Is Everyone Beating Around the Bush?: A Qualitative Study Examining the Status of Shared Decision-Making Between Veterans Affairs Providers and Surgical Patients in the ICU.

Objective: We sought to determine if and how providers use elements of shared decision-making (SDM) in the care of surgical patients in the intensive care unit (ICU). Background: SDM is the gold standard for decision-making in the ICU. However, it is unknown if this communication style is used in caring for critically ill surgical patients. Methods: Qualitative interviews were conducted with providers who provide ICU-level care to surgical patients in Veterans Affairs hospitals. Interviews were designed to examine end-of-life care among veterans who have undergone surgery and require ICU-level care. Results: Forty-eight providers across 14 Veterans Affairs hospitals were interviewed. These participants were diverse with respect to age, race, and sex. Participant dialogue was deductively mapped into 8 established SDM components: describing treatment options; determining roles in the decision-making process; fostering partnerships; health care professional preferences; learning about the patient; patient preferences; supporting the decision-making process; and tailoring the information. Within these components, participants shared preferred tools and tactics used to satisfy a given SDM component. Participants also noted numerous barriers to achieving SDM among surgical patients. Conclusions: Providers use elements of SDM when caring for critically ill surgical patients. Additionally, this work identifies facilitators that can be leveraged and barriers that can be addressed to facilitate better communication and decision-making through SDM. These findings are of value for future interventions that seek to enhance SDM among surgical patients both in the ICU and in other settings.

Barriers to Participation in a Structured Quality Improvement Initiative to Reduce Avoidable Emergency Department Visits-A Qualitative Study.

INTRODUCTION: Barriers to quality improvement (QI) initiatives in multi-institutional hospital settings are understudied. Here we describe a qualitative investigation of factors negatively affecting a QI initiative focused on reducing avoidable emergency department (ED) visits after bariatric surgery across 17 hospitals. Our goal was to explore participant perspectives and identify themes describing why the program was not effectively implemented or why the program may have been ineffective when correctly implemented. METHODS: We performed semistructured group interviews with 17 sites (42 interviews) participating in a statewide bariatric QI program. We used descriptive content analysis to identify challenges, facilitators, and barriers to implementation of the QI program. All analyses were conducted using MAXQDA software. RESULTS: Results revealed barriers across hospitals related to four themes: buy-in, provider accessibility, resources at participating hospitals, and patient barriers to care. In particular, the initiative faced difficulty if it was not well-matched to the factors driving increasing ED visits at a particular site, such as lack of patient access to outpatient or primary care. Additional challenges occurred if the initiative was not adapted and customized to the working systems in place at each site, involving employees, surgeons, support staff, and leadership. CONCLUSIONS: Overall, findings can direct future focused efforts aimed at site-specific interventions to reduce unnecessary postoperative ED visits. Results demonstrated a need for a nuanced approach that can be adapted based on facility needs and resources.

Patient adherence to an oral rehydration solution intervention to prevent dehydration following ileostomy creation: A qualitative study.

BACKGROUND: Patients undergoing surgery for ileostomy creation frequently experience postoperative dehydration and subsequent renal injury. The use of oral rehydration solutions (ORS) has been shown to prevent dehydration, but compliance may be variable. METHODS: Semi-structured qualitative interviews were conducted with 17 patients who received a postoperative hydration kit and dehydration education to assess barriers and facilitators to compliance with ORS kit instructions. RESULTS: Qualitative analysis revealed five themes affecting patient adherence to the ORS intervention: (1) patient's perception of the effectiveness of the ORS solution, (2) existing co-morbidities, (3) kit quality and taste of the ORS product, (4) quality of the dehydration education, and (5) social support. CONCLUSIONS: Given that patient adherence can greatly affect the success of an ORS intervention, the design of future ORS interventions should emphasize the educational component, the "patient friendliness" of the ORS kit, and ways that social supports can be leveraged to increase adherence.

The obstetrical emergency department: need, rationale, and guide to implementation.

