Strengthening Recruitment and Retention: Mitigation Strategies in Two Longitudinal Studies of Pregnant Women in Pakistan.

PURPOSE: Global health researchers have a responsibility to conduct ethical research in a manner that is culturally respectful and safe. The purpose of this work is to describe our experiences with recruitment and retention in Pakistan, a low-middle-income country. DESCRIPTION: We draw on two studies with a combined sample of 2161 low-risk pregnant women who participated in a pilot (n = 300) and a larger (n = 1861) prospective study of psychological distress and preterm birth at one of four centers (Garden, Hyderabad, Kharadar, Karimabad) of the Aga Khan University Hospital in Karachi, Pakistan. ASSESSMENT: Challenges we encountered include economic hardship and access to healthcare; women's position in the family; safety concerns and time commitment; misconceptions and mistrust in the research process; and concerns related to blood draws. To mitigate these challenges, we developed culturally acceptable study incentives, involved family members in the decision-making process about study participation, partnered with participants' obstetrician-gynecologists, accommodated off site study visits, combined research visits with regular prenatal care visits, and modified research participation related to blood draws for some women. CONCLUSION: Implementation of these mitigation strategies improved recruitment and retention success, and we are confident that the solutions presented will support future scientists in addressing sociocultural challenges while embarking on collaborative research projects in Pakistan and other low-middle-income countries.

Investigating associations between maternal stress, smoking and adverse birth outcomes: evidence from the All Our Families cohort.

BACKGROUND: Independently, active maternal and environmental tobacco smoke exposure and maternal stress have been linked to an increased risk of preterm birth and low birth weight. An understudied relationship is the potential for interactive effects between these risk factors. METHODS: Data was obtained from the All Our Families cohort, a study of 3,388 pregnant women < 25 weeks gestation recruited from those receiving prenatal care in Calgary, Canada between May 2008 and December 2010. We investigated the joint effects of active maternal smoking, total smoke exposure (active maternal smoking plus environmental tobacco smoke) and prenatal stress (Perceived Stress Scale, Spielberger State-Trait Anxiety Inventory), measured at two time points (< 25 weeks and 34-36 weeks gestation), on preterm birth and low birth weight. RESULTS: A marginally significant association was observed with the interaction active maternal smoking and Spielberger State-Trait Anxiety Inventory scores in relation to low birth weight, after imputation (aOR = 1.02, 95%CI: 1.00-1.03, p = 0.06). No significant joint effects of maternal stress and either active maternal smoking or total smoke exposure with preterm birth were observed. Active maternal smoking, total smoke exposure, Perceived Stress Scores, and Spielberger State-Trait Anxiety Inventory scores were independently associated with preterm birth and/or low birth weight. CONCLUSIONS: Findings indicate the role of independent effects of smoking and stress in terms of preterm birth and low birthweight. However, the etiology of preterm birth and low birth weight is complex and multifactorial. Further investigations of potential interactive effects may be useful in helping to identify women experiencing vulnerability and inform the development of targeted interventions.

Is HbA1c associated with birth weight? A multivariable analysis of Pakistani pregnant women.

AIM: Globally, one in seven infants is born with low birth weight and 3%-7% of infants are born with high birth weight, with the greatest burden noted in low- and middle-income countries. This study investigated the association between maternal prenatal glucose regulation and birth weight and the moderating effect of fetal sex among Pakistani women. METHODS: Secondary data from a prospective longitudinal study of healthy pregnant women from Pakistan (N = 189) was used. Participants provided a blood sample (12-19 weeks' gestational age) for the assessment of HbA1c (%). Birth weight (g) was collected following delivery. RESULTS: Higher maternal HbA1c was associated with higher birth weight (b = 181.81, t[189] = 2.15, p = 0.03), which was moderated by fetal sex (b = -326.27, t[189] = -2.47, p = 0.02), after adjusting for gestational age at birth, ethnicity, and pregnancy weight. Among women carrying a male fetus, every 1% increase in HbA1c predicted a 182 g increase in birth weight (b = 181.81, t[189] = 2.15, p = 0.03). CONCLUSIONS: Results extend research from high-income countries and indicate that fetal sex may have implications for glucose regulation in early to mid-pregnancy. Future research should examine sociocultural factors, which could elucidate potential mediating factors in the relation between HbA1c and birth weight in healthy pregnancies.

Resilience and prenatal mental health in Pakistan: a qualitative inquiry.

BACKGROUND: Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention. METHODS: The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes. RESULT: A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health. CONCLUSION: In conclusion, these themes were the core components of pregnant women's resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.

Costs of Neonatal Intensive Care for Canadian Infants with Preterm Birth.

