Is it home delivery or health facility? Community perceptions on place of childbirth in rural Northwest Tanzania using a qualitative approach.

BACKGROUND: In low and middle-income countries, pregnancy and delivery complications may deprive women and their newborns of life or the realization of their full potential. Provision of quality obstetric emergency and childbirth care can reduce maternal and newborn deaths. Underutilization of maternal and childbirth services remains a public health concern in Tanzania. The aim of this study was to explore elements of the local social, cultural, economic, and health systems that influenced the use of health facilities for delivery in a rural setting in Northwest Tanzania. METHODS: A qualitative approach was used to explore community perceptions of issues related to low utilization of health facilities for childbirth. Between September and December 2017, 11 focus group discussions were conducted with women (n = 33), men (n = 5) and community health workers (CHWs; n = 28); key informant interviews were conducted with traditional birth attendants (TBAs; n = 2). Coding, identification, indexing, charting, and mapping of these interviews was done using NVIVO 12 after manual familiarization of the data. Data saturation was used to determine when no further interviews or discussions were required. RESULTS: Four themes emerge; self-perceived obstetric risk, socio-cultural issues, economic concerns and health facility related factors. Health facility delivery was perceived to be crucial for complicated labor. However, the idea that childbirth was a "normal" process and lack of social and cultural acceptability of facility services, made home delivery appealing to many women and their families. In addition, out of pocket payments for suboptimal quality of health care was reported to hinder facility delivery. CONCLUSION: Home delivery persists in rural settings due to economic and social issues, and the cultural meanings attached to childbirth. Accessibility to and affordability of respectful and culturally acceptable childbirth services remain challenging in this setting. Addressing barriers on both the demand and supply side could result in improved maternal and child outcomes during labor and delivery.

A single gestational weight gain recommendation is possible for all classes of pregnant women with obesity.

OBJECTIVES: Obesity is a known risk factor for adverse pregnancy outcomes; however, appropriate gestational weight gain (GWG) may mitigate these risks. We investigated whether the singular 2009 Institute of Medicine (IOM) GWG guidelines were appropriate for all women with obesity, or whether separate recommendations were needed by class. METHODS: This cross-sectional study of pregnant women with obesity used 2014 U.S. birth certificate data (N=646,642) and included only term pregnancies. Adjusted log-binomial regression models examined the relative risk of adverse maternal, obstetric, and neonatal outcomes for pregnant women with class I-III obesity who: lost weight during pregnancy, gained below IOM guidelines, or gained above IOM guidelines, compared to women who gained within IOM guidelines. RESULTS: Most women (55.1; 95% CI: 55.0-55.3) gained above IOM guidelines. As BMI severity increased, significantly fewer women had excessive GWG (Class I: 61.6%, 95% CI: 61.4-61.7; II: 50.7%, 95% CI: 50.4-50.9; III: 41.1%, 95% CI: 40.8-41.4). All classes of women with obesity who lost weight during pregnancy or gained below had a significantly decreased risk for caesarean delivery (RR (95% CI) class I: 0.92 (0.90-0.94); II: 0.91 (0.89-0.93); III: 0.92 (0.90-0.93)) and large-for-gestational age (LGA) births (class I: 0.80 (0.77-0.83); II: 0.76 (0.73-0.78); III: 0.73 (0.70-0.75)), but significantly increased risk of small-for-gestational age (SGA) births (class I: 1.34 (1.26-1.43); II: 1.38 (1.28-1.49); III: 1.35 (1.24-1.46)). CONCLUSION: The observed pattern of association was the same for all obese classes, hence evidence supports a possible singular GWG recommendation for all women with obesity, regardless of class.

Hypophosphatemia is Prevalent among Preterm Infants Less than 1,500 Grams.