The past 2 decades have seen dramatic growth in the number of obstetrics and gynecology hospitalists, and many hospitals have created obstetrical-specific emergency departments. The goals of an obstetrics emergency department are to provide safe and efficient care to the pregnant dyad and postpartum patient, while generating revenue for emergency services provided. In an obstetrics emergency department, all patients must be evaluated in person by a licensed practitioner, whereas historically they may have been evaluated in person by nursing staff or a trainee. We make the argument that formation of an obstetrics emergency department has the potential to improve the safety and quality of patient care. In addition, the financial benefits to institutions are substantial and can subsidize the cost of maintaining obstetrician presence all the time in the hospital. There are various regulatory requirements to become certified, accredited, and licensed as an emergency department. In addition, there are many operational and systems issues that institutions should consider before implementation. We provide a guide for healthcare systems considering creating an obstetrics emergency department.

Reproductive outcomes following contraceptive discontinuation for method-related reasons: An analysis of 49 Demographic and Health Surveys.

Contraceptive discontinuation for method-related reasons is a common experience in low- and middle-income countries (LMICs) and may heighten women's risk of unintended pregnancy. Few studies have provided a comprehensive assessment of reproductive outcomes following contraceptive discontinuation in LMICs over the last decade. Using cross-sectional data from 49 Demographic and Health Surveys, we applied competing risks estimation to calculate monthly probabilities of contraceptive resumption and pregnancy over a 12-month period among pooled, regional, and country-specific samples of women who discontinued contraception for method-related reasons (corresponding to 174,726 episodes of discontinuation). We also examined the pregnancy intention status of births/current pregnancies among those who became pregnant in the 12 months following contraceptive discontinuation for method-related reasons. In the pooled sample, the three-month probability of pregnancy and resumption of contraceptive use was 12% and 47%, respectively; by 12 months these probabilities increased to 22% and 55%, respectively. Country-specific analyses show that the probabilities of resuming contraception by three months ranged from 15% in Liberia, Mali, and Sierra Leone to 85% in Bangladesh. On average, the majority of pregnancies/births that occured following discontinuation for method-related reasons were subsequently reported as unintended. However, reports varied depending on when women became pregnant within the 12 months following discontinuation. Our findings suggest the need for more nuanced measures of contraceptive use dynamics-including measures that distinguish between women who resume use of contraception from women who remain at risk of pregnancy in the short period after discontinuation-to better inform specific policies and interventions, particularly aimed at those who remain at risk of pregnancy.

Original Research: What Health Care Staff Who Experienced Assisted Patient Falls Can Teach Us: Implications for Fall and Fall Injury Risk.

PURPOSE: This quality improvement project had three aims: to identify common assisted falls scenarios, describe staff members' experiences with and risk perceptions of such falls, and explore factors that influenced their perceptions. The overarching goal was to gain useful insight for the development of assisted fall-related strategies and policies. METHODS: In the fall of 2020, 16 staff members from 13 health care facilities were purposively recruited and interviewed. Transcript summaries of these interviews, along with secondary narrative data from employee and patient injury databases, were analyzed using thematic content analysis. RESULTS: According to staff members' accounts, assisted falls most commonly took place in patient rooms or bathrooms when patients were ambulating or transferring. The interviewees described assisting falls by grabbing or holding the patient or by using their own body to brace or steady the patient. Interview and secondary narrative data noted various injuries that occurred during assisted fall events. These injuries most often involved the lower back (among staff) and the legs (among patients). Most interviewees perceived that using proper body mechanics would prevent injury. CONCLUSIONS: Interviewees' experiences with assisted falls indicate areas of improvement for fall prevention. The perception that using proper body mechanics will protect staff from injury may be a misconception. Although the literature reports mixed findings concerning whether staff should assist patient falls, this project's results led us to conclude that there is no safe way to physically assist a falling patient without risk of staff injury.

The Relationship Between Contraceptive Method Use and Return of Fecundity Among Women Attempting Pregnancy in Low- and Middle-Income Countries.

