Postpartum family planning: missed opportunities across the continuum of care

Introduction: Postpartum family planning is defined as the prevention of unintended pregnancies and closely spaced pregnancies during the first 12 months following childbirth. Objectives: To assess the practice of family planning (FP) by postpartum mothers in the Regional Director of Health Services (RDHS) division, Kalutara, Sri Lanka. Methods: A community-based, descriptive, cross sectional study was carried out among mothers, 8 to 12 weeks postpartum, in the RDHS division, Kalutara in 2014. Calculated sample size was 1200 and the participants were recruited using cluster sampling method. They were interviewed at their residence about their practice of FP methods using an interviewer administered questionnaire. Results: The response rate was 93.7% (n=1112) of which 730 (65.6%) were practicing a FP method at 8-12 weeks after delivery. Condoms were the most popular modern FP method (30.4%, n=222) followed by intrauterine device (26.7%, n=195) and depot medroxyprogesterone acetate (DMPA) injections (22.9%, n=167). Approximately 80% had utilized government sector FP services. Women with higher level of education (p< 0.05), lower family income (p< 0.01), parity more than 3 (p< 0.001) and more than three living children (p<0.01) were significantly more likely to use a FP method. Conclusions: Prevalence of postpartum FP is not satisfactory. Therefore, FP services should consider reaching postpartum mothers with unmet needs as a priority and ensure that a wide range of contraceptive options are available to them. Postpartum FP should be considered as a continuum of maternal care.

Psychometric evaluation of the Sinhalese version of MacNew Heart Disease Health Related Quality of Life Questionnaire in patients with stable angina.

BACKGROUND: A Sinhalese version of a validated, disease-specific patient-reported heart disease health related quality of life instrument is lacking. The purpose of this study was to validate the interviewer-administered Sinhalese version of the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) in patients with clinically diagnosed stable angina. METHODS: The Sinhalese translation of the MacNew was carried using standard forward- backward translation technique. In this validation study, the MacNew was administered to 200 patients with stable angina. Reliability was assessed by internal consistency and test-retest reliability. Construct validity was explored by exploratory factor analysis using principal component analysis and confirmed by confirmatory factor analysis using the robust maximum likelihood method and known group comparison. The correlation between compatible domain scores of MacNew and the World Health Organization's quality of life -brief questionnaire was used to assess concurrent validity. RESULTS: The original 3-factor model (Physical, Emotional and Social) of the MacNew with cross-loadings was confirmed: principal component analysis with 53.42 % of the explained variance and confirmatory factor analysis with adequate fit for each of the three model fit criteria considered [root mean square error of approximation = 0.044 (90 % CI = 0.031 to 0.056); comparative fit index = 0.99; χ(2)/df = 1.39]. Internal consistency of the MacNew was acceptable with Cronbach's α of 0.92 on the Global scale and on the domain scales ranging from 0.85-0.91. Test-retest reliability was also found to be satisfactory with intraclass correlation coefficients of >0.9 for total and domain scores. A satisfactory level of concurrent validity was demonstrated with statistically significant correlations between compatible domain scores of MacNew and the World Health Organization's quality of life questionnaire (Pearson correlation ranging from 0.36-0.79). CONCLUSIONS: The interviewer-administered Sinhalese MacNew is a valid and reliable patient-reported outcome measure to assess disease specific health-related quality of life among Sinhalese patients with stable angina.

The development and validation of an instrument to assess caregiver burden in cerebral palsy: Caregiver Difficulties Scale.

OBJECTIVES: To develop a valid and reliable instrument to assess caregiver burden in caregivers of children with cerebral palsy (CP). METHODS: A self-administered, multidimensional instrument--Caregiver Difficulties Scale (CDS)--was developed using a combined qualitative-quantitative approach. Items for the preliminary draft were selected from existing caregiver assessment instruments by consensus of experts or key informant interviews with caregivers and service providers of children with CP. Standard item reduction techniques based on responses of 50 caregivers were used to develop the 25 item final draft of CDS. Multidimensionality of CDS was established by exploratory factor analysis, using responses of 125 caregivers. Construct validity of CDS was confirmed by assessing correlations between CDS score and two other constructs: 'Caregiver quality of life' and 'Severity of disease in the care recipient' in a sample of 90 caregivers. Internal consistency and reliability of CDS were assessed using Cronbach's alpha and test/retest reliability. RESULTS: A new instrument (CDS) was developed with four subscales measuring caregiver's concerns for child, impact on self, support for caregiving and social and economic strain. Face validity, content validity and consensual validity of CDS was established through the process of item generation. Caregiver quality of life and severity of disease in care recipient demonstrated significant moderate to high correlations (r ≥ 0.3) with scores of CDS, confirming construct validity. Both internal consistency and reliability of CDS were satisfactory. CONCLUSIONS: CDS is a valid and reliable instrument to assess caregiver burden among caregivers of children with cerebral palsy in Sri Lanka.

