation (CPR) with defibrillation. Demographic information, perceived comfort level, and EPA data were collected. Descriptive statistics and Pearson correlation for postgraduate year (PGY) versus EPA scores were performed. RESULTS: Thirty-six residents participated (24 PGY 1-2, and 12 PGY 3-4). Self-reported prior clinical exposure was lowest for chest tube placement (n = 3, 8.3%), followed by IOs (n = 19, 52.8%). During the sessions, residents showed the highest levels of first attempt proficiency with IO placement (EPA 4-5 in 28 residents/33 who participated) and BVM (EPA 4-5 in 27/33), and the lowest for chest tube placement (EPA 4-5 in 0/35), defibrillation (EPA 4-5 in 5/31 residents) and intubation (EPA 4-5 in 17/31). There was a strong correlation between PGY level and EPA score for intubation, but not for other skills. DISCUSSION: Entrustability in acute care skills is not achieved with current pediatrics training. Research is needed to explore learning curves for skill acquisition and their relative importance.

Children with autism spectrum disorder who demonstrate normal language scores use a bottom-up semantic processing strategy: Evidence from N400 recordings.

INTRODUCTION: The N400 is an electrophysiological component that reflects lexical access and integration of words with mental representations. METHODS: Thirty-five young children with a range of language capabilities (n = 21 neurotypical controls, 10 males, mean age = 6.3 ± 0.9 years; n = 14 children with autism, 12 males, mean age = 6.4 ± 1.1 years) completed an auditory semantic categorization paradigm to evoke the N400. Electroencephalograph (EEG) data were acquired with a 64-channel electrode cap as children listened via ear inserts to binaurally presented single syllable words and decided whether the words were congruent (in) or incongruent (out) with a pre-specified category. EEG data were filtered, epoched, and averaged referenced, and global field power (GFP) was computed. The amplitude of the N400 peak in the GFP was submitted to a multiple linear regression analysis. RESULTS: N400 amplitude was found to predict language scores only for the children with ASD who have language scores in the normal range (r2  = 0.72). CONCLUSIONS: This finding that N400 amplitude only predicted language scores in children with ASD and normal language scores suggests that these children may rely more on basic semantic processing (as reflected by the N400) and less on anticipating and predicting upcoming words. This suggests preferential utilization of a bottom-up strategy to access higher order language.