Contextual factors influencing the implementation of a new midwife education programme in India: a qualitative study.

The Indian Government has committed to educate 90,000 midwives in accordance with international norms. This goal is critical as midwives provide evidence-based, high-quality midwifery care. There is a need to explore the contextual factors influencing this new midwifery education programme. Hence, the aim of this study is to explore contextual factors influencing the implementation of the national midwifery education programme for midwifery educators and the future Nurse Practitioners in Midwifery (NPMs) in India. A qualitative research design was used, with data collected through focus group discussions (n = 8) with a total of 27 participants representing seven national and international organisations supporting the Indian Government in its midwifery initiative. Transcribed interviews were analysed using content analysis. This study on contextual factors influencing the implementation of the new midwifery education programme in India showed that organisational and administrative processes are complex and the development of midwifery educators and nurse practitioners in midwifery needs to be fast tracked. The education of educators and future midwives in India, and elsewhere in similar settings, could benefit from efforts to simplify the organisational and administration processes and, in parallel, mobilize innovative teaching and learning approaches to bridge theory and practice.

Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India.

BACKGROUND: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. METHODS: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. RESULTS: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. CONCLUSIONS: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Utilization of flour from rice brokens in wheat flour chapatti: evaluation of dough rheology, starch digestibility, glycemic index and retrogradation behavior.

Broken rice, a byproduct of the rice milling industry was utilized at different levels to evaluate unleavened flat bread (chapatti) making properties of whole wheat flour. Chapattis were prepared by replacing whole wheat flour with broken rice flour up to 50% level. Mixolab studies revealed that incorporation of rice flour lowered dough development time and dough stability of whole wheat flour up to 23.49% and 78.33%, respectively. Lower retrogradation was observed in whole wheat rice flour blends as revealed from soluble starch/amylose. A positive correlation of mixolab retrogradation was observed with soluble starch and soluble amylose. Whole wheat flour chapatti (fresh and retrograded) containing different level of rice flour were also evaluated for glycemic index (GI), rapidly digestible starch (RDS) and slowly digestible starch (SDS). Chapattis containing rice flour demonstrated higher GI and RDS but lower SDS. RDS correlated positively with GI. Chapattis from the whole wheat rice flour blends had good consumer acceptability.

Relationship of Mixolab characteristics with protein, pasting, dynamic and empirical rheological characteristics of flours from Indian wheat varieties with diverse grain hardness.

Mixolab properties of different Indian extraordinarily soft (Ex-SW), hard (HW) and medium hard (MHW) wheat varieties were evaluated and related to damaged starch content, particle size distribution, pasting, Farinographic and Mixographic properties. Water absorption (WA) of HW varieties was higher as compared to other varieties. Higher damaged starch led to more WA in HW varieties while lower in Ex-SW varieties. Unextratable polymeric protein, damaged starch and arabinoxylans were related to dough consistency. Mixolab measurement C3 (peak viscosity) and C5 (starch retrogradation) decreased with increase in grain hardness index, damaged starch content, and sodium solvent retention capacity. Dough stability (DS) and dough development time (DDT) measured by Mixolab and farinograph were significantly correlated. Mixolab parameters (C3, C4 and C5) related positively to DDT and DS while negatively to WA. HW varieties showed higher shear thinning as compared to MHW and Ex-SW varieties. C4 (hot paste stability) was lower for HW but higher for Ex-SW varieties. SuSRC was negatively related to C4 indicating that HW flours had lower starch retrogradation due to higher arabinoxylans. C3, C4 and C5 related positively to small size particles while negatively to large size particles. Slope beta (ß) measured by mixolab indicated that the speed of starch gelatinization was lower for Ex-SW varieties than MHW and HW varieties.

The transition of childbirth practices among tribal women in Gujarat, India - a grounded theory approach.