One of the most common barriers to using effective family planning methods is the belief that hormonal contraceptives and contraceptive devices have adverse effects on future fertility. Recent evidence from high-income settings suggests that some hormonal contraceptive methods are associated with delays in return of fecundity, yet it is unclear if these findings generalize to low- and middle-income populations, especially in regions where the injectable is widely used and pressure to bear children is significant. Using reproductive calendar data pooled across 47 Demographic and Health Surveys, we find that the unadjusted 12-month probability of pregnancy for women attempting pregnancy after discontinuing traditional methods, condoms, the pill, and the IUD ranged from 86% to 91%. The 12-month probability was lowest among those who discontinued injectables and implants, with approximately 1 out of 5 women not becoming pregnant within one year after discontinuation. Results from multivariable analysis showed that compared with users of either periodic abstinence or withdrawal, users of the pill, IUD, injectable, and implant had lower fecundability following discontinuation, with the largest reductions occurring among women who used injectables and implants. These findings indicate that women's concerns about potential short-term reductions in fecundity following contraceptive use are not unfounded.

Racial equity in trauma injury: An unresolved enigma.

BACKGROUND: Racial disparities in healthcare have been attributed to socioeconomic inequalities while the relative risk (RR) of traumatic injury in people of color has yet to be described. METHODS: Demographics of our patient population were compared to the population of our service area. The racial and ethnic identities of gunshot wound (GSW) and motor vehicle collision (MVC) patients were used to establish RR of traumatic injury adjusting for socioeconomic status defined by payor mix and geography. RESULTS: GSW assaults were more common in Blacks (59.1%) while self-inflicted GSWs were more common in Whites (46.2%). RR of having a GSW was 4.65 times greater (95% CI 4.03-5.37; p < 0.01) among Blacks than other populations. MVC patients were 36.8% Black, 26.6% White, and 32.6% Hispanic. Blacks had an increased risk of MVC compared to other races (RR 2.13; 95% CI 1.96-2.32; p < 0.01). The racial and ethnic identity of the patient was not a predictor of GSW or MVC mortality. CONCLUSIONS: Increased risk of GSW and MVC was not correlated with local population demographics or socioeconomic status.

Stop or Switch: Correlates of Stopping Use or Switching Contraceptive Methods While Wanting to Avoid Pregnancy in 48 Low- and Middle-Income Countries.

Contraceptive discontinuation for method-related reasons, while presumably wanting to avoid pregnancy, is a common phenomenon and can contribute to high levels of unmet need and unplanned pregnancies. Some women discontinue contraceptive use and do not quickly resume a method ("stopping"), while others are able to quickly switch to another method to achieve their reproductive goal of avoiding pregnancy ("switching"). We use Demographic and Health Survey data from 48 countries to examine what differentiates women who were able to switch to another method versus those who ultimately stopped entirely, among women who discontinued contraception for method-related reasons. Results show that wanting to limit births, having ever been married, and recent prior use are all associated with switching versus stopping. In addition, we find that women in West and Middle Africa were more likely to stop use compared to women in other regions. Addressing obstacles to contraceptive continuation, including effective method switching, among women who wish to delay or avoid pregnancy should be a priority for global and country initiatives aiming to deliver client-centered care that supports women and couples to make their best family planning choices.

Use of Obstetric and Gynecologic Hospitalists Is Associated With Decreased Severe Maternal Morbidity in the United States.

OBJECTIVES: This study aimed to evaluate the prevalence of obstetric and gynecologic (Ob/Gyn) hospitalists and determine if an association exists between the presence of Ob/Gyn hospitalists and severe maternal morbidity (SMM). METHODS: This observational study included data from hospitals listed in the USA TODAY 's 2019 article titled, "Deadly deliveries: Childbirth complication rates at maternity hospitals." Telephone and email surveys of staff in these hospitals identified the presence or absence of continuous providers in the hospital 24 hours, 7 days a week (24/7 coverage) and the types of providers who are employed, then compared these responses with the SMM cited by USA TODAY . RESULTS: Eight hundred ten hospitals were contacted, with participation from 614 labor and delivery units for a response rate of 75.8%. Fifty-seven percent of units were staffed with 24/7 coverage, with 46% of hospitals' coverage primarily provided by an Ob/Gyn hospitalist and 54% primarily by a nonhospitalist OB/Gyn provider. The SMM and presence of 24/7 coverage increased with the level of neonatal care and delivery volume. Of hospitals with 24/7 coverage, those that primarily used Ob/Gyn hospitalists had a lower SMM for all mothers (1.7 versus 2.0, P = 0.014) and for low-income mothers (1.9 versus 2.30, P = 0.007) than those who primarily used nonhospitalist OB/Gyn providers. CONCLUSIONS: Severe maternal morbidity increases with delivery volume, level of neonatal care, and 24/7 coverage. Of hospitals with 24/7 coverage, units that staff with Ob/Gyn hospitalists have lower levels of SMM than those that use nonhospitalist Ob/Gyn providers.

