Assisted vaginal delivery in low and middle income countries: an overview.

OBJECTIVE: To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use. DESIGN: Cross-sectional health facility assessments. SETTING: Up to 40 countries in Latin America, sub-Saharan Africa and Asia. POPULATION: Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors. METHODS: Descriptive secondary data analysis. MAIN OUTCOME MEASURES: Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced. RESULTS: Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find <1% of institutional births delivered by AVD. Vacuum extraction appears preferred over forceps. Lack of equipment and trained health workers were the most frequent reasons for non-performance. CONCLUSIONS: The low use of AVD in LMICs is in contrast with many high-income countries, where high caesarean rates are also associated with significant rates of AVD. In many LMICs, rising caesarean rates have not been associated with maintenance of skills and practice of AVD. AVD is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where caesarean delivery can be relatively unsafe. TWEETABLE ABSTRACT: Many LMICs exhibit low use of assisted vaginal delivery where access to EmONC continues to be a hardship.

The disappearing art of instrumental delivery: time to reverse the trend.

PURPOSE: This paper focuses attention on declining rates of instrumental (vacuum or forceps) delivery. The decline often means that women must travel further to deliver in hospitals with capacity for cesarean delivery. BACKGROUND: The paper illustrates recent trends in the use of vacuum extraction and forceps in low- and high-income countries. It describes some of the obstacles to the use of instrumental delivery and why the techniques, especially vacuum extraction, should be reintroduced. Over the past two decades, many countries have observed a decline in instrumental delivery rates while cesarean rates have increased. Objections to instrumental delivery are largely due to the potential harm it causes newborns. Some medical schools no longer train their professionals to perform instrumental delivery. Elsewhere, only specialists are permitted to perform the procedures. METHODS AND RESULTS: As this is a policy paper rather than a research report, the methods and results sections are not applicable. CONCLUSIONS: Vacuum extraction can be taught to midlevel practitioners (midwives, nurse practitioners and general physicians), thereby increasing access to emergency obstetric care especially at the periphery. This allows women to give birth closer to home in midlevel facilities when hospitals are not easily accessible or are overcrowded. Where instrumental and cesarean delivery are both available, instrumental delivery could potentially reduce the risks associated with cesarean delivery and reduce the costs of obstetric care.

Relation between arterial blood pressure and blood volume and effect of infused albumin in sick preterm infants.

The relation between directly measured arterial blood pressure and blood volume was studied in 61 sick preterm infants. Mean blood volume (derived from plasma volume [T1824 ten-minute albumin space] and hematocrit value) of 26 hypotensive infants (89.1 +/- 17.26 ml/kg) was not significantly different from that of 35 normotensive, but otherwise comparable, infants (91.4 +/- 14.57 ml/kg). There was no relation between arterial mean blood pressure and blood volume. Twenty-one infants with arterial mean blood pressure less than 30 mm Hg were given 1.0 g/kg of 10% salt-poor albumin. Significant increases in blood pressure occurred but were small in magnitude; more than one half of infants had arterial mean blood pressures persistently less than 30 mm Hg. Arterial/alveolar PO2 ratio decreased significantly with albumin infusion in six infants with hyaline membrane disease not receiving continuous distending-airway pressure, suggesting an association between infused albumin and impaired oxygen exchange.

Feeding the low-birthweight infant: orally or parenterally?: II. Corrected bromide space in parenterally supplemented infants.

Previously published data suggested that the faster rate of weight gain observed in parenterally supplemented neonates compared to their orally fed peers might be attributable to water retention rather than to more rapid tissue accretion. The present study was designed to test that hypothesis by observing changes in extracellular water, estimated as corrected bromide space (CBS). Ten neonates with a mean birthweight of 1,250 gm (range, 800 to 1,980 gm) and a mean gestational age of 31 weeks (range, 24 to 38 weeks) were randomly assigned to a 67 cal/dl formula feeding or an oral 100 cal/dl formula feeding supplemented parenterally with dextrose and amino acids. CBS was estimated within 19 hours of birth and between the 7th and 28th postnatal days. Mean total daily water and protein intakes during the intervening period were similar for orally fed and supplemented neonates, but the latter took significantly less orally and received more parenterally. CBS increased in all but one of the supplemented neonates whereas two of four orally fed babies had decreasing values and one had stable values. Shorter times before regaining birthweight, faster rates of weight gain, and lower arterial pH were associated with larger CBS as well as with parenteral supplementation. These data suggest that parenteral supplementation may result in water retention and/or shifts from the intracellular to the extracellular space. Previously reported earlier and greater mean daily weight gains in supplemented babies may be related to water accumulation rather than tissue accretion, but definitive conclusions must await further studies, including concomitant estimates of total and extracellular body water.