BACKGROUND: Under the National Rural Health Mission, the current emphasis is on achieving universal institutional births through incentive schemes as part of reforms related to childbirth in India. There has been rapid progress in achieving this goal. To understand the choices made as well as practices and perceptions related to childbirth amongst tribal women in Gujarat and how these have been influenced by modernity in general and modernity brought in through maternal health policies. METHOD: A model depicting the transition in childbirth practices amongst tribal women was constructed using the grounded theory approach with; 8 focus groups of women, 5 in depth interviews with traditional birth attendants, women, and service providers and field notes on informal discussions and observations. RESULTS: A transition in childbirth practices across generations was noted, i.e. a shift from home births attended by Traditional Birth Attendants (TBAs) to hospital births. The women and their families both adapted to and shaped this transition through a constant 'trade-off between desirable and essential'- the desirable being a traditional homebirth in secure surroundings and the essential being the survival of mother and baby by going to hospital. This transition was shaped by complex multiple factors: 1) Overall economic growth and access to modern medical care influencing women's choices, 2) External context in terms of the international maternal health discourses and national policies, especially incentive schemes for promoting institutional deliveries, 3) Socialisation into medical childbirth practices, through exposure to many years of free outreach services for maternal and child health, 4) Loss of self reliance in the community as a consequence of role redefinition and deskilling of the TBAs and 5) Cultural belief that intervention is necessary during childbirth aiding easy acceptance of medical interventions. CONCLUSION: In resource poor settings where choices are limited and mortality is high, hospital births are perceived as increasing the choices for women, saving lives of mothers and babies, though there is a need for region specific strategies. Modern obstetric technology is utilised and given meanings based on socio-cultural conceptualisations of birth, which need to be considered while designing policies for maternal health.

Contextual factors influencing the implementation of midwifery-led care units in India.

BACKGROUND: The Government of India has committed to educate 90,000 midwives functioning in midwifery-led care units (MLCUs) to care for women during labour and birth. There is a need to consider local circumstances in India, as there is no 'one size fits all' prescription for MLCUs. AIM: To explore contextual factors influencing the implementation of MLCUs across India. METHOD: Data were collected through six focus group interviews with 16 nurses, midwives, public health experts and physicians, representing six national and international organisations supporting the Indian Government in its midwifery initiative. Transcribed interviews were analysed using content analysis. FINDINGS: Four generic categories describe the contextual factors which influence the implementation of MLCUs in India: (i) Perceptions of the Nurse Practitioner in Midwifery and MLCUs and their acceptance, (ii) Reversing the medicalization of childbirth, (iii) Engagement with the community, and (iv) The need for legal frameworks and standards. CONCLUSION: Based on the identified contextual factors in this study, we recommend that in India and other similar contexts the following should be in place when designing and implementing MLCUs: legal frameworks to enable midwives to provide full scope of practice in line with the midwifery philosophy and informed by global standards; pre- and in-service training to optimize interdisciplinary teamwork and the knowledge and skills required for the implementation of the midwifery philosophy; midwifery leadership acknowledged as key to the planning and implementation of midwifery-led care at the MLCUs; and a demand among women created through effective midwifery-led care and advocacy messages.

Fibrolipoma of Flexor Digitorum Profundus Tendon of Ring Finger Causing Triggering and Intermittent Carpal Tunnel Syndrome.

Introduction: Lipomas are most common soft-tissue tumors but rarely are found to be symptomatic. <1% of lipomas are found in hand. Subfascial lipomas can cause pressure symptoms. Carpal tunnel syndrome (CTS) can be idiopathic or secondary to any space-occupying lesion. Triggering usually occurs due to inflammation/thickening of A1 pulley. Most have reported a lipoma in distal forearm or near median nerve, leading to triggering of index or middle finger and carpal tunnel symptoms. All the cases reported had either an intramuscular lipoma in flexor digitorum superficialis (FDS) tendon slip of index or middle finger, with or without accessory belly of FDS muscle or a neurofibrolipoma of the median nerve. In our case, the lipoma was under palmer fascia, in flexor digitorum profundus (FDP) tendon sheath of fourth finger causing triggering of the ring finger and CTS symptoms in flexion of the ring finger. Hence, this is a first report of this kind in the literature. Case Report: We hereby report a one of its kind case in which a 40-year-old Asian male patient had triggering of the ring finger with associated intermittent CTS symptoms, on making a fist, secondary to space-occupying lesion in palm, which was diagnosed by ultrasound as lipoma in FDP tendon of the ring finger in palm. This lipoma was surgically removed by AO ulnar palmer approach and carpal tunnel was decompressed. Histopathology report confirmed the lump to be fibrolipoma. The patient had complete relief of symptoms postoperatively. At 2 years follow-up, there was no recurrence.

