Trends in birth attendants in Sudan using three consecutive household surveys (from 2006 to 2014).

Introduction: Improving maternal health and survival remains a public health priority for Sudan. Significant investments were made to expand access to maternal health services, such as through the training and deployment of providers with varying skills and competencies to work across the country. This study investigates trends in the coverage of different birth attendants and their relationship with the maternal mortality ratio (MMR). Methods: Trend analyses were conducted using data from the 2006, 2010, and 2014 Sudan Household surveys. Three categories of birth attendants were identified: (1) skilled birth attendants (SBA) such as doctors, nurse-midwives, and health visitors, (2) locally certified midwives, and (3) traditional birth attendants (TBA). Multivariable logistic regression models were used to examine trends in SBAs (vs. locally certified midwives and TBAs), locally certified midwives (vs SBAs and TBAs), and SBAs and locally certified midwives by place of birth (health facility and home). The analyses were adjusted for potential confounders. An ecological analysis was conducted to assess the relationship between birth attendants by place of birth and MMR at the state level. Results: Births by 15,848 women were analysed. Locally certified midwives attended most births in each survey year, with their contribution increasing from 36.3% in 2006 to 55.5% in 2014. The contributions of SBAs and TBAs decreased over the same period. In 2014 compared with 2006, births were more likely to be attended by a locally certified midwife (aOR: 2.19; 95%CI: 1.82-2.63) but less likely to be attended by a SBA (aOR: 0.46; 95%CI: 0.37-0.56). The decrease in SBA was more substantial for births taking place at home (aOR: 0.17; 95%CI: 0.12-0.23) than for health facility births (aOR: 0.45; 95%CI: 0.31-0.65). In the ecological analysis 2014-2016, the proportion of births attended by SBA in health facilities correlated negatively with MMR at state level (rho -0.55; p: 0.02). Conclusion: This analysis suggests that although an improved coverage of maternal health with locally certified midwives has been observed, it has not provided the skill level reached by SBA. SBAs working in facility settings were a key correlating factor to reduced maternal mortality. Urgent action is needed to improve access to SBAs in health facilities, thereby accelerating progress in reducing maternal mortality.

Factors related to environmental barriers experienced by persons with and without disabilities in diverse African settings.

This paper explores differences in experienced environmental barriers between individuals with and without disabilities and the impact of additional factors on experienced environmental barriers. Data was collected in 2011-2012 by means of a two-stage cluster sampling and comprised 400-500 households in different sites in South Africa, Sudan Malawi and Namibia. Data were collected through self-report survey questionnaires. In addition to descriptive statistics and simple statistical tests a structural equation model was developed and tested. The combined file comprised 9,307 participants. The Craig Hospital Inventory of Environmental Factors was used to assess the level of environmental barriers. Transportation, the natural environment and access to health care services created the biggest barriers. An exploratory factor analysis yielded support for a one component solution for environmental barriers. A scale was constructed by adding the items together and dividing by number of items, yielding a range from one to five with five representing the highest level of environmental barriers and one the lowest. An overall mean value of 1.51 was found. Persons with disabilities scored 1.66 and persons without disabilities 1.36 (F = 466.89, p < .001). Bivariate regression analyses revealed environmental barriers to be higher among rural respondents, increasing with age and severity of disability, and lower for those with a higher level of education and with better physical and mental health. Gender had an impact only among persons without disabilities, where women report more barriers than men. Structural equation model analysis showed that socioeconomic status was significantly and negatively associated with environmental barriers. Activity limitation is significantly associated with environmental barriers when controlling for a number of other individual characteristics. Reducing barriers for the general population would go some way to reduce the impact of these for persons with activity limitations, but additional and specific adaptations will be required to ensure an inclusive society.

A description of assistive technology sources, services and outcomes of use in a number of African settings.

