Traditional medicine consumption in postpartum for HBV-infected women enrolled in the ANRS 12345 TA PROHM study in Cambodia.

In Cambodia, traditional medicine was commonly described as being used by pregnant women at two time points: one month before birth and during early postpartum. The present study aims to describe traditional medicine consumption during postpartum phase for women enrolled in the TA PROHM study and to investigate the possible association between traditional medicine consumption and acute liver toxicity. An ethnobotanical survey was conducted in 2 groups of HBV-infected pregnant women (with and without postpartum hepatocellular injury) enrolled in the study. Hepatocellular injury was defined by having Alanine Aminotransferase (ALT) > 2.5 times the Upper Limit of Normal (ULN = 40 U/L) at the 6th week postpartum visit. Interviews were done using a standardized questionnaire. Plant samples were collected and later identified by two traditional healers. Chi-square test was used to find the association between hepatocellular injury and traditional medicine consumption or a specific plant species. In total, 75 women were enrolled and 52 (69.3%) used at least one traditional remedy composed of 123 different plants and 12 alcoholic macerations of porcupine stomach. Orally consuming at least one remedy with alcohol was significantly associated with hepatocellular injury (33% vs 13%, p = 0.034). Among the 123 plants species identified, four were found to be associated with hepatocellular injury, namely Amphineurion marginatum (Roxb.) D.J.Middleton [Apocynaceae] (p = 0.022), Selaginella tamariscina (P.Beauv.) Spring [Selaginellaceae] (p = 0.048), Mitragyna speciosa Korth. [Rubiaceae] (p = 0.099) and Tetracera indica (Christm. & Panz.) Merr. [Dilleniaceae] (p = 0.079). Consumption of traditional medicine in postpartum is a common practice for women enrolled in the TA PROHM study. Alcohol-based remedies may exacerbate the risk of acute hepatocellular injury in HBV-infected women already exposed to immune restoration. The complex mixtures of herbs need to be further evaluated by in vitro and in vivo studies.

State of midwifery research in France.

OBJECTIVE: We describe French midwives' experience and perception of research and publication as well as their publications in scientific and professional journals. DESIGN: We conducted an online cross sectional survey of midwives from June to November 2016; complemented by a bibliometric analysis of their publications in any language. SETTING: This study was conducted in France, where it is necessary to question some midwifery and obstetrical practices. PARTICIPANTS: 146 midwives working/residing in France or holding/studying in France for a PhD or a Masters' degree at the time of the study; or having already published articles in any scientific or professional journal. FINDINGS: Of the 146 eligible midwives, 91.8% were female; 15 (10.3%) had a PhD degree, 26 (17.8%) and 80 (54.8%) were preparing a PhD and a Master's degree, respectively. A total of 140 midwives (95.8%) were working in midwifery and 54 (37.0%) respondents reported having already participated in midwifery research programs. Publication experience was reported by 73 midwives, including 26 (17.8%) who have published at least one article on midwifery in a journal accessible online and peerreviewed. 97.2% of midwives with publication experience consider it useful to publish but 75.7% consider that it is a difficult process. Lack of time, not mastering scientific writing and English language are their main barriers to publication. We identified 218 articles published by these midwives before January 2016, including 180 (82.6%) on maternal and perinatal health. Of their 134 unique articles on midwifery accessible online, 77 (57.5%) dealt with bio-medical topics, 49 (36.6%) with health system issues, and 17 (12.7%) used human and social sciences approaches. Pregnancy and birth were the two most studied reproductive life phases. Eighty-nine (28.4%) of these 314 articles were about midwifery practices or interventions. Since 1990, 93 articles have been published on midwifery in peer-reviewed journals, including 32 in the French language. The number of publications increased significantly with time with a progression coefficient at +1.18% per year, in particular in scientific journals (+0.78% per year). KEY CONCLUSIONS AND IMPLICATION: We evidenced that even though midwives in France have a still limited experience of research, and few of them have completed a PhD degree, or receive a salary for doing research, they publish an increasing number of scientific articles on midwifery topics. However, very few research programs in France examine aspects of midwifery. This scarcity is a major barrier to the involvement of midwives in research. Scientific publications about midwifery in French language are limited mainly due to the lack of adequate and specialized journal in French. However, publishing in French would facilitate the access to knowledge and evidence of midwifery practitioners in Frenchspeaking countries, including French-speaking Africa, where maternal mortality ratios can be very high. We suggest and discuss a number of approaches to increase access to scientific knowledge on midwifery in France and French-speaking countries.

Factors associated with caesarean sections in Phnom Penh, Cambodia.

C-sections are an increasingly performed medical practice which can save lives but may also lead to major complications. Through a mixed methods study conducted in 2015 in Cambodia, we aimed to analyze the reasons for requesting a c-section and to explore factors that are associated with c-sections. 60% of the women in the cohort who gave birth by c-section reported having requested it. Through 31 in-depth interviews, we determined the reasons given by women for requesting a c-section before and during labour. Before labour, reasons for requesting a c-section were: choosing the delivery date; bringing luck and joy to the family; protecting the genitals, and the belief that c-section is safer for the mother and for the baby. Reasons given during labour were fear, pain, and having no more energy. We also observed two major factors driving the women's request for a c-section: family support for requesting a c-section, and the over-usage of ultrasound examinations. Our multivariate analysis of the interviews of 143 women before and after delivery showed that having a previous c-section, delivering in a private facility, being older than median at the time of sexual debut, residing outside of Phnom Penh and having the delivery costs covered by the family were all factors independently and significantly associated with a higher chance of c-section delivery. We conclude that women are not well informed to give consent for c-delivery, and that their request is often affected by false belief and poor knowledge.