Cultural adaptation and psychometric evaluation of Childbirth Experience Questionnaire 2 in Karnataka state, India.

BACKGROUND: Women's birthing experience is a sensitive indicator of the quality of childbirth care and can impact the physical and mental health of both women and their neonates. Negligible evidence exists on Indian women's birth experiences and-to the best of authors' knowledge-no questionnaire has been tested in India for measuring women's birthing experiences. This study aimed to test the construct validity and reliability of the Kannada-translated Revised Childbirth Experience Questionnaire. METHODOLOGY: A cross-sectional survey was carried out among postnatal women (n = 251, up to six months postpartum, with a live healthy neonate) who had given birth at a public or private health facility using the Kannada-translated CEQ2 in two districts of Karnataka. Data were collected at participants' homes after seeking written informed consent. Model fit was determined by Confirmatory Factor Analyses. RESULTS: The 4-factor model of the CEQ2 showed good fit after deletion of one item (item 8, subcategory "participation") with CMIN = 1.33; SRMR = 0.04; GFI = 0.92, CFI = 0.98, TLI = 0.99, RMSEA = 0.037 and p value 0.002). The Cronbach alpha values were acceptable for the four subscales (0.92, 0.93, 0.97, 0.91) as well as for the overall 21-item scale (0.84). CONCLUSIONS: The Kannada-translated CEQ2 is a reliable tool to measure the childbirth experiences among Kannada-speaking women and can serve as a reliable ongoing evaluation of women's birth experiences.

A Prospective Multi-centric Study of Acceptance, Insertion and Follow-Up of Postpartum Insertions of IUCD.

Purpose of the Study: The unmet need for contraception in the postpartum period is a major challenge in our country. Unintended pregnancies are highest in the first year after birth, and postpartum IUCD insertion is an effective way to counter this problem. This study was planned to build up data for acceptance and follow-up of postpartum IUCD insertions. Methods: The present study has included data of PPIUCD insertions and follow-up from seven institutions over a period of 6 months. The case recruitment lasted for 3 months, including only those who had PPIUCD insertions in this period, and they were followed up for a period of 6 months. The follow-up of patients was at 6 weeks and 6 months. All issues were addressed including side effects, expulsions, myths surrounding the device, etc., along with routine postnatal care. Results and Conclusion: There were 5227 deliveries and 1895 insertions. The acceptance rate was 36%, and a follow-up at 6 weeks and 6 months showed up an expulsion rate of approximately 4% and a removal rate of 5%. Overall, at the end of 6 months we have a continuation rate of 90%. This shows that a dedicated approach to postpartum contraception will definitely bring down incidence of unintended pregnancies.

Are there mechanistic differences between ultraviolet and visible radiation induced skin pigmentation?

Most of the studies on sunlight-induced pigmentation of skin are mainly focused on ultraviolet (UV) radiation-induced pigmentation and ways to prevent it. Recent studies have shown that the visible component of sunlight can also cause significant skin pigmentation. In the current study, the extent of pigmentation induced by UV and visible regions of sunlight in subjects with Fitzpatrick skin type IV-V was measured and compared with pigmentation induced by total sunlight. The immediate pigment darkening (IPD) induced by the visible fraction of sunlight is not significantly different from that induced by the UV fraction. However, the persistent pigment darkening (PPD) induced by visible fraction of sunlight in significantly lower than that induced by the UV fraction. The dose responses of IPD induced by UV, visible light and total sunlight suggest that both UV and visible light interact with the same precursor although UV is 25 times more efficient in inducing pigmentation per J cm(-2) of irradiation compared to visible radiation. The measured diffused reflection spectra and decay kinetics of UV and visible radiation-induced pigmentation are very similar, indicating that the nature of the transient and persistent species involved in both the processes are also likely to be same.

African midwifery students' self-assessed confidence in postnatal and newborn care: A multi-country survey.