OBJECTIVE: To develop and validate an itemized costing algorithm for in-patient neonatal intensive care unit (NICU) costs for infants born prematurely that can be used for quality improvement and health economic analyses. STUDY DESIGN: We sourced patient resource use data from the Canadian Neonatal Network database, with records from infants admitted to 30 tertiary NICUs in Canada. We sourced unit cost inputs from Ontario hospitals, schedules of benefits, and administrative sources. Costing estimates were generated by matching patient resource use data to the appropriate unit costs. All cost estimates were in 2017 Canadian dollars and assigned from the perspective of a provincial public payer. Results were validated using previous estimates of inpatient NICU costs and hospital case-cost estimates. RESULTS: We assigned costs to 27 742 infants born prematurely admitted from 2015 to 2017. Mean (SD) gestational age and birth weight of the cohort were 31.8 (3.5) weeks and 1843 (739) g, respectively. The median (IQR) cost of hospitalization before NICU discharge was estimated as $20 184 ($9739-51 314) for all infants; $11 810 ($6410-19 800) for infants born at gestational age of 33-36 weeks; $30 572 ($16 597-$51 857) at gestational age of 29-32 weeks; and $100 440 ($56 858-$159 3867) at gestational age of <29 weeks. Cost estimates correlated with length of stay (r = 0.97) and gestational age (r = -0.65). The estimates were consistent with provincial resource estimates and previous estimates from Canada. CONCLUSIONS: NICU costs for infants with preterm birth increase as gestation decreases and length of stay increases. Our cost estimates are easily accessible, transparent, and congruent with previous cost estimates.

Continuous nasogastric milk feeding versus intermittent bolus milk feeding for preterm infants less than 1500 grams.

BACKGROUND: Milk feedings can be given via nasogastric tube either intermittently, typically over 10 to 20 minutes every two or three hours, or continuously, using an infusion pump. Although the theoretical benefits and risks of each method have been proposed, their effects on clinically important outcomes remain uncertain.  OBJECTIVES: To examine the evidence regarding the effectiveness of continuous versus intermittent bolus tube feeding of milk in preterm infants less than 1500 grams. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 7) in the Cochrane Library; Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on 17 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA: We included RCTs and quasi-RCTs comparing continuous versus intermittent bolus nasogastric milk feeding in preterm infants less than 1500 grams. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all trials for relevance and risk of bias. We used the standard methods of Cochrane Neonatal to extract data. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were: age at full enteral feedings; feeding intolerance; days to regain birth weight; rate of gain in weight, length and head circumference; and risk of necrotising enterocolitis (NEC). MAIN RESULTS: We included nine randomised trials (919 infants) in this updated Cochrane Review. One study is awaiting classification. Seven of the nine included trials reported data from infants with a maximum weight of between 1000 grams and 1400 grams. Two of the nine trials included infants weighing up to 1500 grams. Type(s) of milk feeds varied, including human milk (either mother's own milk or pasteurised donor human milk), preterm formula, or mixed feeding regimens. In some instances, preterm formula was initially diluted. Earlier studies also used water to initiate feedings. We judged six trials as unclear or high risk of bias for random sequence generation. We judged four trials as unclear for allocation concealment. We judged all trials as high risk of bias for blinding of care givers, and seven as unclear or high risk of bias for blinding of outcome assessors. We downgraded the certainty of evidence for imprecision, due to low numbers of participants in the trials, and/or wide 95% confidence intervals, and/or for risk of bias. Continuous compared to intermittent bolus (nasogastric and orogastric tube) milk feeding Babies receiving continuous feeding may reach full enteral feeding almost one day later than babies receiving intermittent feeding (mean difference (MD) 0.84 days, 95% confidence interval (CI) -0.13 to 1.81; 7 studies, 628 infants; low-certainty evidence).  It is uncertain if there is any difference between continuous feeding and intermittent feeding in terms of number of days of feeding interruptions (MD -3.00 days, 95% CI -9.50 to 3.50; 1 study, 171 infants; very low-certainty evidence). It is uncertain if continuous feeding has any effect on days to regain birth weight (MD -0.38 days, 95% CI -1.16 to 0.41; 6 studies, 610 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm. It is uncertain if continuous feeding has any effect on rate of gain in weight compared with intermittent feeding (standardised mean difference (SMD) 0.09, 95% CI -0.27 to 0.46; 5 studies, 433 infants; very low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in length compared with intermittent feeding (MD 0.02 cm/week, 95% CI -0.04 to 0.08; 5 studies, 433 infants; low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in head circumference compared with intermittent feeding (MD 0.01 cm/week, 95% CI -0.03 to 0.05; 5 studies, 433 infants; low-certainty evidence). It is uncertain if continuous feeding has any effect on the risk of NEC compared with intermittent feeding (RR 1.19, 95% CI 0.67 to 2.11; 4 studies, 372 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm. AUTHORS' CONCLUSIONS: Although babies receiving continuous feeding may reach full enteral feeding slightly later than babies receiving intermittent feeding, the evidence is of low certainty. However, the clinical risks and benefits of continuous and intermittent nasogastric tube milk feeding cannot be reliably discerned from current available randomised trials. Further research is needed to determine if either feeding method is more appropriate for the initiation of feeds. A rigorous methodology should be adopted, defining feeding protocols and feeding intolerance consistently for all infants. Infants should be stratified according to birth weight and gestation, and possibly according to illness.