Purpose statement: The article explores assistive technology sources, services and outcomes in South Africa, Namibia, Malawi and Sudan. METHODS: A survey was done in purposively selected sites of the study countries. Cluster sampling followed by random sampling served to identify 400-500 households (HHs) with members with disabilities per country. A HH questionnaire and individual questionnaire was completed. Country level analysis was limited to descriptive statistics. RESULTS: Walking mobility aids was most commonly bought/provided (46.3%), followed by visual aids (42.6%). The most common sources for assistive technology were government health services (37.8%), "other" (29.8%), and private health services (22.9%). Out of the participants, 59.3% received full information in how to use the device. Maintenance was mostly done by users and their families (37.3%). Devices helped a lot in 73.3% of cases and improved quality of life for 67.9% of participants, while 39.1% experienced functional difficulties despite the devices. CONCLUSION: Although there is variation between the study settings, the main impression is that of fragmented or absent systems of provision of assistive technology. Implications for rehabilitation Provision of assistive technology and services varied between countries, but the overall impression was of poor provision and fragmented services. The limited provision of assistive technology for personal care and handling products is of concern as many of these devices requires little training and ongoing support while they can make big functional differences. Rural respondents experienced more difficulties when using the device and received less information on use and maintenance of the device than their urban counterparts. A lack of government responsibility for assistive device services correlated with a lack of information and/or training of participants and maintenance of devices.

Human resources for primary health care in sub-Saharan Africa: progress or stagnation?

BACKGROUND: The World Health Organization defines a "critical shortage" of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. We aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. METHODS: This study is a review of published and unpublished "grey" literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa. RESULTS: Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. In Mali, few community health centres have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. CONCLUSION: There is an "inverse primary health care law" in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. Information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.

Perceived Barriers for Accessing Health Services among Individuals with Disability in Four African Countries.

There is an increasing awareness among researchers and others that marginalized and vulnerable groups face problems in accessing health care. Access problems in particular in low-income countries may jeopardize the targets set by the United Nations through the Millennium Development Goals. Thus, identifying barriers for individuals with disability in accessing health services is a research priority. The current study aimed at identifying the magnitude of specific barriers, and to estimate the impact of disability on barriers for accessing health care in general. A population based household survey was carried out in Sudan, Namibia, Malawi, and South Africa, including a total of 9307 individuals. The sampling strategy was a two-stage cluster sampling within selected geographical areas in each country. A listing procedure to identify households with disabled members using the Washington Group six screening question was followed by administering household questionnaires in households with and without disabled members, and questionnaires for individuals with and without disability. The study shows that lack of transport, availability of services, inadequate drugs or equipment, and costs, are the four major barriers for access. The study also showed substantial variation in perceived barriers, reflecting largely socio-economic differences between the participating countries. Urbanity, socio-economic status, and severity of activity limitations are important predictors for barriers, while there is no gender difference. It is suggested that education reduces barriers to health services only to the extent that it reduces poverty. Persons with disability face additional and particular barriers to health services. Addressing these barriers requires an approach to health that stresses equity over equality.

Predictors of breast-feeding in a developing country: results of a prospective cohort study.

OBJECTIVE: Data on the prevalence and predictors of breast-feeding remain scarce in Lebanon. Moreover, no study has previously addressed the effect of the paediatrician's sex on breast-feeding. The present study aimed to assess the prevalence and predictors of breast-feeding at 1 and 4 months of infant age while exploring the potential role of the sex of the paediatrician. DESIGN: Prospective cohort study. Predictors of breast-feeding significant at the bivariate level were tested at 1 and 4 months through two stepwise regression models. SETTING: Infants were enrolled through the clinics and dispensaries of 117 paediatricians located in Beirut, Lebanon, and its suburbs. SUBJECTS: A total of 1,320 healthy newborn infants born between August 2001 and February 2002 were prospectively followed during the first year. FINDINGS: Breast-feeding rates at 1 and 4 months were 56.3 % and 24.7 %, respectively. Early discharge, high parity and religion were significantly associated with higher breast-feeding rates at 1 and 4 months of age. Maternal age proved significant only at 1 month, while maternal working status and sex of the paediatrician were significant at 4 months. A novel finding of our study was the positive effect of female paediatricians on breast-feeding continuation until 4 months of age (OR = 1.49; 95 % CI 1.03, 2.15). CONCLUSIONS: Breast-feeding rates are low at 1 and 4 months of infant age in Beirut. Further research to investigate the interactions between female physicians and lactating mothers in maintaining breast-feeding in other populations is warranted. The results constitute the basis for designing interventions targeting policy makers, health professionals and mothers.