OBJECTIVE: This article identifies the prevalence and associated factors of hypophosphatemia (HP) in very low birth weight (VLBW) infants in the first week of life. STUDY DESIGN: Prospective exploratory cohort study of 106 consecutive VLBW infants admitted to neonatal intensive care at Foothills Hospital, Calgary, Canada. HP was defined as at least one measurement of serum phosphate < 1.5 mmol/L (4.5 mg/dL). RESULTS: Seventy-seven percent (82/106) of the VLBW infants had HP, with significantly higher prevalence in infants < 1,000 g (94%) compared to infants ≥ 1,000 g (61%) (p < 0.001). Hypophosphatemic infants had lower birth weight (p < 0.001), gestational age (p < 0.001), and their increase in phosphate intake was slower (p = 0.003). Respiratory distress syndrome (RDS) (p = 0.002), intraventricular hemorrhage (IVH) ≥ grade III (p = 0.020), and hyperglycemia (p = 0.013) were more frequent among hypophosphatemic infants, especially among those < 1,000 g. Mortality, seizures, arrhythmias, and need for transfusion were not different between groups. Birth weight modified the association between RDS, IVH, hyperglycemia, and HP. CONCLUSION: HP was ubiquitous among infants < 1,000 g and highly prevalent among those weighing 1,000 to 1,500 g. While the direction of effect was not clear, RDS, IVH, and hyperglycemia were associated with HP. Prevention of HP in these physiologically immature neonates might improve neonatal outcomes.

Missed opportunities in antenatal care for improving the health of pregnant women and newborns in Geita district, Northwest Tanzania.

BACKGROUND: Despite the significant benefits of early detection and management of pregnancy related complications during antenatal care (ANC) visits, not all pregnant women in Tanzania initiate ANC in a timely manner. The primary objectives of this research study in rural communities of Geita district, Northwest Tanzania were: 1) to conduct a population-based study that examined the utilization and availability of ANC services; and 2) to explore the challenges faced by women who visited ANC clinics and barriers to utilization of ANC among pregnant women. METHODS: A sequential explanatory mixed method design was utilized. Household surveys that examined antenatal service utilization and availability were conducted in 11 randomly selected wards in Geita district. One thousand, seven hundred and nineteen pregnant women in their 3rd trimester participated in household surveys. It was followed by focus group discussions with community health workers and pregnant women that examined challenges and barriers to ANC. RESULTS: Of the pregnant women who participated, 86.74% attended an ANC clinic at least once; 3.62% initiated ANC in the first trimester; 13.26% had not initiated ANC when they were interviewed in their 3rd trimester. Of the women who had attended ANC at least once, the majority (82.96%) had been checked for HIV status, less than a half (48.36%) were checked for hemoglobin level, and only a minority had been screened for syphilis (6.51%). Among women offered laboratory testing, the prevalence of HIV was 3.88%, syphilis, 18.57%, and anemia, 54.09%. In terms of other preventive measures, 91.01% received a tetanus toxoid vaccination, 76.32%, antimalarial drugs, 65.13%, antihelminthic drugs, and 76.12%, iron supplements at least once. Significant challenges identified by women who visited ANC clinics included lack of male partner involvement, informal regulations imposed by health care providers, perceived poor quality of care, and health care system related factors. Socio-cultural beliefs, fear of HIV testing, poverty and distance from health clinics were reported as barriers to early ANC utilization. CONCLUSION: Access to effective ANC remains a challenge among women in Geita district. Notably, most women initiated ANC late and early initiation did not guarantee care that could contribute to better pregnancy outcomes.

Early childhood language outcomes after arterial switch operation: a prospective cohort study.