What stakeholders think: perceptions of perinatal depression and screening in China's primary care system.

BACKGROUND: Mental health in China is a significant issue, and perinatal depression has been recognized as a concern, as it may affect pregnancy outcomes. There are growing calls to address China's mental health system capacity issues, especially among vulnerable groups such as pregnant women due to gaps in healthcare services and inadequate access to resources and support. In response to these demands, a perinatal depression screening and management (PDSM) program was proposed. This exploratory case study identified strategies for successful implementation of the proposed PDSM intervention, informed by the Consolidated Framework for Implementation Research (CFIR) framework, in Ma'anshan city, Anhui province. METHODS: This qualitative study included four focus group discussions and two in-depth individual interviews with participants using a semi-structured interview guide. Topics examined included acceptance, utility, and readiness for a PDSM program. Participants included perinatal women and their families, policymakers, and healthcare providers. Interviews were transcribed verbatim, coded, and analyzed for emergent themes. RESULTS: The analysis revealed several promising factors for the implementation of the PDSM program including: utilization of an internet-based platform, generation of perceived value among health leadership and decision-makers, and the simplification of the screening and intervention components. Acceptance of the pre-implementation plan was dependent on issues such as the timing and frequency of screening, ensuring high standards of quality of care, and consideration of cultural values in the intervention design. Potential challenges included perceived barriers to the implementation plan among stakeholders, a lack of trained human health resources, and poor integration between maternal and mental health services. In addition, participants expressed concern that perinatal women might not value the PDSM program due to stigma and limited understanding of maternal mental health issues. CONCLUSION: Our analysis suggests several factors to support the successful implementation of a perinatal depression screening program, guidelines for successful uptake, and the potential use of internet-based cognitive behavioral therapy. PDSM is a complex process; however, it can be successfully navigated with evidence-informed approaches to the issues presented to ensure that the PDSM is feasible, effective, successful, and sustainable, and that it also improves maternal health and wellbeing, and that of their families.

Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review.

INTRODUCTION: Total adverse childhood experiences (ACEs) are gaining prominence as a risk factor for preterm birth (PTB). The emerging literature examining this relationship reports inconsistent findings. The purpose of this systematic review was to summarize the available evidence exploring whether total ACEs predict PTB. METHODS: A total of 386 studies were returned from searches on PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Nine studies were selected for final analysis and synthesis based on reporting of total ACEs and preterm birth gestational weeks or standard definition of birth before 37 weeks' gestational age. A systematic review rather than meta-analysis was selected to present the findings given the clinical and methodological (e.g., sample studied, measurement tools) heterogeneity of the retrieved studies and pregnancy outcomes measured. RESULTS: The nine studies report on birth outcomes for 6,087 women from a range of sociodemographic and ethnic backgrounds. Despite a wide range of study designs, measurement tools, and timings of ACEs exposure across studies, seven of the nine included studies showed significant relationships between ACEs and PTB. CONCLUSION: Systematic review of the literature suggests that total ACEs are associated with PTB and provides an overview on the known associations. However, to date only nine studies have assessed this link, and more studies are needed, to explore the associations between ACEs and PTB using appropriate and valid instruments and doing so among more diverse populations. Future research should also explore possible biological mechanisms (allostatic load), and moderating and mediating variables.

Higher versus lower protein intake in formula-fed low birth weight infants.