Patterns and predictors of tobacco smoking cessation: a hospital-based study of pregnant women in Lebanon.

OBJECTIVES: To describe patterns of cigarette and narghile (hubble-bubble or water-pipe) smoking before and during pregnancy and identify predictors of successful smoking cessation. METHODS: A survey was conducted on 4660 pregnant women who delivered single live births between September 1st, 2001 and December 31st, 2002 at five hospitals in Beirut, Lebanon. Women were classified into four groups according to patterns of tobacco use before and during pregnancy: 1) consistent non-users, 2) successful quitters, 3) unsuccessful quitters and 4) consistent users. RESULTS: High education (OR = 2.03, 95% CI: 0.99-4.15), adequate prenatal care (OR = 1.72, 95% CI: 1.02-2.91) and mild smoking at baseline (OR = 2.35, 95% CI: 1.36-4.09) were main determinants of successful cigarette smoking cessation, whereas successful quitters of narghile use were more likely to be nulliparous (OR = 1.80, 95% CI: 1.08-2.99) or to have a nonsmoking partner (OR = 7.57, 95 % CI: 2.31-24.78). CONCLUSIONS: Different populations should be targeted when designing smoking cessation interventions for cigarette and narghile users.

Intrauterine growth standards in a developing country: a study of singleton livebirths at 28-42 weeks' gestation.

This study aimed to develop fetal growth charts for the population of Greater Beirut, Lebanon, and compare them with previously established references. A survey of consecutive singleton livebirths admitted to normal nurseries and neonatal intensive care units of major hospitals, through the database project of the National Collaborative Perinatal Neonatal Network was used as a design. The study was conducted in nine major healthcare institutions serving the population of Beirut and its suburbs. A total of 24 767 singleton livebirths delivered between 28 and 42 weeks' gestation, with known data on gender, gestational age and anthropometric characteristics were recorded between 1 April 1999 and 31 March 2002. Growth charts were developed by plotting birthweight, length and head circumference percentiles against gestational age for male and female infants separately. Overall, 1348 (5.4%) pregnancies were delivered before 37 weeks' gestation and 1227 (4.9%) were low birthweight. Male infants were delivered slightly earlier than their female counterparts and the mean birthweight, length and head circumference were consistently higher in males. A total of 2247 (9.1%) infants were small-for-gestational-age, with a male-to-female sex ratio of 1.03. Using previously established growth references that overestimated small-for-gestational-age prevalence resulted in a greater proportion of false positives. The opposite was true for growth references that underestimated small-for-gestational-age prevalence. The current growth charts present useful tools for assessing the general health status of newborn infants delivered at sea level in the urban areas of Lebanon and other East Mediterranean countries.

Prevalence of hepatitis B in a presumably healthy Lebanese population.

OBJECTIVE: Policy makers need data on the prevalence of infection with HBV in order to determine the cost effectiveness of universal immunization against hepatitis B. This study aims at determining the prevalence rate of infection with HBV in a basically healthy group of Lebanese adults. METHODS: Sera from 2634 presumably healthy Lebanese individuals, mean age 32.1 years, obtained between 1995-1997, were tested for hepatitis B surface antigen (HBsAg). The sample was composed of subjects residing in different areas in Lebanon. Detection of HBsAg was performed utilizing the ELISA technique. The analysis took place in the Clinical Microbiology Laboratory, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon. Chi-square test was used to examine statistical associations. RESULTS: The prevalence of HBsAg among the samples was 1.6%. Blue-collar employees, smokers and those living in the South of Lebanon were significantly more likely to be infected with hepatitis B virus. CONCLUSIONS: The data presented indicates that Lebanon has a low prevalence of HBV infection. Costeffective studies are needed to justify universal iminunization against hepatitis B especially in countries where budgets are tight.

Effect of consanguinity on birth weight for gestational age in a developing country.