Plasma thrombin assay using a chromogenic substrate in disseminated intravascular coagulation due to snake bite envenomation.

Using the chromogenic substrate, Tos-Gly-Pro-Arg-pNA-HCl (Chromozym TH, Boehringer Mannheim) plasma thrombin was estimated in six cases of envenomation by Australian elapid snakes. All patients manifested findings characteristic of defibrination due to envenomation by these snakes. Fibrin-fibrinogen degradation products were grossly elevated, as was plasma thrombin in all cases. Following treatment with antivenene, all abnormal coagulation parameters returned rapidly towards normal by 24 hours and plasma thrombin disappeared.

Multihormonal responses to apomorphine in mental illness.

The neuroendocrine responses to subcutaneous (SC) administration of the dopamine (DA) agonist apomorphine (APO) hydrochloride (0.75 mg) were studied in a large group of subjects: 110 drug-free inpatients with either DSM-III-R schizophrenia (SCZ, n = 46), schizoaffective disorder (SAD, n = 14), or major depressive episode (MDE, n = 50), plus 18 hospitalized controls. Compared to a saline test, APO induced a significant increase of growth hormone (GH), adrenocorticotropin (ACTH), and cortisol (COR) release and a decrease in prolactin (PRL) secretion. No change in thyrotropin (TSH) levels was observed. In the total sample the extents of ACTH, COR and GH responses were correlated, but in the group of 88 subjects who exhibit a normal GH stimulation this correlation disappeared. This discrepancy suggests that APO-induced ACTH and COR stimulation may be mediated by pathways different from those mediating GH stimulation. According to diagnostical categories, we found significant lower ACTH and COR stimulation in the schizophrenic group and in patients with SAD, compared with that among controls or depressed patients. We found also a significant difference between subgroups of schizophrenic patients. These results agree with the hypothesis that different aspects of psychosis might involve different subtypes of DA-receptors with different localizations and sensitivities.

Multihormonal responses to clonidine in patients with affective and psychotic symptoms.

The neuroendocrine responses to the alpha(2)-adrenoreceptor agonist clonidine (CLO) (0.35 mg if body weight <65 kg or 0.375 mg if body weight> or =65 kg, PO) were studied in a large group of subjects: 134 drug-free inpatients--with either DSM-IV schizophrenia (SCZ, n=31), schizoaffective disorder (SAD, n=16), or major depressive episode (MDE, n=87) - and 22 hospitalized controls (HCs). Comparison with a previous placebo test performed in a subgroup of 92 subjects (46 MDEs, 20 SCZs, 8 SADs, and 18 HCs) showed that CLO induced a significant increase of growth hormone, prolactin (PRL) and thyrotropin (TSH) levels but no significant change in adrenocorticotropin and cortisol release. According to diagnostic categories, we found significantly lower GH stimulation in MDEs and in SADs compared to HCs or to SCZs. In addition, we found significantly lower CLO induced PRL and TSH stimulations in paranoid SCZ patients compared to controls and disorganized SCZ patients. Taken together, these results suggest a hyposensitivity of noradrenergic alpha(2)-receptors in patients with affective symptoms.

A randomized double-blind placebo-controlled study of tropisetron in the treatment of outpatients with generalized anxiety disorder.

The selective 5HT3 antagonist tropisetron was studied in 91 outpatients meeting DSM-III criteria for Generalized Anxiety Disorder. Following a placebo washout period of up to 1 week, one of three active treatments (tropisetron 0.5 mg, 5 mg, or 25 mg daily) or placebo was given for a further 3 weeks. After 7 days treatment termination rates due to inefficacy showed a statistically significant dose-related therapeutic effect of tropisetron. Similar effects were seen on the Hopkins Symptom Check List total score and the Global Impression Scale. The Hamilton Anxiety Scale showed a similar trend which, however, failed to reach statistical significance. At day 21 tropisetron showed significant dose-dependent effects on all anxiety-related outcome measures. The incidence of adverse events was low and the severity generally mild. Most frequent complaints were headache, nausea, constipation and nervousness. Laboratory tests and physical examination performed at baseline and study end showed no significant treatment effects.

Dopaminergic function and the cortisol response to dexamethasone in psychotic depression.