BACKGROUND: The ideal quantity of dietary protein for formula-fed low birth weight infants is still a matter of debate. Protein intake must be sufficient to achieve normal growth without leading to negative effects such as acidosis, uremia, and elevated levels of circulating amino acids. OBJECTIVES: To determine whether higher (≥ 3.0 g/kg/d) versus lower (< 3.0 g/kg/d) protein intake during the initial hospital stay of formula-fed preterm infants or low birth weight infants (< 2.5 kilograms) results in improved growth and neurodevelopmental outcomes without evidence of short- or long-term morbidity. Specific objectives were to examine the following comparisons of interventions and to conduct subgroup analyses if possible. 1. Low protein intake if the amount was less than 3.0 g/kg/d. 2. High protein intake if the amount was equal to or greater than 3.0 g/kg/d but less than 4.0 g/kg/d. 3. Very high protein intake if the amount was equal to or greater than 4.0 g/kg/d. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 8), in the Cochrane Library (August 2, 2019); OVID MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R) (to August 2, 2019); MEDLINE via PubMed (to August 2, 2019) for the previous year; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (to August 2, 2019). We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-randomized trials. SELECTION CRITERIA: We included RCTs contrasting levels of formula protein intake as low (< 3.0 g/kg/d), high (≥ 3.0 g/kg/d but < 4.0 g/kg/d), or very high (≥ 4.0 g/kg/d) in formula-fed hospitalized neonates weighing less than 2.5 kilograms. We excluded studies if infants received partial parenteral nutrition during the study period, or if infants were fed formula as a supplement to human milk. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane and the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We identified six eligible trials that enrolled 218 infants through searches updated to August 2, 2019. Five studies compared low (< 3 g/kg/d) versus high (3.0 to 4.0 g/kg/d) protein intake using formulas that kept other nutrients constant. The trials were small (n = 139), and almost all had methodological limitations; the most frequent uncertainty was about attrition. Low-certainty evidence suggests improved weight gain (mean difference [MD] 2.36 g/kg/d, 95% confidence interval [CI] 1.31 to 3.40) and higher nitrogen accretion in infants receiving formula with higher protein content (3.0 to 4.0 g/kg/d) versus lower protein content (< 3 g/kg/d), while other nutrients were kept constant. No significant differences were seen in rates of necrotizing enterocolitis, sepsis, or diarrhea. We are uncertain whether high versus low protein intake affects head growth (MD 0.37 cm/week, 95% CI 0.16 to 0.58; n = 18) and length gain (MD 0.16 cm/week, 95% CI -0.02 to 0.34; n = 48), but sample sizes were small for these comparisons. One study compared high (3.0 to 4.0 g/kg/d) versus very high (≥ 4 g/kg/d) protein intake (average intakes were 3.6 and 4.1 g/kg/d) during and after an initial hospital stay (n = 77). Moderate-certainty evidence shows no significant differences in weight gain or length gain to discharge, term, and 12 weeks corrected age from very high protein intake (4.1 versus 3.6 g/kg/d). Three of the 24 infants receiving very high protein intake developed uremia. AUTHORS' CONCLUSIONS: Higher protein intake (≥ 3.0 g/kg/d but < 4.0 g/kg/d) from formula accelerates weight gain. However, limited information is available regarding the impact of higher formula protein intake on long-term outcomes such as neurodevelopment. Research is needed to investigate the safety and effectiveness of protein intake ≥ 4.0 g/kg/d.

Investigating the association between stress. Anxiety and geophagy among pregnant women in mwanza, Tanzania.

Geophagy, the craving and intentional consumption of soil, is common especially among pregnant women in some low- and middle-income settings. Soils may contain a variety of non-nutritive components such as heavy metals and microbes or substances that interfere with gastrointestinal absorptive processes, posing health risks to pregnant women. Several hypotheses regarding the practice have been proposed but very few have examined the role of maternal stress. The practice of geophagy may help to alleviate stress or anxiety during gestation from perceived dietary or other pregnancy-related concerns. In this study, we evaluated several measures of maternal stress (general anxiety, Pregnancy-Related Anxiety Scores (10-item revised), and Perceived Stress Scores) and other covariates in relation to geophagic behaviour in early pregnancy in 227 women (12-19 weeks gestation) recruited from two hospitals in the Nyamagana district of Mwanza City, Tanzania. Geophagy was reported by 24.7% of the pregnant women. Using LASSO regression, self-reported treatment of nausea or vomiting during pregnancy (adjusted OR = 3.12, 95%CI: 1.43 to 6.83), paternal education level (adjusted OR = 2.79, 95%CI: 1.32 to 5.87 for primary or lower education level), antenatal hospital site (adjusted OR = 3.71, 95%CI: 1.78 to 7.75), prescription drug use prior to pregnancy (adjusted OR = 1.76, 95%CI: 0.87 to 3.56) and general anxiety (feeling worried, tense or anxious in the past four weeks) (adjusted OR = 1.81, 95%CI: 0.88 to 3.72) were associated with geophagic behaviour. Given that relatively little has been done to examine geophagy in relation to the public health risk it may pose to pregnant women, these findings suggest the need for further investigations regarding maternal stress.

Determinants of bed net policy implementation: A case study of Southern Benin.