Consanguinity, the marriage between relatives, has been associated with adverse child health outcomes because it increases homozygosity of recessive alleles. The objective of this study was to assess the effect of consanguinity on the birth weight of newborns in Greater Beirut, Lebanon. Cross-sectional data were collected on 10,289 consecutive liveborn singleton newborns admitted to eight hospitals belonging to the National Collaborative Perinatal Neonatal Network during the years 2000 and 2001. Birth weight was modeled by use of the fetal growth ratio, defined as the ratio of the observed birth weight to the median birth weight for gestational age. A mixed-effect multiple linear regression model was used to predict the net effect of first- and second-cousin marriage on the birth weight for gestational age, accounting for within-hospital clustering of data. After controlling for medical and sociodemographic covariates, the authors found a statistically significant negative association between consanguinity and birth weight at each gestational age. No significant difference was observed in the decrease in birth weight between the first- and second-cousin marriages. Overall, consanguinity was associated with a decrease in birth weight for gestational age by 1.8% (beta = -0.018, 95% confidence interval: -0.027, -0.008). The largest effects on fetal growth were seen with lower parity and smoking during pregnancy.

Vitamins A and E status in an urban Lebanese population: a case study at Dar Al-Fatwa area, Beirut.

Vitamin A and E status are widely studied in various populations because of their association with several diseases. Fasting plasma vitamin A and E status of 857 Lebanese adults residing in Dar Al-Fatwa, Beirut were assessed using high performance liquid chromatography (HPLC). Mean retinol and alpha-tocopherol concentrations were 59.8 +/- 29 microg/dL and 1.0 +/- 0.5 mg/dL, respectively in which only 0.2% were retinol-deficient, while 0.7% were alpha-tocopherol-deficient. Vitamin A and E correlated positively with plasma concentrations of total cholesterol, low-density lipoprotein (LDL)-cholesterol, and triglycerides. Vitamin E, but not vitamin A, correlated positively with blood pressure and glucose. A good status of vitamins A and E was found among the studied Lebanese sample and the elevation in vitamin A and E levels was associated with unfavorable lipid profile.

Predicting neonatal outcomes: birthweight, body mass index or ponderal index?

AIMS: To compare birthweight (BW), body mass index (BMI) and ponderal index (PI) as predictors of selected short-term (ST) outcomes, namely Neonatal Intensive Care Unit (NICU) admission and prolonged hospitalization (PH), among newborn (NB) infants. METHODS: Data was collected prospectively on 9,226 infants born during one year at nine tertiary care hospitals in Greater Beirut, Lebanon. The predictive abilities of BW, BMI and PI were compared using the area under the receiver operator characteristic (ROC) curves and sensitivity analysis was performed at the optimal cut-off points for the best anthropometric measurement. RESULTS: The area under the ROC curve suggested superior discriminative power for BW as compared to BMI or PI, as a predictor of NICU admission (ROC area = 0.73) and PH (ROC area = 0.74). The optimal BW cut-off point was 2750 g (sensitivity: 0.49; specificity: 0.89) and 2950 g (sensitivity: 0.62; specificity: 0.78) for NICU admission and PH, respectively. CONCLUSION: In our population of NB infants, BW--a crude measure of fetal growth--is a better predictor than either BMI--a measure of adiposity in adults and children--or PI--a measure of thinness at birth--for selected ST outcomes in NB infants.

Risk factors for term or near-term fetal growth restriction in the absence of maternal complications.

The objective of this study was to examine risk factors for term or near-term fetal growth restriction (FGR) in the absence of pregnancy complications. We completed a survey of uncomplicated single live births delivered in Greater Beirut, Lebanon. FGR cases were defined as below the 10th percentile of expected weight at gestational age. Multivariate logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CIs). Main predictors of FGR were female gender (OR, 1.94; 95% CI, 1.46 to 2.59), nulliparity (Or, 1.66; 95% CI, 1.25 ton 2.20), low prepregnancy weight (OR, 2.52; 95% CI, 1.58 to 4.01), short stature (OR, 2.59; 95% CI, 1.57 to 4.28), and low pregnancy weight gain (OR, 1.75; 95% CI, 1.21 to 2.55). Anthropometric characteristics of mothers are important modifiable determinants of fetal size in our developing urban population of uncomplicated births.