1. It has been hypothesized that psychotic symptoms in depression may be due to increased dopamine activity secondary to hypothalamic-pituitary-adrenal (HPA) axis overactivity. 2. To test this hypothesis, the authors examined the cortisol response to dexamethasone suppression test (DST, 1 mg orally) and multihormonal responses to apomorphine (APO, 0.75 mg s.c.)--a dopamine agonist--in 150 drug-free hospitalized patients with DSM-IV major depressive episode with psychotic features (MDEP, n=35), major depressive episode without psychotic features (MDE, n=74), or schizophrenia paranoid type (SCZ, n=41), and 27 hospitalized healthy controls (HCs). 3. MDEPs showed increased activity of the HPA system (i.e. higher post-DST cortisol levels) than HCs, SCZs and MDEs. However, there were no differences in adrenocorticotropic hormone (ACTH), cortisol, prolactin and growth hormone (GH) responses to APO between MDEPs and MDEs and HCs. On the other hand, SCZs showed lower APO-induced ACTH stimulation and a higher rate of blunted GH than HCs, MDEs and MDEPs, suggesting a functional alteration of the hypothalamic dopamine receptors in SCZs. 4. In the total sample and in each diagnostic group, DST suppressors and non-suppressors showed no differences in hormonal responses to APO. 5. These results suggest a lack of causal link between HPA axis hyperactivity and dopamine dysregulation. In contrast to schizophrenia, psychotic symptoms in depression seem not to be related to dopamine function dysregulation.

Costing pathology services: a practical approach to a difficult problem.

Recent developments in funding healthcare have created a need to know the cost of each input into a patient episode of care. In most cases pathology departments will be faced with a complex costing problem in their efforts to meet this need, owing to the diversity of investigations performed and the variation in cost between the least and the most expensive investigations. Most methods for costing pathology services are resource intensive, from the point of view both of the initial set up and of maintenance of the data. They often require a level of financial detail that may not be available. The model described in this paper will accept crude financial data and can be refined as better data become available. In our hands the model has yielded useful information and has raised the awareness of staff to the cost of the work they perform. Although the model has been applied to an analysis of pathology costs, the principles are transferable to other areas which have a wide range of "products" for which individual costs may be difficult to identify.

Condom use among high-risk women in Honduras: evaluation of an AIDS prevention program.

In 1988, the Honduran Ministry of Health initiated an intervention study designed to increase AIDS awareness and promote preventive behavior, especially condom use, among registered commercial sex workers (CSWs). The program consisted of weekly talks and free condom distribution to all CSWs who attended the sexually transmitted disease clinic during a 10-week period. Pre- and postintervention surveys were used to evaluate change in knowledge and condom use. Condom diaries were used to measure condom use during the program. One hundred thirty-four women who participated in the intervention completed the initial and follow-up surveys. There was a statistically significant increase in mean condom use from 64% to 70% of client contacts. Condom use recorded in diaries during the program period appeared even higher. Factors found to be associated with increased use postintervention include low baseline condom use and higher client fee. The reliability of the methods of measuring condom use and the implications of the findings for future intervention studies among sex workers and their clients are discussed.

Physicians' attitudes, recommendations and practice of male and female sterilization in São Paulo.

While prevalence of vasectomy is low in Brazil, female sterilization is very high. The potential for growth of vasectomy services may be related to attitudes and practices of physicians. In 1984, 660 physicians at seven major hospitals in São Paulo were randomly selected from a total population of 2207 physicians in these hospitals. They were interviewed about their attitudes towards family planning in general, and specifically towards voluntary sterilization. A high degree of vasectomy among this medical community is indicated by its relatively high prevalence among married physicians and their spouses; about one in ten reported that either they or their spouse had had a vasectomy. Half of the physicians who perform sterilizations perform vasectomies: 22% of obstetricians and gynecologists, 85% of surgeons, and all urologists. In general, physicians would recommend vasectomy and tubal ligation equally often to their clients. Depending on the circumstances, up to 85% of all physicians recommend some sterilization procedure. Recommendation was modified by the type of procedure a physician performed, and by the patient's characteristics. Physician's recommendations of sterilization increased with age and parity of patient and was related to the health conditions and socioeconomic circumstances of the couple.

Adolescent pregnancy 1 year later: the effects of abortion vs. motherhood in Northeast Brazil.