BACKGROUND: Malaria is a major global health challenge. This study aims to clarify the manner in which contextual factors determine the use and maintenance of bed nets and the extent to which malaria prevention policy is responsive to them in Southern Benin. METHODS: Semi-structured interviews and direct observations were undertaken with 30 pregnant women in the municipality of So-Ava from June to August 2015. Key informants in the Ministry of Health and local community health workers were also interviewed regarding malaria prevention policy formation, and the monitoring and evaluation of bed net interventions, respectively. Data were analyzed through categorical content analysis and grouped into themes. RESULTS: The majority of pregnant women participants (80%) declared non-adherence to instructions for hanging and maintaining insecticide-treated nets (ITNs). The distributed bed nets were washed like clothes, which affected their bio-efficacy, and were in poor condition (ie, torn or had holes). Multiple factors contributed to the poor condition of ITNs: Pregnant women's limited understanding of risk including their inability to connect the key environmental factors to personal risk, gendered responsibility for installing bed nets, and lack of public measures that would enable women to re-treat or access new bed nets as needed. Poverty that determined structural aspects of housing such as the size and quality of homes and access to bed nets exacerbated the challenges. CONCLUSION: Institutionalizing an iterative process of monitoring, review, and responsive adaptation throughout the entire policymaking cycle would better support malaria preventive policy implementation in Benin.

Mother's level of confidence in caring for her late preterm infant: A mixed methods study.

AIM AND OBJECTIVES: To examine what it means to be a mother of a late preterm infant including a mother's level of confidence in caring for her late preterm infant over time and the effect of maternal depression of this experience. BACKGROUND: Little is known about mothers' experiences of caring for their late preterm infants in the community, including their level of confidence and parenting stress within the context of a supported care environment by public health nurses. DESIGN: A mixed methods study, sequential explanatory quantitative and qualitative study. METHODS: A convenience sample of mothers with LPIs (n = 71) completed questionnaires on maternal confidence (3-4 weeks and 6-8 weeks), parenting stress (6-8 weeks), social support (6-8 weeks) and postpartum depression (6-8 weeks). A purposive sample of mothers (n = 11) underwent in-depth, semi-structured interviews. RESULTS: Maternal confidence decreased from 3-4 weeks-6-8 weeks after delivery, and similar results were found for mothers who reported depressive symptoms. Narratives of the mothers suggested the decrease in maternal confidence over time was influenced by the demanding characteristics of the late preterm infant, the prospect of their rehospitalisation and the mother's reported interactions with public health nurses. Depression had an effect on maternal confidence; that is, the depressed mothers demonstrated less confidence about their caretaking role than the nondepressed mothers at 6-8 weeks. Mothers did not discuss mental health issues, which may reflect the protective effects of social support on emotional instability or an inability to recognise postpartum depression. CONCLUSION: The confidence of mothers with LPIs decreased over the first 2 months following delivery and being home with their infants. Assisting mothers to meet their personal needs and the needs of their infant should promote maternal skills, which will likely increase maternal confidence related to the care of their late preterm infant. RELEVANCE FOR CLINICAL PRACTICE: Characteristics of LPIs contributed more to parenting stress score than parent characteristics; mothers however attempted to normalise the late preterm infant in order to minimise the parenting stress. Evidence-informed brief interventions tailored based on late preterm infant and parent characteristics may improve maternal confidence over time. Healthcare professional should provide education and anticipatory guidance prior to discharge, consistent care in hospital and postdischarge as this may impact maternal level of confidence. Future research needs to examine standards of care for discharge of LPIs and adherence to these standards.

Caring for late preterm infants: public health nurses' experiences.

BACKGROUND: Public health nurses (PHNs) care for and support late preterm infants (LPIs) and their families when they go home from the hospital. PHNs require evidence-informed guidelines to ensure appropriate and consistent care. The objective of this research study is to capture the lived experience of PHNs caring for LPIs in the community as a first step to improving the quality of care for LPIs and support for their parents. METHODS: To meet our objectives we chose a descriptive phenomenology approach as a method of inquiry. We conducted semi-structured interviews with PHNs (n = 10) to understand PHN perceptions of caring for LPIs and challenges in meeting the needs of families within the community. Interpretative thematic analysis revealed PHN perceptions of caring for LPIs and challenges in meeting the needs of families within the community. RESULTS: Four themes emerged from the data. First, PHNs expressed challenges with meeting the physiological needs of LPIs and gave voice to the resulting strain this causes for parents. Second, nurses conveyed that parents require more anticipatory guidance about the special demands associated with feeding LPIs. Third, PHNs relayed that parents sometimes receive inconsistent advice from different providers. Lastly, PHNs acknowledged that due to lack of resources, families sometimes did not receive the full scope of evidence informed care required by fragile, immature infants. CONCLUSION: The care of LPIs by PHNs would benefit from more research about the needs of these infants and their families. Efforts to improve quality of care should focus on: evidence-informed guidelines, consistent care pathways, coordination of follow up care and financial resources, to provide physical, emotional, informational support that families require once they leave the hospital. More research on meeting the challenges of caring for LPIs and their families would provide direction for the competencies PHNs require to improve the quality of care in the community.