Enforcing the International Code of Marketing of Breast-milk Substitutes for Better Promotion of Exclusive Breastfeeding: Can Lessons Be Learned?

Exclusive breastfeeding, one of the best natural resources, needs protection and promotion. The International Code of Marketing of Breast-milk Substitutes (the Code), which aims to prevent the undermining of breastfeeding by formula advertising, faces implementation challenges. We reviewed frequently overlooked challenges and obstacles that the Code is facing worldwide, but particularly in Southeast Asia. Drawing lessons from various countries where we work, and following the example of successful public health interventions, we discussed legislation, enforcement, and experiences that are needed to successfully implement the Code. Successful holistic approaches that have strengthened the Code need to be scaled up. Community-based actions and peer-to-peer promotions have proved successful. Legislation without stringent enforcement and sufficient penalties is ineffective. The public needs education about the benefits and ways and means to support breastfeeding. It is crucial to combine strong political commitment and leadership with strict national regulations, definitions, and enforcement. National breastfeeding committees, with the authority to improve regulations, investigate violations, and enforce the laws, must be established. Systematic monitoring and reporting are needed to identify companies, individuals, intermediaries, and practices that infringe on the Code. Penalizing violators is crucial. Managers of multinational companies must be held accountable for international violations, and international legislative enforcement needs to be established. Further measures should include improved regulations to protect the breastfeeding mother: large-scale education campaigns; strong penalties for Code violators; exclusion of the formula industry from nutrition, education, and policy roles; supportive legal networks; and independent research of interventions supporting breastfeeding.

Reasons for routine episiotomy: A mixed-methods study in a large maternity hospital in Phnom Penh, Cambodia.

First documented in 1741, the practice of episiotomy substantially increased worldwide during the 20th century. However, research shows that episiotomy is not effective in reducing severe perineal trauma and may be harmful. Using a mixed-methods approach, we conducted a study in 2013-14 on why obstetricians and midwives in a large maternity hospital in Phnom Penh, Cambodia, still do routine episiotomies. The study included the extent of the practice, based on medical records; a retrospective analysis of the delivery notes of a random sample of 365 patients; and 22 in-depth interviews with obstetricians, midwives and recently delivered women. Of the 365 women, 345 (94.5%, 95% CI: 91.7-96.6) had had an episiotomy. Univariate analysis showed that nulliparous women underwent episiotomy more frequently than multiparous women (OR 7.1, 95% CI 2.0-24.7). The reasons given for this practice by midwives and obstetricians were: fear of perineal tears, the strong belief that Asian women have a shorter and harder perineum than others, lack of time in overcrowded delivery rooms, and the belief that Cambodian women would be able to have a tighter and prettier vagina through this practice. A restrictive episiotomy policy and information for pregnant women about birthing practices through antenatal classes should be implemented as soon as possible.

Klebsiella pneumoniae related community-acquired acute lower respiratory infections in Cambodia: clinical characteristics and treatment.

BACKGROUND: In many Asian countries, Klebsiella pneumoniae (KP) is the second pathogen responsible for community-acquired pneumonia. Yet, very little is known about KP etiology in ALRI in Cambodia, a country that has one of the weakest medical infrastructures in the region. We present here the first clinico-radiological description of KP community-acquired ALRI in hospitalized Cambodian patients. METHODS: Through ALRI surveillance in two provincial hospitals, KP was isolated from sputum and blood cultures, and identified by API20E gallery from patients ≥ 5 years-old with fever and respiratory symptoms onset ≤14 days. Antibiotics susceptibility testing was provided systematically to clinicians when bacteria were isolated. We collected patients' clinical, radiological and microbiological data and their outcome 3 months after discharge. We also compared KP-related with other bacteria-related ALRI to determine risk factors for KP infection. RESULTS: From April 2007 to December 2009, 2315 ALRI patients ≥ 5 years-old were enrolled including 587 whose bacterial etiology could be assigned. Of these, 47 (8.0%) had KP infection; their median age was 55 years and 68.1% were females. Reported prior medication was high (42.5%). Patients' chest radiographs showed pneumonia (61.3% including 39% that were necrotizing), preexisting parenchyma lesions (29.5%) and pleural effusions alone (4.5%) and normal parenchyma (4.5%). Five patients had severe conditions on admission and one patient died during hospitalization. Of the 39 patients that were hospital discharged, 14 died including 12 within 1 month after discharge. Only 13 patients (28%) received an appropriate antibiotherapy. Extended-spectrum beta-lactamases (ESBL) - producing strains were found in 8 (17.0%) patients. Female gender (Odds ratio (OR) 2.1; p = 0.04) and diabetes mellitus (OR 3.1; p = 0.03) were independent risk factors for KP-related ALRI. CONCLUSIONS: KP ALRI in Cambodia has high fatality rate, are more frequently found in women, and should be considered in diabetic patients. The extremely high frequency of ESBL-producing strains in the study is alarming in the context of uncontrolled antibiotic consumption and in absence of microbiology capacity in most public-sector hospitals.