Sustaining Long-Term Asthma Outcomes at a Community and Tertiary Care Pediatric Hospital.

BACKGROUND AND OBJECTIVES: Implementing asthma Clinical Practice Guidelines (CPG) have been shown to improve length of stay (LOS) and readmission rates on a short-term basis at both tertiary care and community hospital settings. Whether these outcomes are sustained long term is not known. The goal of this study was to measure the long-term impact of CPG implementation at both tertiary and community sites in 1 hospital system. METHODS: A retrospective study was conducted using the Pediatric Health Information System database. LOS and 7- and 14-day emergency department (ED) revisit and readmission rates from 2009 to 2020 were compared pre and post implementation of asthma CPG in 2012 at both sites. Implementation involved electronic order sets, early metered dose inhaler introduction, and empowering respiratory therapists to wean per the bronchodilator weaning protocol. Interrupted time series and statistical process control charts were used to assess CPG impact. RESULTS: Implementation of asthma CPG was associated with significant reductions in the variability of LOS without impacting ED revisit or readmission rates at both the tertiary and community sites. Secular trends in the interrupted time series did not demonstrate significant impact of CPG on LOS. However, the overall trend toward decreased LOS that started before CPG implementation was sustained for 7 years after CPG implementation. CONCLUSIONS: Early metered dose inhaler introduction, respiratory therapist-driven bronchodilator weaning, and electronic order sets at both the community and tertiary care site led to a significant reduction in the variation of LOS, without impacting ED revisit or readmission rate.

Multisite Agricultural Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) Pilot Program: Protocol for a Responsive Mixed Methods Evaluation Study.

BACKGROUND: Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) is an innovative pilot program to provide supportive resources for veterans with interests in agricultural vocations. Implemented at 10 pilot sites, VA FARMS will provide mental health services and resources for veterans while supporting training in gardening and agriculture. As each pilot site project has unique goals, outreach strategies, and implementation efforts based on the local environment and veteran population, evaluating the pilot program provides a unique challenge for evaluators. This paper describes the protocol to evaluate VA FARMS, which was specifically designed to enable site variation by providing both site-specific and cross-site understanding of site implementation processes and outcomes. OBJECTIVE: The objectives of this paper are to (1) describe the protocol used for evaluating VA FARMS, as an innovative Department of Veterans Affairs (VA) agriculturally based, mental health, and employment pilot program serving veterans at 10 pilot sites across the Veterans Health Administration enterprise; and (2) provide guidance to other evaluators assessing innovative programs. METHODS: This evaluation uses the context, inputs, process, product (CIPP) model, which evaluates a program's content and implementation to identify strengths and areas for improvement. Data collection will use a concurrent mixed methods approach. Quantitative data collection will involve quarterly program surveys, as well as three individual veteran participant surveys administered upon the veteran's entrance and exit of the pilot program and 3 months postexit. Quantitative data will include baseline descriptive statistics and follow-up statistics on veteran health care utilization, health care status, and agriculture employment status. Qualitative data collection will include participant observation at each pilot site, and interviews with participants, staff, and community stakeholders. Qualitative data will provide insights about pilot program implementation processes, veterans' experiences, and short-term participation outcomes. RESULTS: Evaluation efforts began in December 2018 and are ongoing. Between October 2018 and September 2020, 494 veterans had enrolled in VA FARMS and 1326 veterans were reached through program activities such as demonstrations, informational presentations, and town-hall discussions. A total of 1623 community members and 655 VA employees were similarly reached by VA FARMS programming during that time. Data were collected between October 2018 and September 2020 in the form of 336 veteran surveys, 30 veteran interviews, 27 staff interviews, and 11 community partner interviews. Data analysis is expected to be completed by October 2022. CONCLUSIONS: This evaluation protocol will provide guidance to other evaluators assessing innovative programs. In its application to the VA FARMS pilot, the evaluation aims to add to existing literature on nature-based therapies and the rehabilitation outcomes of agricultural training programs for veterans. Results will provide programmatic insights on the implementation of pilot programs, along with needed improvements and modifications for the future expansion of VA FARMS and other veteran-focused agricultural programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40496.

