Correct diagnosis of childhood pneumonia in public facilities in Tanzania: a randomised comparison of diagnostic methods.

OBJECTIVE: This study compares two methods for clinical diagnosis of childhood pneumonia that aim to estimate rates of underdiagnosis and overdiagnosis of childhood pneumonia by examining the sensitivity of Integrated Management of Childhood Diseases implementation in routine care against lung ultrasound (LUS) diagnosis. SETTING: We conducted observations in 83 public health facilities (dispensaries, health centres and district hospitals) in Pwani, Dodoma and Tabora, Tanzania between October and December 2017. METHODS: We used a novel method to estimate rates of underdiagnosis and overdiagnosis of childhood pneumonia by comparing directly observed public provider diagnoses to the results of diagnoses made by trained clinicians using Mindray DP-10 ultrasound machines. We perform multivariate analysis to identify confounding effects and robustness checks to bound the result. We also explore a number of observable characteristics correlated with higher rates of agreement between provider diagnoses and ultrasound diagnoses. RESULTS: We observed 93 providers conducting exams on patients aged 2 months-5 years who presented respiratory symptoms or were given a respiratory diagnosis by the provider. Of these 957 patients, 110 were excluded from analysis resulting in a final sample of 847.17.6% of cases identified as pneumonia via LUS examinations in our sample were diagnosed as pneumonia by providers, suggesting that a significant number of pneumonia cases for which care is sought in the public sector go undiagnosed. Provider knowledge of breath counting and years of experience are positively correlated with higher agreement. While clinical examination rates are not statistically correlated with agreement, it is notable that providers conducted a clinical examination on only about one-third of patients in the sample. CONCLUSION: Our results suggest that provider training and knowledge of clinical examination protocols for pneumonia diagnosis are predictive of correct diagnosis of pneumonia and should be further explored in future research as a tool for improving quality of care.

Prepregnancy Obesity and Birth Outcomes.

OBJECTIVE: To investigate the association between prepregnancy obesity and birth outcomes using fixed effect models comparing siblings from the same mother. METHODS: A total of 7496 births to 3990 mothers from the National Longitudinal Survey of Youth 1979 survey are examined. Outcomes include macrosomia, gestational length, incidence of low birthweight, preterm birth, large and small for gestational age (LGA, SGA), c-section, infant doctor visits, mother's and infant's days in hospital post-partum, whether the mother breastfed, and duration of breastfeeding. Association of outcomes with maternal pre-pregnancy obesity was examined using Ordinary Least Squares (OLS) regression to compare across mothers and fixed effects to compare within families. RESULTS: In fixed effect models we find no statistically significant association between most outcomes and prepregnancy obesity with the exception of LGA, SGA, low birth weight, and preterm birth. We find that prepregnancy obesity is associated with a with lower risk of low birthweight, SGA, and preterm birth but controlling for prepregnancy obesity, increases in GWG lead to increased risk of LGA. CONCLUSIONS: Contrary to previous studies, which have found that maternal obesity increases the risk of c-section, macrosomia, and LGA, while decreasing the probability of breastfeeding, our sibling comparison models reveal no such association. In fact, our results suggest a protective effect of obesity in that women who are obese prepregnancy have longer gestation lengths, and are less likely to give birth to a preterm or low birthweight infant.