Variation in Maternal Co-morbidities and Obstetric Interventions across Area-Level Socio-economic Status: A Cross-Sectional Study.

BACKGROUND: Multiple studies indicate a significant association between area-level socio-economic status (SES) and adverse maternal health outcomes; however, the impact of area-level SES on maternal co-morbidities and obstetric interventions has not been examined. OBJECTIVE: To examine the variation in maternal co-morbidities and obstetric interventions across area-level SES. METHODS: This study used data from the Discharge Abstract Database that comprised birth data in Alberta between 2005-2007 (n = 120 285). Co-morbidities and obstetric interventions were identified using validated case-definitions. Material deprivation index was obtained for each dissemination area through linkage of hospitalisation and census data. Multilevel logistic regression was used to analyse the data adjusting for potential confounding variables. RESULTS: The prevalence of any co-morbidity varied across area-level SES. Drug abuse odds ratio (OR) 2.5 (95% confidence interval (CI) 1.8, 3.5), pre-existing diabetes OR 1.7 (95% CI 1.1, 2.6), and prolonged hospital stay OR 1.5 (95% CI 1.4, 1.6) were significantly more likely to occur in the most deprived areas compared to the least deprived areas. In contrast, caesarean delivery OR 0.9 (95% CI 0.8, 0.9) was less likely to occur in the most deprived areas compared to the least deprived areas. Area-level deprivation explained area-level variance of drug abuse, HIV, and other mental diseases only. CONCLUSION: Many co-morbidities and obstetric interventions vary at the area-level, but only some are associated with area-level SES, and few of them vary due to the area-level SES. This indicates that other area-level factors, in addition to area-level SES, need to be considered when investigating maternal health and use of health interventions.

Preterm Birth and Social Support during Pregnancy: a Systematic Review and Meta-Analysis.

BACKGROUND: Additional social support is often recommended for women during the prenatal period to optimise birth outcomes, specifically to avoid preterm birth. Social support is thought to act in one of two ways: by reducing stress and anxiety, or by providing coping mechanisms for women with high stress. However, evidence in this area is mixed. The purpose of this meta-analysis is to determine if low levels of social support are associated with an increased risk for preterm birth. METHODS: Six databases were searched for randomised control trials and cohort studies regarding social support and preterm birth with no limits set on date or language. Inclusion criteria included the use of a validated instrument to measure social support, and studies conducted in high-income or high-middle-income countries. RESULTS: There were 3467 records retrieved, 16 of which met the inclusion criteria. Eight studies (n = 14 630 subjects) demonstrated a pooled odds ratio (OR) of 1.22 (95% CI 0.84, 1.76) for preterm birth in women with low social support compared with high social support. Among women with high stress levels, two studies (n = 6374 subjects) yielded a pooled OR of 1.52 (95% CI 1.18, 1.97). The results of six studies could not be pooled due to incompatibility of outcome measures. CONCLUSIONS: There is no evidence for a direct association between social support and preterm birth. Social support, however, may provide a buffering mechanism between stress and preterm birth.

Decision-making and evidence use during the process of prenatal record review in Canada: a multiphase qualitative study.

BACKGROUND: Prenatal records are potentially powerful tools for the translation of best-practice evidence into routine prenatal care. Although all jurisdictions in Canada use standardized prenatal records to guide care and provide data for health surveillance, their content related to risk factors such as maternal smoking and alcohol use varies widely. Literature is lacking on how prenatal records are developed or updated to integrate research evidence. This multiphase project aimed to identify key contextual factors influencing decision-making and evidence use among Canadian prenatal record committees (PRCs), and formulate recommendations for the prenatal record review process in Canada. METHODS: Phase 1 comprised key informant interviews with PRC leaders across 10 Canadian jurisdictions. Phase 2, was a qualitative comparative case study of PRC factors influencing evidence-use and decision-making in five selected jurisdictions. Interview data were analysed using qualitative content analysis. Phase 3 involved a dissemination workshop with key stakeholders to review and refine recommendations derived from Phases 1 and 2. RESULTS: Prenatal record review processes differed considerably across Canadian jurisdictions. PRC decision-making was complex, revealing the competing functions of the prenatal record as a clinical guide, documentation tool and data source. Internal contextual factors influencing evidence use included PRC resources to conduct evidence reviews; group composition and dynamics; perceived function of the prenatal record; and expert opinions. External contextual factors included concerns about user buy-in; health system capacities; and pressures from public health stakeholders. Our recommendations highlight the need for: broader stakeholder involvement and explicit use of decision-support strategies to support the revision process; a national template of evidence-informed changes that can be used across jurisdictions; consideration of both clinical and surveillance functions of the prenatal record; and dissemination plans to communicate prenatal record modifications. CONCLUSIONS: Decision-making related to prenatal record content involves a negotiated effort to balance research evidence with the needs and preferences of prenatal care providers, health system capacities as well as population health priorities. The development of a national template for prenatal records would reduce unnecessary duplication of PRC work and enhance the consistency of prenatal care delivery and perinatal surveillance data across Canada.