Staff Low Back Injury Risk During Assisted Falls Virtual Reality Simulations.

BACKGROUND: Assisted falls occur when staff try to minimize the impact of falls by slowing a patient's descent. Assisting a patient fall may decrease patient injury risk, but biomechanical risk of injury to staff has not been evaluated. Assisted falls virtual reality (VR) simulations were conducted to examine staff low back injury risk during common assisted falls scenarios. METHODS: VR simulations of a toilet to wheelchair transfer were developed with a male patient avatar for three assisted falls scenarios: standing up from toilet, sitting down on wheelchair, and ambulation. Patient avatar weight was modified to reflect normal, underweight, and overweight adult patients. The average spinal compression force at L5/S1 was calculated for each participant with five trials per three scenarios while utilizing physical ergonomic techniques and compared to the safe spinal compression limit of 3,400 Newtons (N). FINDINGS: Six staff participants completed 90 VR simulations in total. The average calculated spinal compression force ranged from 7,132 N to 27,901 N. All participant trials exceeded the safe spinal compression limit of 3,400 N for every assisted falls scenario and avatar weight despite application of ergonomic techniques including wide stance, knees bent, and backs straight. CONCLUSIONS/APPLICATION TO PRACTICE: Staff are at risk for low back injury if they assist falls regardless of the adult patient weight and application of ergonomic techniques. Safer alternatives like the implementation of mobility screening tools and safe patient handling and mobility technology are needed to help prevent assisted falls to decrease injury risk to both patients and staff.

"We're all one bad day away": Impacts on Food Access in Buffalo, New York during the COVID-19 pandemic.

When COVID-19 arrived in Buffalo, New York in March 2020, there was already significant food insecurity in the region. However, barriers to food access were greatly exacerbated by the pandemic. This study assesses the pandemic's impact on food access in Buffalo through 75 surveys and 30 qualitative interviews conducted with users of food pantries. Results show that, while the pandemic did contribute to food insecurity, many food pantry users were already experiencing chronic food access issues. Specifically, issues related to transportation, stigma, and chronic poverty must be addressed for food insecure households to better endure emergency events like pandemics.

Assessing the Impact of Vaginal Hysterectomy with Vaginal Mesh Attachment on Outcomes and Complications during Minimally Invasive Sacrocolpopexy.

STUDY OBJECTIVE: To compare mesh complications and failure rates after 1 year in laparoscopic minimally invasive sacrocolpopexy (MISC) with ultralightweight mesh attached vaginally during total vaginal hysterectomy (TVH), laparoscopically if posthysterectomy (PH), or laparoscopically during supracervical hysterectomy. DESIGN: Single-center retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Women with symptomatic pelvic organ prolapse who elected for MISC. INTERVENTIONS: Laparoscopic MISC with ultralightweight mesh attached vaginally during TVH, laparoscopically if PH, or laparoscopically during supracervical hysterectomy. Composite failure was defined as recurrent prolapse symptoms, prolapse past the hymen, or retreatment for prolapse. MEASUREMENTS AND MAIN RESULTS: Between 2010 and 2017, 650 patients met the inclusion criteria with 278 PH, 82 supracervical hysterectomy, and 290 vaginal hysterectomy patients. Median follow-up was similar for all groups (382 days vs 379 vs 345; p = .31). The majority in all groups were white (66.6%), nonsmokers (74.8%), postmenopausal (82.5%), and did not use estrogen (70.3%). Mesh complications did not differ among groups (1.6% PH, 2.5% supracervical hysterectomy, 2.2% vaginal hysterectomy; p >.99). There was no difference in anatomic failure (5% PH, 1.2% supracervical hysterectomy, 2.1% vaginal hysterectomy; p = .07), reoperation for prolapse (1.4% vs 1.2% vs 0.7%; p = .57), or composite failure (9.0% vs 3.7% vs 4.8%; p = .07). CONCLUSIONS: TVH with vaginal mesh attachment of ultralightweight mesh had similar adverse events, mesh exposure rates, and failure rates to those of laparoscopic PH sacrocolpopexy or supracervical hysterectomy with laparoscopic mesh attachment.