PURPOSE: To determine social and behavioral consequences of pregnancy and how these differed according to the pregnancy outcome (live birth or abortion) 1 year after the event. METHODS: This was a prospective study of two groups of young women aged 12-18 years, one attending prenatal services and the other admitted for abortion complications at the same hospital in northeast Brazil. Adolescents who gave birth were subsequently classified as having intended or unintended pregnancies, and those who aborted were divided between those who terminated their pregnancies and those who miscarried. Baseline data were collected between 1995 and 1997 from all teens who met the eligibility criteria. Information was collected through one-on-one interviews using a questionnaire that was structured and precoded. Multiple logistic regression was used to identify characteristics that predicted outcomes at 1 year. RESULTS: Teens who terminated their pregnancies were the most likely to be in school or working 1 year later. They also showed the greatest increase in self-esteem. The young mothers, however, had the highest self-esteem but perceived the impact of pregnancy on their lives as being more negative than they did initially. Group affiliation was not associated with the quality of partner relationships, which tended to deteriorate over time. The young mothers used contraception at 1 year at higher rates and had experienced fewer subsequent pregnancies than the two abortion groups. CONCLUSIONS: The experience of adolescent pregnancy for this group of teens produced mixed findings, some more negative than others. Interventions to decrease the adolescent's desire to have a baby will have to be tailored differently from those designed to prevent an unintended pregnancy, but both are needed.

The relationship between self-esteem and psychiatric disorders in adolescents.

OBJECTIVE: To examine the relationship between self-esteem and psychiatric disorders in adolescents. METHODS: Seventy-six adolescents (mean age: 16.02 years; range: 12-20) treated in an inpatient unit and presenting with DSM-IV psychotic disorder, depressive disorder, anxious disorder, anorexia nervosa, personality disorder, or conduct disorder were compared with a control group of 119 adolescents drawn from a normal population. All the subjects were assessed with the French translation of the Coopersmith self-esteem inventory (SEI). RESULTS: Self-esteem was significantly higher in the control than in the clinical population (P = 0.0001). Female patients showed significantly lower SEI scores than male patients. Self-esteem increased significantly after 12 weeks in patients with a first psychotic episode who responded successfully to antipsychotic drug treatment. In the clinical group, a history of suicide attempts and sexual abuse was associated with significantly lower SEI scores. Lack of boy- or girlfriend, dropping out of school, and social withdrawal were also associated with lower self-esteem. CONCLUSION: The presence of a psychiatric disorder in adolescents is associated with decreased self-esteem. This decrease in self-esteem varies according to the psychiatric disorder. Appropriate treatment can enhance self-esteem in adolescent patients.

Promoting accountability in obstetric care: use of criteria-based audit in Viet Nam.

Audits can improve clinical and managerial practices, enhance the rational use of limited resources, and improve staff morale and motivation. Staff at five hospitals in Thanh Hoa and Quang Tri provinces (Viet Nam) used criteria-based audit (CBA) as a tool to improve the quality of emergency obstetric and newborn care. CBA compares current practice with standards based on the best available evidence and the local context. The audit cycle begins with a known problem, proceeds with an initial assessment and data collection, analysis of those data, formulation and implementation of an action plan, and a re-evaluation of the topic initially assessed. Teams found that clinical protocols for treating major obstetric complications were not followed, although, national guidelines had been issued in 2002. In an audit of facility organisation, staff addressed obstacles to the timely treatment of obstetric emergencies during off hours. In each audit, teams devised mechanisms to correct problems that resulted in significant improvements when the audit cycle was repeated. CBA improved adherence to national guidelines, improved record-keeping, heightened teamwork, and showed staff that they could identify and solve many of their own problems.

The repertory grid as a measure of change and predictor of outcome in the treatment of alcoholism.

Fifty male in-patients receiving treatment for alcohol dependence were studied on admission using the repertory grid and the grids analysed using the principal component technique (INGRIDA). Three self-elements were examined: self-when-sober, self-when-drunk, and ideal self. Sober-ideal self distance was below average in 90 per cent and drunk-ideal above average in 83 per cent, suggesting unrealistically favourable perceptions of sobriety and unrealistically unfavourable perceptions of drunkenness. The percentage of total variation accounted for by the first two components (VAR1 + VAR2) was generally high, suggesting tightness of construing. The first grid did not predict treatment completion. Twenty-eight subjects completed treatment and were given a second grid test on discharge. Consistent changes in grid measures with treatment were not apparent. Forty-nine subjects were followed up six months after discharge. For the 28 who had completed treatment, tightening of construing during treatment (i.e. a higher value of VAR1 + VAR2 in the second grid than in the first) was associated with drinking at follow-up. Measures derived from the first grid alone or from the second grid alone were not associated with status at follow-up.