BACKGROUND: Developmental and language outcomes at 2 years of age of children who had arterial switch operation (ASO) for transposition of the great arteries 2004-2010 are described. METHODS: In this prospective cohort study, 91/98 (93 %) children who underwent ASO were assessed at 2 years of age with the Bayley Scales of Infant & Toddler Development-3rd Edition. Outcomes were compared by patient and perioperative variables using bivariate and multivariate regression analyses to identify predictors of language delay. RESULTS: Infants without ventricular septal defect (VSD) (n = 60) were more likely to be outborn (73 vs 58 %, p = 0.038), require septostomy (80 vs 58 %, p = 0.026), have a shorter cross clamp time (min) (62.7 vs 73.0, p = 0.019), and a lower day 1 post-operative plasma lactate (mmol/L) (3.9 vs 4.8, p = 0.010). There were no differences in cognitive, motor and language outcomes based on presence of a VSD. Language delay (<85) of 29 % was 1.8 times higher than the normative sample; risk factors for this in multivariate analyses included <12 years of maternal education (AOR 19.3, 95 % CI 2.5-148.0) and cross-clamp time ≥70 min (AOR 14.5, 95 % CI 3.1-68.5). Maternal education <12 years was associated with lower Language Composite Scores (-20.2, 95 % CI -32.3 to -9.1). CONCLUSIONS: Outcomes at 2 years of age in children who undergo ASO are comparable to the normative sample with the exception of language. There is a risk of language delay for which maternal education and cross-clamp duration are predictors. These findings suggest that focused post-operative early language interventions could be considered.

Prediction of Late Death or Disability at Age 5 Years Using a Count of 3 Neonatal Morbidities in Very Low Birth Weight Infants.

OBJECTIVE: To evaluate bronchopulmonary dysplasia (BPD), serious brain injury, and severe retinopathy of prematurity (ROP) as predictors of poor long-term outcome in very low birth weight infants. STUDY DESIGN: We examined the associations between counts of the 3 morbidities and long-term outcomes in 1514 of 1791 (85%) infants with birth weights of 500-1250 g who were enrolled in the Caffeine for Apnea of Prematurity trial from October 1999, to October 2004, had complete morbidity data, and were alive at 36 weeks postmenstrual age (PMA). BPD was defined as use of supplemental oxygen at 36 weeks PMA. Serious brain injury on cranial ultrasound included grade 3 and 4 hemorrhage, cystic periventricular leucomalacia, porencephalic cysts, or ventriculomegaly of any cause. Poor long-term outcome was death after 36 weeks PMA or survival to 5 years with 1 or more of the following disabilities: motor impairment, cognitive impairment, behavior problems, poor general health, deafness, and blindness. RESULTS: BPD, serious brain injury, and severe ROP occurred in 43%, 13%, and 6% of the infants, respectively. Each of the 3 morbidities was similarly and independently correlated with poor 5-year outcome. Rates of death or disability (95% CI) in children with none, any 1, any 2, and all 3 morbidities were 11.2% (9.0%-13.7%), 22.9% (19.6%-26.5%), 43.9% (35.5%-52.6%), and 61.5% (40.6%-79.8%), respectively. CONCLUSIONS: In very low birth weight infants who survive to 36 weeks PMA, a count of BPD, serious brain injury, and severe ROP predicts the risk of a late death or survival with disability at 5 years.

The 'picky eater': The toddler or preschooler who does not eat.

The majority of children between one and five years of age who are brought in by their parents for refusing to eat are healthy and have an appetite that is appropriate for their age and growth rate. Unrealistic parental expectations may result in unnecessary concern, and inappropriate threats or punishments may aggravate a child's refusal to eat. A detailed history and general physical examination are necessary to rule out acute and chronic illnesses. A food diary and assessment of parental expectations about eating behaviour should be completed. Where the child's 'refusal' to eat is found to be related to unrealistic expectations, parents should be reassured and counselled about the normal growth and development of children at this age.

La majorité des enfants de un à cinq ans pour qui les parents consultent parce qu'ils refusent de manger sont en bonne santé et ont un appétit qui convient à leur âge et à leur rythme de croissance. Les attentes irréalistes des parents peuvent donner lieu à des inquiétudes inutiles, et les menaces et punitions déplacées peuvent aggraver le refus de manger de l'enfant. Les médecins doivent procéder à une anamnèse détaillée et à un examen physique général pour écarter une maladie aiguë ou chronique. Ils doivent demander un journal alimentaire et évaluer les attentes des parents à l'égard du comportement alimentaire. Lorsque le « refus de manger ¼ de l'enfant semble lié à des attentes irréalistes, il faut rassurer les parents et leur donner des conseils sur la croissance et le développement normaux des enfants de cet âge.

Mortality after neonatal cardiac surgery: Prediction from mean arterial pressure after rewarming in the operating room.