The Know-Do Gap: Understanding and Improving Service Quality Among Pharmacies Providing Injectable Contraceptives Through a Mystery Client Study in Nepal.

Nepal is one of the first countries to license pharmacists to administer injectable contraceptives, through Nepal CRS Company's (CRS) Sangini private pharmacy network. There are more than 3,400 Sangini pharmacies in Nepal, including in hard-to-reach mountain areas, where these outlets are a key access point to injectables and other short-acting methods for those who lack access through the public sector or prefer the private sector.We compared the performance of Sangini pharmacists in (1) CRS-led technical support visits, when providers were aware of being observed, and (2) mystery client visits, when providers were not aware of being observed, to assess any gaps between pharmacists' knowledge and practices. We also assessed how well Sangini providers counseled on injectables and compared counseling on injectables with counseling for oral contraceptives.We found high levels of adherence to training guidelines on counseling on injectables. However, we identified significant differences between pharmacists' understanding of what they should do and what they actually do in practice, referred to as the know-do gap, in providing privacy, assessing client needs, and determining medical eligibility for hormonal methods. CRS took several steps to narrow the know-do gap through its programming, which may be a useful example for other countries as they expand the role of pharmacies in family planning service provision. Despite highlighting several areas for improvement, the findings show that Sangini providers both know how to and practice appropriate counseling on both injectable and oral contraceptives, suggesting that pharmacists can successfully expand their family planning offerings and equip clients with the information needed to select an appropriate method of their choice.

Where Women Access Contraception in 36 Low- and Middle-Income Countries and Why It Matters.

We examined where women access modern contraceptives, using recent Demographic and Health Survey data from 36 low- and middle-income countries and disaggregating results by contraceptive method, age, marital status, residence, socioeconomic status, and country income. We used bivariate and multivariate regression analysis to assess how demographic factors are associated with contraceptive source. In pooled analysis across countries analyzed, we found that 34% of users rely on private sources, 63% use public sources, and 3% use other sources. Among private sector users, 41% use pharmacies or drug shops, 11% general shops or markets, 36% private hospitals and clinics, and 12% nongovernmental or faith-based organizations. This analysis demonstrates the importance of the private sector for specific population segments including women in the wealthiest population quintile (odds ratio [OR]: 4.09, P<.001 compared with women in the poorest quintile), adolescents (OR: 2.03, P<.001 compared with women ages 40-49), never married women (OR 1.55, P<.001 compared with ever-married women), and urban women (OR: 1.42, P<.001 compared with rural women). The private sector does not only serve these populations, however. On average across countries analyzed, 22% of the poorest contraceptive users and 27% of rural users use private sources. Leveraging both sectors is key to meeting the reproductive needs of women across all sociodemographic groups in low- and middle-income countries.

Best practices for repair of iatrogenic bladder injury.

