Rates and risk factors for preterm birth and low birthweight in the global network sites in six low- and low middle-income countries.

BACKGROUND: Preterm birth continues to be a major public health problem contributing to 75% of the neonatal mortality worldwide. Low birth weight (LBW) is an important but imperfect surrogate for prematurity when accurate assessment of gestational age is not possible. While there is overlap between preterm birth and LBW newborns, those that are both premature and LBW are at the highest risk of adverse neonatal outcomes. Understanding the epidemiology of preterm birth and LBW is important for prevention and improved care for at risk newborns, but in many countries, data are sparse and incomplete. METHODS: We conducted data analyses using the Global Network's (GN) population-based registry of pregnant women and their babies in rural communities in six low- and middle-income countries (Democratic Republic of Congo, Kenya, Zambia, Guatemala, India and Pakistan). We analyzed data from January 2014 to December 2018. Trained study staff enrolled all pregnant women in the study catchment area as early as possible during pregnancy and conducted follow-up visits shortly after delivery and at 42 days after delivery. We analyzed the rates of preterm birth, LBW and the combination of preterm birth and LBW and studied risk factors associated with these outcomes across the GN sites. RESULTS: A total of 272,192 live births were included in the analysis. The overall preterm birth rate was 12.6% (ranging from 8.6% in Belagavi, India to 21.8% in the Pakistani site). The overall LBW rate was 13.6% (ranging from 2.7% in the Kenyan site to 21.4% in the Pakistani site). The overall rate of both preterm birth and LBW was 5.5% (ranging from 1.2% in the Kenyan site to 11.0% in the Pakistani site). Risk factors associated with preterm birth, LBW and the combination were similar across sites and included nulliparity [RR - 1.27 (95% CI 1.21-1.33)], maternal age under 20 [RR 1.41 (95% CI 1.32-1.49)] years, severe antenatal hemorrhage [RR 5.18 95% CI 4.44-6.04)], hypertensive disorders [RR 2.74 (95% CI - 1.21-1.33], and 1-3 antenatal visits versus four or more [RR 1.68 (95% CI 1.55-1.83)]. CONCLUSIONS: Preterm birth, LBW and their combination continue to be common public health problems at some of the GN sites, particularly among young, nulliparous women who have received limited antenatal care services. Trial registration The identifier of the Maternal and Newborn Health Registry at ClinicalTrials.gov is NCT01073475. TRIAL REGISTRATION: The identifier of the Maternal and Newborn Health Registry at ClinicalTrials.gov is NCT01073475.

Detection and risk stratification of women at high risk of preterm birth in rural communities near Nagpur, India.

BACKGROUND: Presently, preterm birth is globally the leading cause of neonatal mortality. Prompt community based identification of women at high risk for preterm births (HRPB) can either help to avert preterm births or avail effective interventions to reduce neonatal mortality due to preterm births. We evaluated the performance of a package to train community workers to detect the presence of signs or symptoms of HRPB. METHODS: Pregnant women enrolled in the intervention arm of a cluster randomized trial of Antenatal Corticosteroids (ACT Trial) conducted at Nagpur, India were informed about 4 directly observable signs and symptoms of preterm labor. Community health workers actively monitored these women from 24 to 36 weeks of gestation for these signs or symptoms. If they were present (HRPB positive) the identified women were brought to government health facilities for assessment and management. HRPB positive could also be determined by the provider if the woman presented directly to the facility. Risk stratification was based on the number of signs or symptoms present. The outcome of preterm birth was based on the clinical assessment of gestational age < 37 weeks at delivery or a birth weight of <2000 g. RESULTS: Between July 1, 2012 and 30 November, 2013, 686 of 7050 (9.7%) pregnant women studied, delivered preterm. 732 (10.4%) women were HRPB positive, of whom 333 (45.5%) delivered preterm. Of the remaining 6318(89.6%) HRPB negative women 353 (5.6%) delivered preterm. The likelihood ratio (LR) of a preterm birth in the HRPB positives was 8.14 (95% confidence interval 7.16-9.26). The LR of a preterm birth increased in women who had more signs or symptoms of HRBP (p < 0.00001). More signs or symptoms of HRPB were also associated with a shorter time to delivery, lower birth weight and higher rates of stillbirths, neonatal deaths and postnatal complications. Addition of risk stratification improved the prediction of preterm delivery (Integrated Discrimination Improvement 17% (95% CI 15-19%)). CONCLUSIONS: The package for detection of signs and symptoms of HRPB is feasible, promising and likely to improve management of preterm labor. TRIAL REGISTRATION: NCT01073475 on February 21, 2010 and NCT01084096 on March 9, 2010.

Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India.

BACKGROUND: In 2008, the Indian government introduced financial assistance to encourage health facility deliveries. Facility births have increased, but maternal and neonatal morbidity and mortality have not decreased raising questions about the quality of care provided in facilities and access to a quality referral system. We evaluated the potential role of inter-institutional transfers of women admitted for labor and delivery on adverse maternal and neonatal outcomes in an ongoing prospective, population-based Maternal and Newborn Health Registry in Central India. METHODS: Pregnant women from 20 rural Primary Health Centers near Nagpur, Maharashtra were followed throughout pregnancy and to day 42 post-partum. Inter- institutional referral was defined as transfer of a woman from a first or second level facility where she was admitted for labor and delivery to facility providing higher level of care, after admission to the day of delivery. Maternal mortality, stillbirth, early and late neonatal mortality were compared in mothers who were and were not referred. Factors associated with inter-institutional referral were analyzed using multivariable models with generalized estimating equations, adjusted for clustering at the level of the Primary Health Center. RESULTS: Between June 2009 and June 2013, 3236 (9.4%) of 34,319 women had inter-institutional referral. Factors associated with referrals were maternal age (adjusted Relative Risk or aRR 1.1; 1.0-1.2); moderate or severe anemia (aRR 1.2; 1.2-1.4), gestational age <37 weeks (aRR 1.16; 1.05-1.27), multiple gestation (aRR 1.6; 1.2-2.1), absent fetal heart rate (aRR 1.7; 1.3-2.2), primigravida (aRR 1.4; 1.3, 1.6), primigravida with any pregnancy related maternal condition such as obstructed or prolonged labor; major antepartum or post-partum hemorrhage, hypertension or preeclampsia and breech, transverse or oblique lie (aRR 4.7; 3.8, 5.8), multigravida with any pregnancy related conditions (aRR 4.2; 3.4-5.2). Stillbirths, early neonatal,late neonatal and early infant deaths occurred in 7.3% referred mothers vs. 3.7% of not referred. CONCLUSIONS: Almost 10% of the women had an inter-institutional referral and still birth or neonatal deaths were doubled in referred women. Conditions associated with referral were often known before onset of labor and delivery. Improvements in maternal and neonatal outcomes will likely require pregnant women with conditions associated with referral to be directly admitted at facilities equipped to care for complicated pregnancies and at risk neonates, as well as prompt detection and transfer those who develop "at risk" conditions during labor and delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT01073475 .

Evaluating the Impact of Training Teachers to Identify Learning Disabilities: A Pre-experimental Study on Knowledge Enhancement.