OBJECTIVE: To examine the predictive contribution of mean arterial pressure after rewarming to > or =34 degrees C in the operating room to mortality after cardiac surgery in infants < or =6 weeks old. METHODS: In this prospective inception cohort study, 70 consecutive infants who had open cardiac surgery with deep hypothermic circulatory arrest when < or =6 weeks old in the years 1996 to 1999 had follow-up to 5 years of age. Demographic, preoperative, operative, and postoperative variables were recorded prospectively. The previously unexplored variables of lowest mean arterial pressure in the operating room after rewarming to 34 degrees C were recorded retrospectively from anesthesia records. Predictor variables for death were examined using univariate and multivariate analyses. RESULTS: Deep hypothermic circulatory arrest time, re-cardiopulmonary bypass in the operating room, duration of mean arterial pressure below 40, 35, 30, and 25 mm Hg after rewarming in the operating room, time for lactate to return to < or =2 mmol/L postoperatively, and cardiopulmonary resuscitation were significantly associated with death at 1 and 5 years of age on univariate analysis. Multivariate stepwise forward logistic regression analysis found the duration of mean arterial pressure after rewarming below 30 mm Hg (odds ratio 1.094; 95% confidence interval 1.033-1.158) and cardiopulmonary resuscitation (odds ratio 13.800, 95% CI 3.062-62.194) were significant predictors of death by 5 years of age. Stepwise multiple regression using pre- and intraoperative variables accounted for 30.1% of the variability related to mean arterial pressure < or =30 mm Hg after rewarming. CONCLUSION: In these infants, low mean arterial pressure after rewarming in the operating room, even for brief times, is significantly associated with death.

Clinical correlations and pulmonary function at 8 years of age after severe neonatal respiratory failure.

OBJECTIVES: The aim of this study was to determine the pulmonary sequelae of severe neonatal respiratory failure. STUDY DESIGN: This was a multicenter, prospective study. Fifty-four survivors of neonatal respiratory failure (oxygenation indices >25 on two occasions), completed pulmonary function testing at 8 years of age. Thirty-one (57%) received extracorporeal membrane oxygenation (ECMO). Pulmonary outcome was based on spirometry and lung volume data. Pulmonary outcome for each diagnostic and treatment group is reported as mean and as percent predicted. Individually subjects were also classified based on spirometry, as either normal, obstructed (defined as forced expiratory volume (FEV(1)) in 1 sec:forced vital capacity (FVC) of <80 % predicted, or with reduced FVC (FCV of <80% predicted) with normal FEV(1)/FVC. Risk for adverse outcome was determined using univariate analysis. RESULTS: Mean FVC, FEV(1) and FEV(25-75) were reduced in the total cohort. The reduction was greatest in the subgroup with CDH and the group treated with ECMO. Assessed individually, 54% of subjects had normal spirometry and lung volumes, 19% airflow obstruction, and 27% reduced FVC. Poorer pulmonary outcome was linked to ECMO, congenital diaphragmatic hernia (CDH), birth weight for gestational age <10th percentile, duration of hospitalization, or need for prolonged supplemental oxygen. CONCLUSION: Neonates with severe respiratory failure due to CDH or needing ECMO and small for gestation are at increased risk of poorer pulmonary outcome and require close follow-up.

Intermediate-term outcomes of the arterial switch operation for transposition of great arteries in neonates: alive but well?