Antenatal depression is associated with pregnancy-related anxiety, partner relations, and wealth in women in Northern Tanzania: a cross-sectional study.

BACKGROUND: Psychosocial health problems, specifically depression during pregnancy, can have negative impact on birth outcomes, postnatal mental health of the mother, and infant health. Antenatal depression is more prevalent among women in low- and middle-income countries than among women in high-income countries. Risk factors for antenatal depression reported in the literature relate to pregnant women in South Asia. Consequently, this study assessed depression in pregnancy and related psychosocial risk factors among select pregnant women residing in Mwanza region, Northern Tanzania. METHODS: We analysed data from 397 pregnant women recruited from three antenatal clinics for the period June-August 2013 for this cross-sectional study. Women provided data at one time point during their pregnancy by completing the Edinburgh Postnatal Depression Scale and a structured questionnaire assessing psychosocial, demographic, and behavioural risk factors related to antenatal depression. Multiple logistic regression analysis was performed to determine the relationship between risk factors examined and antenatal depression. RESULTS: Overall, 33.8 % (n = 134) of pregnant women had antenatal depression. Pregnancy-related anxiety was associated with antenatal depression (odds ratio (OR) 1.36, 95 % confidence interval (CI) 1.23 to 1.5). Pregnant women with poor relationship with partner and low/moderate socio-economic status had the highest OR for antenatal depression (82.34, 95 % CI 4.47, 1516.60) after adjusting for other covariates. Pregnant women with poor relationship with partner and high socio-economic status had an OR of 13.48 (95 % CI 1.71, 106.31) for antenatal depression. "Reference" pregnant women were those with very good relationship with partner and high socio-economic status. CONCLUSIONS: High proportion of self-reported depression among select pregnant women attending antenatal clinics in Mwanza, Tanzania merit integrating depression assessment into existing antenatal care services. Health care providers need to assess pregnancy-related risk factors (pregnancy-related anxiety), socio-demographic factors (socio-economic status), and interpersonal risk factors (relationship with partner). Future research should appraise effectiveness of interventions that enhance partner relationships in reducing antenatal depression across all wealth distributions.

Higher versus lower protein intake in formula-fed low birth weight infants.

BACKGROUND: The ideal quantity of dietary protein for formula-fed low birth weight infants is still a matter of debate. Protein intake must be sufficient to achieve normal growth without negative effects such as acidosis, uremia, and elevated levels of circulating amino acids. OBJECTIVES: To determine whether higher (≥ 3.0 g/kg/d) versus lower (< 3.0 g/kg/d) protein intake during the initial hospital stay of formula-fed preterm infants or low birth weight infants (< 2.5 kilograms) results in improved growth and neurodevelopmental outcomes without evidence of short- and long-term morbidity.To examine the following distinctions in protein intake. 1. Low protein intake if the amount was less than 3.0 g/kg/d. 2. High protein intake if the amount was equal to or greater than 3.0 g/kg/d but less than 4.0 g/kg/d. 3. Very high protein intake if the amount was equal to or greater than 4.0 g/kg/d.If the reviewed studies combined alterations of protein and energy, subgroup analyses were to be carried out for the planned categories of protein intake according to the following predefined energy intake categories. 1. Low energy intake: less than 105 kcal/kg/d. 2. Medium energy intake: greater than or equal to 105 kcal/kg/d and less than or equal to 135 kcal/kg/d. 3. High energy intake: greater than 135 kcal/kg/d.As the Ziegler-Fomon reference fetus estimates different protein requirements for infants based on birth weight, subgroup analyses were to be undertaken for the following birth weight categories. 1. < 800 grams. 2. 800 to 1199 grams. 3. 1200 to 1799 grams. 4. 1800 to 2499 grams. SEARCH METHODS: The standard search methods of the Cochrane Neonatal Review Group were used. MEDLINE, CINAHL, PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched. SELECTION CRITERIA: Randomized controlled trials contrasting levels of formula protein intake as low (< 3.0 g/kg/d), high (≥ 3.0 g/kg/d but < 4.0 g/kg/d), or very high (≥ 4.0 g/kg/d) in formula-fed hospitalized neonates weighing less than 2.5 kilograms were included. Studies were excluded if infants received partial parenteral nutrition during the study period or were fed formula as a supplement to human milk. Studies in which nutrients other than protein also varied were added in a post-facto analysis. DATA COLLECTION AND ANALYSIS: The standard methods of the Cochrane Neonatal Review Group were used. MAIN RESULTS: Five studies compared low versus high protein intake. Improved weight gain and higher nitrogen accretion were demonstrated in infants receiving formula with higher protein content while other nutrients were kept constant. No significant differences were seen in rates of necrotizing enterocolitis, sepsis, or diarrhea.One study compared high versus very high protein intake during and after an initial hospital stay. Very high protein intake promoted improved gain in length at term, but differences did not remain significant at 12 weeks corrected age. Three of the 24 infants receiving very high protein intake developed uremia.A post-facto analysis revealed further improvement in all growth parameters in infants receiving formula with higher protein content. No significant difference in the concentration of plasma phenylalanine was noted between high and low protein intake groups. However, one study (Goldman 1969) documented a significantly increased incidence of low intelligence quotient (IQ) scores among infants of birth weight less than 1300 grams who received a very high protein intake (6 to 7.2 g/kg). AUTHORS' CONCLUSIONS: Higher protein intake (≥ 3.0 g/kg/d but < 4.0 g/kg/d) from formula accelerates weight gain. However, limited information is available regarding the impact of higher formula protein intake on long-term outcomes such as neurodevelopmental abnormalities. Available evidence is not adequate to permit specific recommendations regarding the provision of very high protein intake (> 4.0 g/kg/d) from formula during the initial hospital stay or after discharge.

