Stakeholders' Perspectives on the Challenges of Emergency Obstetric Referrals and the Feasibility and Acceptability of an mHealth Intervention in Northern Iraq.

The health system in northern Iraq has been weakened by conflict and the internal displacement of over three million people. Mobile phone-based interventions (mHealth) may improve maternal and neonatal health outcomes by enabling emergency referrals, facilitating communication between patients and providers, and improving patient data management; however, they have not been sufficiently studied in conflict-affected settings. We explored stakeholders' perspectives on challenges to obstetric referrals and the feasibility and acceptability of a mobile phone-based application to reduce delays in reaching emergency obstetric care in order to inform its development. We conducted a qualitative study in the Kurdistan region of northern Iraq from May to July, 2018. Using purposive sampling, we carried out 15 semi-structured interviews with coordination actors including healthcare management staff, government health officials, non-government health program managers and ambulance staff. The interviews explored obstetric care delivery, referral processes, mobile phone usage and mHealth implementation strategies. Eleven focus group discussions, which incorporated participatory activities on similar topics, were conducted with ambulance drivers, hospital and primary health center staff. Audio-recorded, transcribed and translated data were coded iteratively to identify emerging concepts, and analyzed thematically. Sixty-eight stakeholders (36 women and 32 men) participated. Challenges regarding the referral system included resource limitations, security concerns, costs and women's reluctance to be transported in male-staffed ambulances. In terms of obstetric care and decision-making, participants noted gaps in communication and coordination of services with the current paper-based system between health care providers, ambulance drivers, and hospital staff. Ambulance drivers reported incurring delays through lack of patient information, poor road conditions, and security issues. A prototype mobile phone application was found to be acceptable based on perceived usefulness to address some of the challenges to safe obstetric care and focused on phone usage, access to information, Global Positioning System (GPS), connectivity, cost, and user-friendliness. However, the feasibility of the innovation was considered in relation to implementation challenges that were identified, including poor connectivity, and digital literacy. Implementation of the app would need to account for the humanitarian context, cultural and gender norms regarding obstetric care, and would require substantial commitment and engagement from policymakers and practitioners.

Gunshot wound injuries to the male external genitalia.

OBJECTIVE: To identify the patterns of civilian gunshot wound (GSW) injuries to the male external genitalia, and to present our experience in the management of such injuries. METHODS: This descriptive study was carried out in the Urology and Nephrology Center, Al-Thawra Modern General and Teaching Hospital, Sanaa, Yemen from June 2005 to April 2008, and included 20 men that presented with GSW injuries to the external genitalia. After clinical and radiological evaluation with retrograde urethrography when indicated, early surgical repair was undertaken for all patients with evident, or suspected deep genito-urinary wounds. RESULTS: The mean age of the patients was 33.2 years. In 15 (75%) patients, injuries were inflicted by high-velocity weapons, and in 5 by low-velocity pistols, and 18 (90%) patients had other associated injuries. The penis was involved alone in 10 (50%), scrotum in 4 (20%), and the penis and scrotum in combination in 6 (30%) patients. In 5 patients, the lesions were superficial. Corporeal injuries were detected in 13 patients, and urethral injuries were detected in 6 patients. In post-repair, mild curvature during erection was experienced by 5 patients, severe angulation by one, and sexual dysfunction by 2 patients. We encountered 9 testicular ruptures, and our testicular salvage rate was 45.5%. CONCLUSION: Although the dominant inflicting weapons were high-velocity automatic rifles, the severity of injuries and their related outcomes were almost comparable to other low-velocity series. This is possibly due to the primary involvement of nearby bulky muscles in 90% of cases, which may absorb the blasts effect of the projectiles on the genitalia.

Management of penile fractures.

OBJECTIVE: To present our experience with surgical and conservative management of penile fracture. METHODS: This prospective study was carried out in the Urology and Nephrology Center, at Al-Thawra Modern General and Teaching Hospital, Sana'a, Yemen from June 2003 to September 2007, and included 30 patients presenting with penile fracture. Diagnosis was made clinically in all our patients. Six patients with simple fracture were treated conservatively while 24 patients with more severe injuries were operated upon. RESULTS: Patients' ages ranged from 24-52 years (mean 31.3 years), 46.7% of patients were under the age of 30 years and 56.7% were unmarried. Hard manipulation of the erect penis for example during masturbation was the most frequent mechanism of fracture in 53.3% of patients. Solitary tear was found in 22 patients and bilateral corporal tears associated with urethral injury were found in 2 patients. Corporal tears were sutured with synthetic absorbable sutures and urethral injury was repaired primarily. All operated patients described full erection with straight penis except 3 of the 8 patients who were managed by direct longitudinal incision, in whom mild curvature during erection was observed. The conservatively treated patients described satisfactory penile straightness and erection. CONCLUSION: The optimal functional and cosmetic results are achieved following immediate surgical repair of penis fracture. Good results can also be obtained in some selected patients with conservative management.