BACKGROUND: Majority of maternal and new-born deaths occur within 28 hours and one week after birth. These can be prevented by well-educated midwives. Confidence in postnatal and newborn care skills depend on the quality of midwifery education. OBJECTIVE: To assess confidence and its associated factors for basic postnatal and new-born care skills of final year midwifery students , from seven African countries. METHODS: A multi-country cross-sectional study where final year midwifery students answered a questionnaire consisting of basic skills of postnatal and newborn care listed by the International Confederation of Midwives. The postnatal care area had 16 and newborn care area had 19 skill statements. The 16 skills of postnatal care were grouped into three domains through principle component analysis (PCA); Basic postnatal care; postnatal complications and educating parents and documentation. The 19 skills under the newborn care area were grouped into three domains; Basic care and care for newborn complications; Support parents for newborn care; and Care for newborns of HIV positive mothers and documentation. RESULTS: In total 1408 midwifery students from seven Sub-Saharan countries participated in the study namely; Kenya, Malawi, Tanzania, Uganda, Zambia, Zimbabwe, and Somaliland Overall high confidence for all domains under Post Natal Care ranged from 30%-50% and for Newborn care from 39-55%. High confidence for postnatal skills was not found to be associated with any background variables (Age, sex, type and level of educational programme). High confidence for newborn care was associated with being female students, those aged 26-35 years, students from the direct entry programmes and those enrolled in diploma programmes. CONCLUSIONS: Almost half of the study participants expressed lack of confidence for skills under postnatal and newborn care. No association was found between high confidence for domains of postnatal care and background variables. High confidence was associated with being a female, between 26-35 years of age, from direct entry or diploma programmes for newborn care area. The results of the study indicate gaps in midwifery education. Countries could use the ICM list of competencies to develop country specific standards for midwifery education. However, actual competence remains to be measured.

Modifying the dough mixing behavior, protein & starch digestibility and antinutritional profile of minor millets by sprouting.

The objective of this study was to evaluate the impact of sprouting (0, 12, 24, 36, 48 hr) on enzyme activity, protein solubility, dough mixing behavior, anti-nutritional components and in vitro starch and protein digestibility of minor millets. Sprouting decreased starch, fat, protein and ash contents while the dietary fiber content, amylase and protease activity significantly (p < 0.05) increased. Sprouting promoted a significant (p < 0.05) decrease in anti-nutritonal components like phytic acid and condensed tannin. The protein solubility enhanced that also resulted in improved protein digestibility (in vitro) of sprouted millets. Sprouting exerted a significant (p < 0.05) effect on mixolab dough rheology indicating a decrease in dough consistency (C1), peak and final viscosity whilst protein weakening and breakdown increased (p < 0.05). This process produced an increase in free glucose thereby improving rapidly digestible starch and increasing glycemic index. A significant (p < 0.05) reduction in resistant starch along with slowly digestible starch was promoted during sprouting. In conclusion, sprouting provides millet flours with modified nutritional quality and better technofunctional properties than the raw flours that may suggest their potential utilization in complementary food formulations and baked products.

Maternal health situation in India: a case study.

Since the beginning of the Safe Motherhood Initiative, India has accounted for at least a quarter of maternal deaths reported globally. India's goal is to lower maternal mortality to less than 100 per 100,000 livebirths but that is still far away despite its programmatic efforts and rapid economic progress over the past two decades. Geographical vastness and sociocultural diversity mean that maternal mortality varies across the states, and uniform implementation of health-sector reforms is not possible. The case study analyzes the trends in maternal mortality nationally, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health and suggests measures to rectify them. It recommends better reporting of maternal deaths and implementation of evidence-based, focused strategies along with effective monitoring for rapid progress. It also stresses the need for regulation of the private sector and encourages further public-private partnerships and policies, along with a strong political will and improved management capacity for improving maternal health.

Maternal health in Gujarat, India: a case study.

Gujarat state of India has come a long way in improving the health indicators since independence, but progress in reducing maternal mortality has been slow and largely unmeasured or documented. This case study identified several challenges for reducing the maternal mortality ratio, including lack of the managerial capacity, shortage of skilled human resources, non-availability of blood in rural areas, and infrastructural and supply bottlenecks. The Gujarat Government has taken several initiatives to improve maternal health services, such as partnership with private obstetricians to provide delivery care to poor women, a relatively-short training of medical officers and nurses to provide emergency obstetric care (EmOC), and an improved emergency transport system. However, several challenges still remain. Recommendations are made for expanding the management capacity for maternal health, operationalization of health facilities, and ensuring EmOC on 24/7 (24 hours a day, seven days a week) basis by posting nurse-midwives and trained medical officers for skilled care, ensuring availability of blood, and improving the registration and auditing of all maternal deaths. However, all these interventions can only take place if there are substantially-increased political will and social awareness.