Sociocultural influences on newborn health in the first 6 weeks of life: qualitative study in a fishing village in Karachi, Pakistan.

BACKGROUND: Given regional variability and minimal improvement in infant mortality rates in Pakistan, this study aimed to explicate sociocultural influences impacting mothers' efforts to maintain or improve newborn health. METHODS: We used a qualitative phenomenological approach. A total of 10 mothers and 8 fathers from a fishing village in Karachi, Pakistan were purposefully sampled and interviewed individually. A focus group was undertaken with four grandmothers (primary decision makers). Transcripts were independently reviewed using interpretive thematic analysis. RESULTS: A multigenerational approach was used in infant care, but mothers did not have a voice in decision-making. Parents connected breast milk to infant health, and crying was used as cue to initiate feeding. Participants perceived that newborns required early supplementation, given poor milk supply and to improve health. There were tensions between traditional (i.e., home) remedies and current medical practices. Equal importance was given to sons and daughters. CONCLUSION: Findings suggest that social and cultural influences within families and the community must be considered in developing interventions to improve newborn health. Introducing non-breast milk substances into newborn diets may reduce the duration of exclusive or partial breastfeeding and increase risks to infant health.

Geophagy practices and the content of chemical elements in the soil eaten by pregnant women in artisanal and small scale gold mining communities in Tanzania.

BACKGROUND: Geophagy, a form of pica, is the deliberate consumption of soil and is relatively common across Sub-Saharan Africa. In Tanzania, pregnant women commonly eat soil sticks sold in the market (pemba), soil from walls of houses, termite mounds, and ground soil (kichuguu). The present study examined geophagy practices of pregnant women in a gold mining area of Geita District in northwestern Tanzania, and also examined the potential for exposure to chemical elements by testing soil samples. METHOD: We conducted a cross sectional study using a convenience sample of 340 pregnant women, ranging in age from 15-49 years, who attended six government antenatal clinics in the Geita District, Tanzania. Structured interviews were conducted in June-August, 2012, to understand geophagy practices. In addition, soil samples taken from sources identified by pregnant women practicing geophagy were analysed for mineral element content. RESULTS: Geophagy was reported by 155 (45.6%) pregnant women with 85 (54.8%) initiating the practice in the first trimester. A total of 101 (65%) pregnant women reported eating soil 2 to 3 times per day while 20 (13%) ate soil more than 3 times per day. Of 155 pregnant women 107 (69%) bought pemba from local shops, while 48 (31%) consumed ground soil kichuguu. The estimated mean quantity of soil consumed from pemba was 62.5 grams/day. Arsenic, chromium, copper, iron, manganese, nickel and zinc levels were found in both pemba and kichuguu samples. Cadmium and mercury were found only in the kichuguu samples. Based on daily intake estimates, arsenic, copper and manganese for kichuguu and copper and manganese for pemba samples exceed the oral Minimum Risk Levels designated by the U.S. Agency for Toxic Substance and Disease Registry. CONCLUSION: Almost 50% of participants practiced geophagy in Geita District consistent with other reports from Africa. Both pemba and kichuguu contained chemical elements at varying concentration, mostly above MRLs. As such, pregnant women who eat soil in Geita District are exposed to potentially high levels of chemical elements, depending upon frequency of consumption, daily amount consumed and the source location of soil eaten.