Introduction Learning disability (LD) affects many school-going children and is seldom recognized or treated. As teachers spend time with students, they can easily recognize LD by observing academic activities and behaviors. In this context, the present study was conducted to assess the knowledge and practices of teachers regarding LD and evaluate the impact of an educational intervention on teachers' knowledge regarding LD and its screening and referral. Methods A pre-experimental study, including pre-post interventional assessments of teachers, was conducted from June 2018 to December 2019. A universal sample of 150 teachers from 10 schools teaching primary (first to fifth grade) and upper primary (sixth to eight grade) grades was included. Their knowledge about LD was assessed using the Dyslexia Assessment for the Languages of India (DALI), and an educational intervention for assessing, screening, and identifying LD was implemented. Data was analyzed using SPSS version 24.0 (IBM Inc., Armonk, New York). Using descriptive statistics (mean, median, and standard deviation). The pre-post test results were compared using the McNemar test. Results Overall knowledge about LD was 24.7% at baseline, and improved to 76% post-intervention (p<0.001). The knowledge for most of the components showed improvement. Teachers with a good level of knowledge increased from 21% to 84%. Post-intervention screening of students increased from 0.53% to 13.37%. The suspicion rate for LD increased from 0.04% to 1.94% post-intervention. Conclusion Knowledge about LD was poor among the school teachers. However, the overall knowledge about LD, its specific domains, screening as well as actual LD screening significantly improved after the intervention (p<0.001). This emphasizes the need of training primary and post-primary school teachers about LD and the services available for children with LD.

Influence of social media on psychological health of youth during COVID-19 pandemic.

Context: Medical undergraduates, being away from their institutes due to the lockdown, are at a greater risk of being affected by the negative news, which may easily instill fear and panic among them. Therefore, the present study was planned with the objective to study the effects of media exposure on the psychological health of undergraduate medical students at a tertiary health institute. Aim: To assess the psychological effects of social media/media use and coping mechanisms adopted during the COVID-19 pandemic. Settings and Design: Tertiary care teaching Institute and Cross-sectional study. Material and Methods: It is a cross-sectional observational study performed among (under graduate) UG students, which was assessed using a pre-tested questionnaire including the pre-validated DASS-21 scale. Statistical Analysis: Data collected was entered in MS Excel. Descriptive statistics and correlation of the study variables were analyzed while controlling for demographics using Epi-info software version 7.2.2. Results: It was observed that around one-fifth of the participants have moderate depression, followed by mild 10.97%; one-fifth of the participants have moderate levels of anxiety 20.41% followed by extremely severe anxiety 13.27% and about two-thirds of the study participants having no stress 64.29% followed by mild stress 14.80% and moderate stress 9.69%. Conclusion: There was a significant psychological impact of the use of social media among young populations, particularly anxiety, stress, and depression with exposure to negative news and reports on social media platforms.

Childhood illness in households using biomass fuels in India: secondary data analysis of nationally representative national family health surveys.

BACKGROUND: Half of the world's population uses solid fuels for energy and cooking, resulting in 1.5 million deaths annually, approximately one-third of which occur in India. Most deaths are linked to childhood pneumonia or acute lower respiratory tract infection (ALRI), conditions that are difficult to diagnose. The overall effect of biomass combustion on childhood illness is unclear. OBJECTIVES: To evaluate whether type of household fuel is associated with symptoms of ALRI (cough and difficulty breathing), diarrhea or fever in children aged 0-36 months. METHODS: We analyzed nationally representative samples of households with children aged 0-36 months from three national family health surveys conducted between 1992 and 2006 in India. Households were categorized as using low (liquid petroleum gas/electricity), medium (coal/kerosene) or high polluting fuel (predominantly wood/agricultural waste). Odds ratios adjusted for confounders for exposure to high and medium polluting fuel were compared with low polluting fuel (LPF). RESULTS: Use of high polluting fuel (HPF) in India changed minimally (82 to 78 %), although LPF use increased from 8% to 18%. HPF was consistently associated with ALRI [adjusted odds ratio (95% confidence interval) 1.48 (1.08-2.03) in 1992-3; 1.54 (1.33-1.77) in 1998-9; and 1.53 (1.21-1.93) in 2005-6). Fever was associated with HPF in the first two surveys but not in the third survey. Diarrhea was not consistently associated with HPF. CONCLUSIONS: There is an urgent need to increase the use of LPF or equivalent clean household fuel to reduce the burden of childhood illness associated with IAP in India.