Incidence and risk factors of falls among the elderly in the District of Colombo.

OBJECTIVES: To assess the incidence and risk factors of falls among the elderly in the District of Colombo. METHODS: Incidence of falls was assessed by a community based descriptive study with prospective follow up. Risk factors for falls were assessed by a nested case control study. Participants above 65 years residing in 40 Grama Niladhari Divisions in the Colombo district (n=1200) were assessed for falls and followed up for four months. Those who had falls were selected as cases (n=151), while two controls per case were selected from others. MEASUREMENTS: Tests for gait problems, disability, cognitive impairment and vision. RESULTS: The incidence rate of falls was 492 per 1000 person years (95% CI 448-536). Risk factors for falls identified in the multivariate analysis were falls in the previous year (OR 4.67), high disability level (OR 2.04) and high house risk level (OR 1.68). CONCLUSIONS: The high incidence of falls among the elderly reported in this study and the preventable risk factors identify / indicate the necessity and feasibility of their prevention.

Mental health status and risk factors for mental health problems in left-behind children of women migrant workers in Sri Lanka.

INTRODUCTION: Many married Sri Lankan women annually migrate for employment overseas. Despite widely speculated psychological consequences in these children, their mental health status has not been systematically studied using validated instruments. OBJECTIVES: To describe mental health status of children of women overseas workers and compare that with children of locally employed women, and to describe socio-demographic factors and risk factors associated with abnormal mental health in these children. METHODS: A cross sectional comparative survey was conducted among 253 children (aged 5-10 years) of women migrant workers in the Colombo District and age and sex matched controls from same neighbourhood. Tools used were the validated Sinhala translation of Child Behaviour Check List (CBCL-S) and questionnaires on socio-demographic/risk factors and school functioning. RESULTS: Mean CBCL-S scores and proportion of children with mental health problems were significantly higher in the study group. Not having an elder sibling, father not living with child, mother educated up to grade 5 or less, change of principal carer (PC) twice or more, living with a relative (or not living in own home), child not communicating freely with PC, and not being permitted to engage in recreational activities at school were significantly associated with abnormal mental health of children of migrant women. CONCLUSIONS: A high awareness is required among health and social care authorities regarding mental health problems in these children and relevant risk factors in order to take preventive measures.

Population-based estimates of injuries in Sri Lanka.

BACKGROUND: Injuries are the leading cause of public hospital admission in Sri Lanka. Data on injury epidemiology to plan prevention programmes to reduce injury burden are not readily available. OBJECTIVES: To assess the incidence of various types of injuries in the Galle district, Sri Lanka. METHODS: 9568 individuals of all ages were selected from 2000 households in a population-based cross-sectional survey using a stratified cluster sampling technique. Data on non-fatal injuries in the last 30 days irrespective of severity, fatal injuries and those that resulted in disability in the last 12 months were documented. Proxy data were used for half of the injury cases. RESULTS: 195 (2%) individuals reported non-fatal injuries during the last 30 days, giving an age-sex-urban-rural adjusted annual incidence of 24.6 per 100 population. The leading causes of non-fatal injuries were falls (adjusted annual incidence 6.7 per 100 population, 95% CI 6.0 to 7.3) and mechanical injuries (6.3; 95% CI 5.7 to 6.8), followed by road traffic injuries (4.9; 95% CI 4.4 to 5.5). 114 (58.5%) individuals needed outpatient care and 50 (25.6%) needed inpatient care for their injuries. The annual injury mortality rate and disability rate were 177 (95% CI 72 to 283) and 290 (95% CI 250 to 330) per 100,000 population, respectively. CONCLUSIONS: Nearly one in four people reported non-fatal injury; the majority sought medical attention in this population. It is important to utilise injury epidemiology to develop and implement interventions to reduce the burden of injuries in the population and on the hospitals in Sri Lanka.

Sinhala translation of child behaviour checklist: validity and reliability.