OBJECTIVES: This interprovincial inception cohort study outlines the operative and intermediate outcomes of all neonates at a single institution with a broad referral area who underwent the arterial switch operation for transposition of great arteries, including complex types. Predictors of outcome are explored. METHODS: A total of 88 consecutive neonates underwent the arterial switch operation between 1996 and 2004 with full-flow (150 mg/kg/min) cardiopulmonary bypass with selective deep hypothermic circulatory arrest. Overall and event-free survivals were calculated. Health and neurodevelopment (Bayley Scales of Infant Development II) were assessed at 18 to 24 months of age. Univariate and multivariate analyses, sensitivity, and specificity were determined to identify preoperative, intraoperative, and postoperative factors associated with mental and/or motor delay. RESULTS: There was 1 operative mortality (1.1%). At the average 4-year follow-up, survival was 98.9% and freedom from reintervention was 93.2%. Eighty-five children were assessed. Three were excluded because of unrelated postoperative diagnoses. For the remaining 82, mean scores were 89 +/- 17 (49-118) for mental skills and 92 +/- 15 (49-125) for motor skills. Anatomic complexity, cardiopulmonary bypass, and deep hypothermic circulatory arrest times were not associated with developmental outcome. Preoperative variables of low gestational age and high preoperative lactate correctly classified 84.1% of mentally and/or motor-delayed children. CONCLUSION: Transposition of great arteries, including complex types, can be corrected with low surgical risk and good intermediate survival; however, neurodevelopmental outcome is a concern. These data suggest that although anatomic complexity may not affect late outcome, there may be potentially modifiable preoperative factors that can be optimized to improve developmental outcomes.

Does necrotising enterocolitis impact the neurodevelopmental and growth outcomes in preterm infants with birthweight < or =1250 g?

AIM: To compare the long-term growth and neurodevelopmental outcomes at 36 months adjusted age in preterm infants (birthweight (BW) < or = 1250 g) with necrotising enterocolitis (NEC) with BW-matched controls. METHODS: This is a case control study performed at a regional tertiary care neonatal intensive care unit. Infants with stage II or III NEC admitted to a regional tertiary care neonatal unit between 1995 and 2000 were identified. Each infant with NEC was matched by BW (+/-100 g) to next two infants admitted in the unit without NEC. Growth and neurodevelopmental outcomes at 36 months are compared. RESULTS: In total, 51 infants with NEC and 102 controls met study eligibility criteria and 146/153 (94.3%) were prospectively followed for 36 months. Infants with NEC had more culture-proven sepsis (35.3% vs. 10.8%, P < 0.001); patent ductus arteriosus requiring therapy (64.7% vs. 45%, P = 0.02), chronic lung disease (60.7% vs. 45%, P = 0.04) and longer hospital stay (84 days vs. 71 days, P < 0.0001). There were no significant differences in growth outcomes between the two groups at 36 months. Overall 24% of infants with NEC had one major neurodevelopmental disability compared with 10% among control infants. Infants who developed NEC had significantly higher cognitive delay (i.e. cognitive index <70) and visual impairment. A logistic regression model identified NEC as a predictor of cognitive delay. CONCLUSION: Preterm infants who develop NEC are at a significantly higher risk for developing neurodevelopmental disability. We recommend close neurodevelopmental follow up for all < or =1250 g infants who develop stage II or III NEC.

Breast is best for babies.

Breastfeeding is the optimal method of infant feeding. Breast milk provides almost all the necessary nutrients, growth factors and immunological components a healthy term infant needs, Other advantages of breastfeeding include reduction of incidences and severity of infections; prevention of allergies; possible enhancement of cognitive development; and prevention of obesity, hypertension and insulin-dependent diabetes mellitus. Health gains for breastfeeding mothers include lactation amenorrhea, early involution of the uterus, enhanced bonding between the mother and the infant, and reduction in incidence of ovarian and breast cancer. From the economic perspective, breastfeeding is less expensive than formula feeding. In most cases, maternal ingestion of medications and maternal infections are not contraindications to breastfeeding. Breastfeeding, however, is contraindicated in infants with galactosemia. The management of common breastfeeding issues, such as breast engorgement, sore nipples, mastitis and insufficient milk, is discussed. Breastfeeding should be initiated as soon after delivery as possible. To promote, protect and support breastfeeding, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) developed the Baby-Friendly Hospital Initiative (BFHI) 10 Steps to Successful Breastfeeding. Healthcare professionals have an important role to play in promoting and protecting breastfeeding.

Internipple distance and internipple index.