Modulation in quality attributes of dough and starch digestibility of unleavened flat bread on replacing wheat flour with different minor millet flours.

The dough characteristics and flat bread quality parameters were studied on replacing a part of wheat flour with different minor millets (finger, foxtail, barnyard, kodo, little, proso) in the proportion 3:1. The dietary fiber and phytic acid increased while damaged starch decreased on replacing wheat flour with millet flour. The millet flours lowered water absorption and dough stability however protein weakening, gelatinization temperature and peak viscosity during heating increased. Flat breads prepared from wheat millet composite flour displayed more shrinkage and bake loss and reduced puffing and starch retrogradation. Rapidly digestible starch and glycemic index lowered while slowly digestible and resistant starch increased significantly (p < 0.05) as a consequence of millet flour addition to wheat flour. Millets as whole flour can be utilized in formulation of food products having higher neutraceutical value by replacing a part of wheat flour with millet flours.

Influence of nutritional and antinutritional components on dough rheology and in vitro protein & starch digestibility of minor millets.

The nutritional and antinutritional components of minor millets were correlated with mixolab dough mixing behavior and in vitro protein and starch digestibility. Total arabinoxylan (r = -0.53, p < 0.05) and dietary fiber (r = -0.66, p < 0.05) content significantly (p < 0.05) increased protein weakening. Peak viscosity negatively correlated with phenolic (r = -0.55, p < 0.05) content. The dietary fiber and phenolics suppressed retrogradation. Protein digestibility negatively correlated with tannin (r = -0.70, p < 0.05), phytic acid (r = -0.69, p < 0.05), phenolics (r = -0.79, p < 0.05), flavonoids (r = -0.72, p < 0.05) and total dietary fiber content (r = -0.84, p < 0.05). A positive correlation of resistant starch (RS) with total dietary fiber (r = 0.85, p < 0.05), phenolics (r = 0.89, p < 0.05), flavonoids (r = 0.83, p < 0.05), phytic acid (r = 0.43, p < 0.05) and tannin content (r = 0.79, p < 0.05) was observed. Millets predicted lower glycemic index than wheat and it was found to be negatively associated with the RS (r = -0.96, p < 0.05) and total dietary fiber content (r = -0.89, p < 0.05) and positively correlated (r = 0.98, p < 0.05) with rapidly digestible starch. The millets may be diversified for personalized nutrition and development of functional food.

The association of teaching-learning methods and self-confidence of nurse-midwives. A survey from one province in India.

BACKGROUND: This study aimed to investigate the association between self-confidence of final-year students in selected midwifery skills and teaching-learning methods used in the two formally recognized education programs for nurse-midwives in India. DESIGN: A cross-sectional survey PARTICIPANTS: 633 final-year students, from 25 educational institutions randomly selected, stratified by type of program (diploma/bachelor), and ownership (private/government) in Gujarat. DATA COLLECTION AND ANALYSIS: Students assessed their confidence on a 4-point scale, in four midwifery competency domains-antepartum, intrapartum, postpartum, and newborn care recommended by the International Confederation of Midwives (ICM). Explorative factor analysis was used to reduce skill statements into subscales separately for each domain. Odds ratios with 95% CI were calculated for students with high confidence (≥75th percentile on each subscale) and not high confidence (all others) between diploma and bachelor students. RESULTS: Classroom teaching was the most practiced method. 'Laboratory demonstrations', 'Practice on models', 'Demonstrations at clinical sites', 'Births Attended' (Hands-on clinical practice), and 'Satisfaction with clinical supervision' were practiced less, lesser in the bachelor's compared to the diploma program. High confidence was associated with 'Births Attended' (Hands-on clinical practice), 'Practice on models', and 'Satisfaction with clinical supervision' for all subscales of all four domains of competencies. CONCLUSIONS: Hands on skills practice in the laboratory and supervised clinical practice during clinical placements were associated with high confidence for basic clinical midwifery skills amongst students. The diploma program followed better pedagogoical approaches than the bachelor's program.

Emotional and Behavioral Problems among Adolescents in Pokhara City in Nepal.