OBJECTIVE: To translate the child behaviour checklist (CBCL) into Sinhala and validate it for assessment of mental health status of children aged 5-10 years. DESIGN AND SETTING: Translation/back-translation method was used to translate the English CBCL into Sinhala. Each item in the Sinhala CBCL (CBCL-S) was rated by mental health professionals to determine semantics, content, and conceptual validity types. To ascertain criterion validity, total scores obtained for CBCL-S by administering it to parents or parent surrogates of 49 girls and 80 boys aged 5-10 years attending the specialist psychiatry clinics and 69 boys and 69 girls in the same age group from the community were compared with clinical diagnoses by a child psychiatrist. Receiver operator characteristic curves were drawn to obtain the cut-off points in CBCL-S for boys and girls separately. RESULTS: Semantics, content, and conceptual and criterion validity of CBCL-S were satisfactory. At the cut-off level of 39, CBCL-S had a sensitivity of 90% and a specificity of 88% for boys and a sensitivity of 89% and a specificity of 92% for girls. Internal consistency, test-retest reliability, and inter-interviewer reliability of CBCL-S were satisfactory. INTERPRETATION: CBCL-S is a valid and reliable instrument to measure mental health status of Sinhalese children aged 5-10 years in Sri Lanka.

Smoking in adults in Sri Lanka: prevalence and attitudes.

A questionnaire was administered to 1565 adults to identify the prevalence of smoking and to assess respondents' attitudes toward smoking. Of men 41% were yearly smokers, 27.8% were monthly smokers and 21% were daily smokers. The corresponding figures for women were 3.4%, 2% and 0.6% respectively. Higher prevalence rates were observed among less educated, middle-aged men who were from underprivileged families. About 23% of men and 0.9% of women were monthly alcohol users. Alcohol use seems to be positively associated with smoking. A considerable portion of both smokers and non-smokers expressed a favorable attitude towards smoking habits of adult males (40.1% of smokers and 12.8% of non-smokers) and towards the tobacco industry (25.1% of smokers and 13.1 of non-smokers). Since the majority of people in Sri Lanka are non-smokers, attitudinal support given by them in promoting smoking in the society needs to be addressed effectively in smoking control interventions.

Perimenopausal symptoms in Sri Lankan women.

OBJECTIVE: To determine the types of perimenopausal symptoms (PMS) associated with the natural menopause and to make a preliminary assessment of the influence of PMS on household work, employment duties and social life, since no published data are available regarding these aspects in Sri Lankan women. DESIGN: A cross-sectional descriptive study of 403 women after natural menopause chosen randomly from four selected groups. METHOD: A pre-tested coded questionnaire administered by trained women medical students to consenting menopausal women. RESULTS: An overwhelming majority of menopausal women (87.1%) had one or more PMS. The principal PMS reported were insomnia (57.8%), joint pains (55.8%), night sweats (55.6%), hot flushes (40.2%), irritability (35.3%) and headaches (33.3%). Of the 171 women employed outside the home, 38% noted some interference with employment duties. PMS causes much morbidity in Sri Lankan perimenopausal women.

Risk factors contributing to acute diarrhoeal disease in children below five years.

Data regarding factors contributing to acute diarrhoea in children under five years in urban populations in Sri Lanka is meagre. Studies of diarrhoeal disease have been limited mainly to descriptive epidemiological investigations. A case control study on 200 families in the Galle Municipality was undertaken to identify some of the social, behavioural and environmental factors contributing to childhood diarrhoea. Twelve variables were studied by logistic regression, and the following variables were identified as conferring a significant risk of causing diarrhoeal disease in children below five years in an urban setting in Sri Lanka; (1) unavailability of pipe-borne water in the house (2) lack of water-seal latrine in the household (3) low level of mother's education and her lack of awareness regarding infectious nature and mode of spread of diarrhoea (4) not disposing of children's faeces in a latrine (5) improper disposal of garbage.

Albendazole in the treatment of goehelminth infections in children.

Children with mixed helminthic infections between the ages of 2 and 14 years, from a slum area, were treated with two regimes of albendazole. A majority of children had moderate to heavy infections with Trichuris trichiura (greater than 70%) and Ascaris lumbricoides (greater than 84%). Children treated with a single 400 mg dose of albendazole showed a very good response in ascariasis with 100% cure rate irrespective of the severity of infection. In Trichuriasis (n = 40), a cure rate of 50% was observed in mild infections, but only a reduction in the egg counts of 60% and 57% respectively were observed in moderate and heavy infections. Only 10 patients with Necator americanus infections were treated with the single dose, and the cure rate in mild infections was satisfactory (86%), with an overall egg reduction rate of 95%. In 47 children included in the multiple dose regime (200 mg daily x 3 days), the cure rates in trichuriasis were, 82%, 66%, and 37% respectively in mild, moderate, and heavy infections. The egg reduction rate was 98% in all degrees of infection in trichuriasis. The cure rate in ascariasis, with the multiple dose regime was similar to that of the single dose, with 100% egg reduction, irrespective of the severity of infection.