OBJECTIVE: To determine the internipple distance and internipple index in Chinese children. METHODS: The internipple distance and chest circumference were measured in 3,290 healthy Chinese children (1,715 males and 1,575 females) aged birth to 18 years seen at the Asian Medical Centre. The internipple distance and chest circumference were obtained at the end of expiration whenever possible, with a standard nonstretch tape measure graduated in millimeters with the arms hanging relaxed alongside the body. Patients under two years of age were measured supine and those over two years of age standing. The internipple distance was measured between the centers of both nipples, and the chest circumference was measured across the internipple line. The internipple index was calculated according to the formula: internipple distance (cm) multiplied by 100 and divided by chest circumference (cm). RESULTS: The internipple distance and chest circumference increased with age. The internipple index was highest in the neonatal period (26.4 +/- 1.6 for males and 26.3 +/- 2 for females), and decreased steadily until the age of four years (23.8 +/- 1.2 for males and 23.8 +/- 1.4 for females), and thereafter was relatively constant through the age of 18 years in males and the age of 11 years in females. In females, the internipple index decreased gradually from the age of 11 years to 18 years. CONCLUSIONS: While internipple index is a more practical way to assess nipple placement, there are ethnic differences in the internipple index. Proper reference standards should be used in the assessment whether the nipples are closely or widely spaced.

Outcomes from an interprovincial program of newborn open heart surgery.

OBJECTIVES: To determine 18-month neurodevelopmental outcome of survivors of complex open heart surgery at

Congenital cytomegalovirus infection.

Cytomegalovirus (CMV) is the most common congenital infection in humans. Congenital CMV infection can follow either a primary or recurrent maternal infection, but the likelihood of fetal infection and the risk of associated damage is higher after a primary infection. Approximately 90% of congenitally infected infants are asymptomatic at birth. Jaundice, petechiae, and hepatosplenomegaly are the most frequently noted clinical triad in symptomatic infants. More frequent and more severe sequelae occur in symptomatic infants, notably psychomotor hearing loss and retardation. Congenital CMV infection can be diagnosed by isolation of the virus from the urine or saliva within the first three weeks of life. Rapid diagnosis can be accomplished by detection of CMV DNA by DNA amplification or hybridization techniques.

Impact of bronchopulmonary dysplasia, brain injury, and severe retinopathy on the outcome of extremely low-birth-weight infants at 18 months: results from the trial of indomethacin prophylaxis in preterms.

CONTEXT: Despite more than 2 decades of outcomes research after very preterm birth, clinicians remain uncertain about the extent to which neonatal morbidities predict poor long-term outcomes of extremely low-birth-weight (ELBW) infants. OBJECTIVE: To determine the individual and combined prognostic effects of bronchopulmonary dysplasia (BPD), ultrasonographic signs of brain injury, and severe retinopathy of prematurity (ROP) on 18-month outcomes of ELBW infants. DESIGN: Inception cohort assembled for the Trial of Indomethacin Prophylaxis in Preterms (TIPP). SETTING AND PARTICIPANTS: A total of 910 infants with birth weights of 500 to 999 g who were admitted to 1 of 32 neonatal intensive care units in Canada, the United States, Australia, New Zealand, and Hong Kong between 1996 and 1998 and who survived to a postmenstrual age of 36 weeks. MAIN OUTCOME MEASURES: Combined end point of death or survival to 18 months with 1 or more of cerebral palsy, cognitive delay, severe hearing loss, and bilateral blindness. RESULTS: Each of the neonatal morbidities was similarly and independently correlated with a poor 18-month outcome. Odds ratios were 2.4 (95% confidence interval [CI], 1.8-3.2) for BPD, 3.7 (95% CI, 2.6-5.3) for brain injury, and 3.1 (95% CI, 1.9-5.0) for severe ROP. In children who were free of BPD, brain injury, and severe ROP the rate of poor long-term outcomes was 18% (95% CI, 14%-22%). Corresponding rates with any 1, any 2, and all 3 neonatal morbidities were 42% (95% CI, 37%-47%), 62% (95% CI, 53%-70%), and 88% (64%-99%), respectively. CONCLUSION: In ELBW infants who survive to a postmenstrual age of 36 weeks, a simple count of 3 common neonatal morbidities strongly predicts the risk of later death or neurosensory impairment.