Gynecologic surgery carries a known risk of injury to the urinary tract, especially in the presence of risk factors. Injury to the bladder, particularly a mechanical injury, is more common than injury to the ureter. Urinary tract injuries occur in 0.3% to 0.8% of all gynecologic procedures, and injuries to the bladder occur in 0.05% to 0.66% of such surgeries. The risk of bladder injury increases in hysterectomy procedures. Most research studies have cited occurrence of bladder injuries to be 1.0% to 1.8% in laparoscopically assisted vaginal hysterectomies and vaginal hysterectomies. Despite its frequency, there is limited research on best practices for bladder injury repair. The authors performed a literature search through the PubMed database using the terms "bladder anatomy," "bladder injury," "bladder repair," "cystotomy," "routine cystoscopy," and "vesicovaginal fistula." This review uses gynecologic and trauma literature and discusses prevention, recognition, types of iatrogenic bladder injuries, their clinical significance, current guidelines on bladder injury repair, and the expected follow-up care, and concludes by identifying areas for further research.

Sources for and quality of neonatal care in 45 low- and middle-income countries.

Almost half of under-five deaths occur during the neonatal period. Delivery with a skilled attendant, adherence to essential newborn care (ENC) and postnatal care (PNC) standards, and immediate treatment of infections are essential to improve neonatal survival. This article uses Demographic and Health Survey data from 45 low- and middle-income countries to assess 1) levels of ENC and PNC that mothers and newborns receive and how this differs by place of delivery and 2) levels of and sources for care-seeking for neonates sick with fever. For five of the ten ENC and PNC indicators assessed, less than two-thirds of mothers and newborns received care in alignment with global standards. Adherence is higher in private facilities than public facilities for all indicators other than immediate breastfeeding and skin-to-skin contact. Except for immediate breastfeeding, adherence is lowest for newborns born at home with a skilled birth attendant (SBA). Socioeconomic disparities exist in access to skilled delivery and adherence to ENC and PNC, with the largest disparities among newborns delivered at home with a SBA. Private provider adherence to ENC and PNC standards was relatively high for newborns from the wealthiest families, indicating that meeting recommended guidelines is achievable. On average across the 45 countries, half of caregivers for neonates with fever sought care outside the home and 45 percent of those sought care from the private sector. There were substantial socioeconomic disparities in care-seeking for fever, but illness prevalence and sources of care seeking were consistent across wealth quintiles. Closing inequities in neonatal care and care seeking and ensuring that all families, including the poorest, can access high quality maternal and newborn care is crucial to ensure equity and accelerate reductions in neonatal and child mortality.

Impact of gastrointestinal comorbidities in patients with right and left atrial isomerism.

BACKGROUND AND AIM: Heterotaxy syndrome, being right atrial isomerism (RAI) or left atrial isomerism (LAI), often presents with Congenital Heart Disease (CHD). Intestinal abnormalities, including malrotation are common. We assessed the spectrum of gut abnormalities and their impact on medium-term outcome in a cohort of patients with fetal and postnatal diagnoses of heterotaxy syndrome. METHODS: We reviewed the cardiology records of heterotaxy syndrome patients from two centres, regarding the presence of CHD, time for cardiac intervention, presence of gastrointestinal abnormalities, and type/time of surgery. A questionnaire about gastrointestinal status was sent to patients <18 years old. Kaplan-Meier curves were derived for survival data and freedom from intervention. RESULTS: Data were included for 182 patients (49 RAI and 133 LAI) of 247 identified. Questionnaires were sent to 77 families and 47 replied. CHD was present in all RAI and 61.7% of LAI cases. Thirty-eight patients had abdominal surgery (20.9%), similar for RAI and LAI (20.4% versus 21%, p> 0.99): Ladd procedure in 17 (44.7%), non-Ladd in 12 (31.5%), and both procedures in 9 (23.7%). Ten-year freedom from Ladd procedure for all was 86% for the whole cohort (RAI = 87%; LAI = 85%, p = 0.98). Freedom from any gastrointestinal surgery at 10 years was 79% for the whole cohort (RAI = 77%; LAI = 80%, p = 0.54). Ten-year freedom from cardiac surgery was 31% for the whole cohort (RAI = 6%; LAI = 43%, p < 0.0001). CONCLUSIONS: In our cohort, one in five patients required abdominal surgery, mostly in their first year of life, similar for RAI and LAI. Between 1 and 10 years of follow-up, the impact of gastrointestinal abnormalities on outcome was minimal. Medium term survival was related to CHD.