Factors affecting home delivery in the Kathmandu Valley, Nepal.

This nested case-control study compares the characteristics of mothers having home or institutional deliveries in Kathmandu, Nepal, and explores the reasons given by mothers for a home delivery. The delivery patterns of mothers were identified in a cross-sectional survey of two communities: an urban area of central Kathmandu (Kalimati) and a peri-urban area (Kirtipur and Panga) five kilometres from the city centre. 357 pregnant women were identified from a survey of 6130 households: 183 from 3663 households in Kirtipur and Panga, 174 from 2467 households in Kalimati. Methods involved a structured baseline household questionnaire and detailed follow-up of identified pregnant women with structured and semi-structured interviews in hospital and the community. The main outcome measures were social and economic household details of pregnant women; pregnancy and obstetric details; place of delivery; delivery attendant; and reasons given for home delivery. The delivery place of 334/357 (94%) of the pregnant women identified at the survey was determined. 272 (81%) had an institutional delivery and 62 (19%) delivered at home. In univariate analysis comparing home and institutional deliverers, maternal education, parity, and poverty indicators (income, size of house, ownership of house) were associated with place of delivery. After multivariate analysis, low maternal educational level (no education, OR 5.04 [95% CI 1.61-15.8], class 1-10, OR 3.36 [1.04-10.8] compared to those with higher education) and multiparity (OR 3.1 [1.63-5.74] compared to primiparity) were significant risk factors for a home delivery. Of home deliverers, only 24% used a traditional birth attendant, and over half were unplanned due to precipitate labour or lack of transport. We conclude that poor education and multiparity rather than poverty per se increase the risk of a home delivery in Kathmandu. Training TBAs in this setting would probably not be cost-effective. Community-based midwife-run delivery units could reduce the incidence of unplanned home deliveries.

Impact and sustainability of a "baby friendly" health education intervention at a district hospital in Bihar, India.

OBJECTIVES: To evaluate the impact and sustainability of a baby friendly training intervention for staff at an Indian district hospital on initiation of breast feeding and use of prelacteal feeds by mothers. DESIGN: Intervention study with assessment by interviewing mothers. SUBJECTS: 172 mothers recruited before the intervention, 195 recruited immediately after the intervention, and 101 recruited six months later. SETTING: District hospital in a small town in Bihar, India. MAIN OUTCOME MEASURES: Age of infant when breast feeding started, use of prelacteal feeds, and colostrum feeding. INTERVENTION: 10 day training programme for doctors, nurses, and midwives, explaining the benefits and feasibility of early breast feeding and dangers of prelacteal feeds together with instruction on explaining this information to mothers. RESULTS: Breast feeding was started within 24 hours of birth by 53 (29%) of control mothers, 164 (84%) in the early follow up group, and 60 (59%) in the late follow up group. Prelacteal feeds were used by 165 (96%), 84 (43%), and 78 (77%) respectively. Only 36 mothers in the late follow up group reported receiving education on feeding. Mothers in this group who had received the education were significantly more likely than mothers who received no education to breast feed early (28 (78%) v 11 (17%), P < 0.001) and not use prelacteal feeds (21 (58%) v 2 (3%), P < 0.001). CONCLUSIONS: Training doctors and midwives greatly improves the feeding practices of mothers. However, the impact of the training fell off quickly and refresher training is needed to sustain the improvement.

PIP: A health education intervention implemented at a district hospital in Bihar, India, sought to encourage new mothers to abandon harmful traditional practices such as delayed breast feeding initiation, disposal of colostrum, and prelacteal feeds. Hospital physicians, nurses, and midwives were exposed to a 10-day training program focused on "baby friendly" practices. In the 20 days following the staff intervention, 195 mothers were enrolled in the study and interviewed at home two weeks after delivery; also interviewed at home were 172 controls who delivered before the staff training. An additional 101 mothers were enrolled and interviewed six months after the staff training. Most mothers were illiterate Hindus from rural areas. Breast feeding was initiated within 24 hours by 164 mothers (84%) in the early group, 60 (59%) in the late group, and 53 (29%) mothers in the control group. The percentages of mothers giving prelacteal feeds were 43%, 77%, and 96%, respectively. Of note was the finding that only 36 mothers (36%) in the second intervention group reported having received guidance from staff on infant feeding. Overall, these findings suggest that training hospital staff in infant feeding practices has a beneficial effect on maternal behaviors, but this effect declines quickly over time as a result of staff turnover and loss of interest. Refresher training every six months is recommended for program sustainability.

Cerebral energy metabolism studied with phosphorus NMR spectroscopy in normal and birth-asphyxiated infants.

Phosphorus (31P) nuclear magnetic resonance spectroscopy was used to study intracellular metabolism in the brains of 6 normal newborn infants and 10 infants who had been asphyxiated during delivery. In the normal infants spectral peaks mainly attributable to adenosine triphosphate, phosphocreatine (PCr), phosphodiesters plus phospholipids, and inorganic orthophosphate (Pi) were always detected, together with an additional large peak in the phosphomonoester region indicating the presence of a metabolite or metabolites (probably largely phosphoethanolamine) which may be involved in rapid growth of the brain. In the asphyxiated infants, data obtained on the first day of life showed no differences from those in normal infants, but by the second to ninth days inverse changes in the concentrations of PCr and Pi had caused a significant reduction in PCr/Pi. This latency suggest the possibility of effective early treatment before irreversible metabolic damage sets in. Mean intracellular pH when PCr/Pi was minimal was 7.17 +/- 0.10. Values for PCr/Pi below 0.80 were associated with a very bad prognosis for survival and early neuro-developmental outcome.

Non-invasive investigation of cerebral metabolism in newborn infants by phosphorus nuclear magnetic resonance spectroscopy.

Intracellular metabolism in the brains of seven infants, born at 33-40 weeks' gestation and aged 44 h to 17 days, was studied on fourteen occasions by phosphorus nuclear magnetic resonance spectroscopy (31P NMRS). The characteristic spectral peaks of ATP, phosphocreatine (PCr), phosphodiesters, and inorganic orthophosphate (Pi) were always detected, together with a large peak attributed mainly to ribose-5-phosphate. The ratio of PCr to Pi NMRS signals (which are related to concentration) in one infant thought to have a normal brain was 1.7. In three infants who had severe birth asphyxia the PCr/Pi ratio ranged from 0.2 to 1.0 but increased as their clinical condition improved: infusions of mannitol solution caused a rapid increase in the ratio on four occasions in two of these infants. The PCr/Pi ratio was 1.4 in an infant with congenital cerebral atrophy and 0.7 in an infant with meningitis. Grossly abnormal 31P spectra antedated the detection by ultrasound of large porencephalic cysts in two infants. No systematic changes in intracellular pH (calculated from the chemical shift of the Pi resonance) were observed: the mean value for all observations was 7.2 +/- SD 0.1 (n = 14).