Impact of maternal age on preterm delivery and low birthweight: a hospital-based collaborative study of nulliparous Lebanese women in Greater Beirut.

OBJECTIVES: To analyze the impact of maternal age at first childbirth on the incidence of preterm delivery and low birthweight among single live births delivered to nulliparous Lebanese women in Greater Beirut. STUDY DESIGN: Eligible subjects were selected from a consecutive sample of neonatal admissions to nine National Collaborative Perinatal Network participating hospitals over a three-year period (April 1, 1999 to March 31, 2002). Chi-square tests and logistic regression analyses were applied. RESULTS: Out of 5556 nulliparous mothers, 5.4% had a preterm delivery and 5.2% a low-birthweight infant. In the multivariate analysis, preterm delivery was not significantly affected by old maternal age. Mothers aged 25 years or more remained a high-risk group for low birthweight even after controlling for potentially confounding characteristics. CONCLUSIONS: Maternal age at first childbirth above 25 years is an independent risk factor for low birthweight, but not for preterm delivery, an outcome influenced mainly by obstetric complications.

Intestinal parasites among presumably healthy individuals in Lebanon.

OBJECTIVE: To determine the prevalence period of intestinal parasites among presumably healthy subjects in Lebanon. METHODS: One stool specimen from 2634 presumably healthy Lebanese subjects, mean age 32.1 years with a range of 14-71 years, resident of different areas in Lebanon was examined for the presence of parasites. The analysis took place in the Clinical Microbiology Laboratory, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon, over 25-months between 1995-1997. RESULTS: The prevalence of intestinal parasites was 12.4%. The most common parasites identified were Entamoeba coli (38%), Giardia lamblia (3.1%) and Entamoeba histolytica (2.3%) [corrected]. CONCLUSION: The data presented shows the need to improve hygienic conditions to contain the problem of intestinal infections with parasites in Lebanon.

The development of a feasible community-specific cardiovascular disease prevention program: triangulation of methods and sources.

Triangulation of methods, sources, and investigators can lead to a multidimensional understanding of a particular issue. In this study, the combination of qualitative and quantitative data collection methods, and information from community and coalition members resulted in the development of a tailored community-specific intervention. Three components were triangulated after analyzing each separately. A household survey of community members between the ages of 25 and 64 years was conducted to identify knowledge, attitudes, and behaviors related to cardiovascular disease and to assess risk factor levels. Focus group discussions were conducted with community members to describe facilitators and barriers to healthy lifestyles, as well as possible interventions. Natural group discussions with coalition members analyzed the relevance, feasibility, affordability, acceptability, and sustainability of specific intervention activities. Results from the different components were compared and contrasted. Areas of added information, validation, and contradiction were analyzed and guided the development of intervention activities.

Consanguinity and apnea of prematurity.

Consanguinity, marriage between relatives, has been associated with perinatal mortality and morbidity. Apnea of prematurity is defined as the cessation of breathing for longer than 20 seconds or that of any duration if accompanied by cyanosis and sinus bradycardia, for infants born before 37 weeks of gestation. The objective of the study was to examine the association between consanguinity and apnea of prematurity in Greater Beirut, an area having a relatively high prevalence rate of consanguineous marriages. The study was cross-sectional. Between September 1, 1998, and March 31, 2001, 21723 newborn infants were admitted to the National Collaborative Perinatal Neonatal Network in Greater Beirut, Lebanon. The inclusion criteria were infants less than 37 weeks of gestation who were admitted to the intensive care unit, with no congenital malformations, sepsis, or neurologic disorders. Analysis was based on 597 infants of whom 66 had apnea of prematurity. With adjustment for weeks and type of gestation, pregnancy complications, and Apgar score, the odds ratio of apnea of prematurity for first-degree consanguineous parents as compared with other marriages was 2.9 (95% confidence interval: 1.3, 6.4). In addition to the recognized etiologic factors for apnea of prematurity, this study suggests a role played by genetic factors.