Neonatal and post-neonatal mortality in the Galle district.

OBJECTIVE: To determine some factors associated with infant mortality. DESIGN: Descriptive study. SETTING: Galle district in Sri Lanka. SUBJECTS: 350 infant deaths of singleton births. MEASUREMENTS: Association between variables. RESULTS: Neonatal:post-neonatal death ratio was 3.2:1, and 62.3% (218) were early neonatal deaths. First day deaths comprised 28.6% (100); 67.8% (237) died at the Teaching Hospital. A high incidence (65.7%) of low birthweight (LBW) was noted. Mean birthweights of neonates and post-neonates were 1925 +/- 729 and 2520 +/- 620 gram respectively, and the difference between means was statistically significant (p < 0.001). LBW and related disorders were the major cause of death in 44% (154) of the total sample, and in 55.8% (149) of neonates. Infections were the commonest cause (55.8%) of death in post-neonates. Pediatric clinical assessment to differentiate small-for-dates (SFD) was not recorded in 90.3%. Statistically significant associations were found between the period of death (neonatal and post-neonatal) and the following variables: period of gestation (p < 0.001); birthweight (p < 0.001) and cause of death (p < 0.001). CONCLUSIONS: There was a high incidence of neonatal deaths and a high proportion of early neonatal deaths. About one-third of deaths occurred on the first day of life. Incidence of LBW was high. The major cause of death was LBW and related disorders in the total sample and in neonates. Assessment of SFD was not carried out in the vast majority of infants.

PIP: Information was collected from hospitals, government medical centers, private hospitals, and death registrations in Galle district, Sri Lanka, in order to ascertain the factors associated with infant mortality. Deaths were grouped as low birth weight (LBW), birth trauma, infections, congenital anomalies, convulsions, and miscellaneous. The sample included 350 deaths (185 male and 165 female). 38.6% (135 deaths) were preterm at under 37 weeks. 93.3% of term (126 infants) and 65.5% of preterm (141 infants) died in the neonatal period. In the analysis of 336 infants, 65.7% (221 infants) were LBW, and 26.8% were very LBW at under 1500 grams. 85.9% of LBW babies and 57.4% of normal weight babies died during the neonatal period. 89 (40.3%) of the LBW babies were delivered at term, and 48.9% were LBW. 43.7% of the 335 infants were born in hospitals. 73.4% of infant deaths occurred at the hospital during the neonatal period. 14.3% of deaths took place at home. 44% of mortality was attributed to LBW, and LBW and related disorders accounted for 55.8% of neonatal mortality. 57.8% of postneonatal deaths were due to infections. 28.6% of neonatal deaths occurred within the first 24 hours, and 62.3% (218) occurred during the first week. There is a statistically significant association between time of death and period of gestation, birth weight, and cause of death. The importance of birth weight for child survival has been observed in other districts and other studies in Sri Lanka. The mean birth weight of infants dying in the neonatal period was 1925 +or- 729 g. In the postneonatal period, it was 2529 +or- 620 g.

Dietary cravings and aversions during pregnancy.

Although nausea and vomiting in early pregnancy has been studied in detail, there is little information available regarding dietary aversions and some cravings during pregnancy. To study the prevalence and factors associated with dietary aversions and cravings during pregnancy, a survey was carried out on 1000 randomly selected pregnant women attending antenatal clinics in a district in southern Sri Lanka. In this group 473 (47.3%) had pregnancy cravings for wide variety of foods: sour food 65%, unripe fruits 40%, meat and fish 47%, ripe fruits 30%, food from alms giving 26% and jam and bread fruit 22%. Ninety nine per cent of those who had pregnancy cravings had made special attempt to obtain the food of their choice and all of them had their cravings satisfied by eating the food of their choice. Pregnancy cravings was significantly higher in women who married after a love affair's than in those who had on 'arranged' marriage (p < 0.05), in women who were superstitious (believed in devil dancing and gods) than in those who were not (p < 0.05), and in women with a family income of less than Rs. 2,500 than in those with an income of more than Rs. 2,500 (p < 0.05).