BACKGROUND: Adolescents are highly vulnerable to psychiatric disorders, which often have serious negative consequences for their academic achievement and potential social life. The aim of the study is to estimate the prevalence of emotional and behavioral problems among adolescents. METHODS: A descriptive cross-sectional study design was adopted to identify the emotional and behavioral problems among adolescents using cluster sampling technique. Assessment was done on students of grade 7-11 from two schools in city in Nepal using self-administered questionnaire, Youth Self-Report (YSR-11/18) 2001, developed by Achenbach System of Empirical Based Assessment and self developed socio-demographic questionnaires. Data was coded and analyzed using SPSS (20). Descriptive statistic and inferential statistic (Chi square, Fisher Exact and Odds ratio-OR) were used to analyze data. RESULTS: Altogether 330 adolescents were enrolled in study with mean age 14.3 yrs (range 11-18, male-152, female-178). Prevalence of EBPs was 30.0% (Male-38.8% female-22.5%). Internalizing problems (35.8%) were more common than externalizing (18.5%). Occurrence of EBPs was significantly associated with Sex (OR= 2.2 p=0.001), type of family (OR=1.8 p=0.035) and types of school (private: public OR=2.1 p=0.004). Among narrow band scales most common problems were social (17.6%), thought (15.5%), somatic (13%), anxious depression (12.1%) and aggression(10.3%). There was significant association between sex with EBPs on narrow band scales, male adolescents were more likely to have thought-problem (OR=3.7 p=<0.001, rule-breaking problem (OR=8.5, p=0.02), aggressive behavior (OR=3.7 p=0.001) while female were more likely to have social problems (OR=2.6 p=0.002). CONCLUSIONS: Emotional and behavioural are a serious mental health concern among adolescents. An intervention strategy (School-based mental health service) maybe required to understand their problems and provide appropriate counseling.

African midwifery students' self-assessed confidence in antenatal care: a multi-country study.

Background: Evidence-based antenatal care is one cornerstone in Safe Motherhood and educated and confident midwives remain to be optimal caregivers in Africa. Confidence in antenatal midwifery skills is important and could differ depending on the provision of education among the training institutions across Africa.Objective: The aim of the study was to describe and compare midwifery students' confidence in basic antenatal skills, in relation to age, sex, program type and level of program.Methods: A survey in seven sub-Saharan African countries was conducted. Enrolled midwifery students from selected midwifery institutions in each country presented selfreported data on confidence to provide antenatal care. Data were collected using a selfadministered questionnaire. The questionnaire consisted of 22 antenatal skills based on the competency framework from the International Confederation of Midwives. The skills were grouped into three domains; Identify fetal and maternal risk factors and educate parents; Manage and document emergent complications and Physical assessment and nutrition.Results: In total, 1407 midwifery students from seven Sub-Saharan countries responded. Almost one third (25-32%) of the students reported high levels of confidence in all three domains. Direct entry programs were associated with higher levels of confidence in all three domains, compared to post-nursing and double degree programs. Students enrolled at education with diploma level presented with high levels of confidence in two out of three domains.Conclusions: A significant proportion of student midwives rated themselves low on confidence to provide ANC. Midwifery students enrolled in direct entry programs reported higher levels of confidence in all domains. It is important that local governments develop education standards, based on recommendations from the International Confederation of midwives. Further research is needed for the evaluation of actual competence.

Influence of replacing wheat bran with barley bran on dough rheology, digestibility and retrogradation behavior of chapatti.

Refined wheat flour and hulless barley bran (from 9 different cultivars) were blended to create nine composite flours and their functionality compared with a control wheat flour. Mixolab studies revealed that replacing wheat bran with barley bran increased dough water absorption up to 71.5% and consistency at peak during heating up to 2.11Nm, and reduced starch retrogradation by 26.44%. The composite flours contained up to three-times more ß-glucan and significantly more total phenolics including flavonoids. Chapattis prepared from the composite blends had significantly more slowly digestible and resistant starches. Incorporating barley bran lowered starch retrogradation, based on more soluble starch and soluble amylose, and the starch retrogradation index correlated positively with decreases in soluble starch and soluble amylose. Total ß-glucan correlated negatively (r=-0.846, p<0.05) with starch retrogradation index, indicating that ß-glucan is associated with starch retrogradation.