Factors influencing birth preparedness and complication readiness among childbearing age women in Thatta district, Sindh.

INTRODUCTION: Birth preparedness and complication readiness (BPCR) is a broad system to increase the practice of trained health provision at the time of childbirth and the key interventions to decrease mothers' and newborns' death. However, its status and influencing factors have not been well studied at different levels in the study area. The current study aimed to assess the BPCR status and explore its associated factors influencing BPCR among childbearing age women in Thatta, District of Sindh. METHODS: This community-based cross-sectional study was conducted among 770 recently delivered mothers from October 2016 -September 2017, recruited using a multistage cluster sampling technique. A structured validated close-ended questionnaire measuring BPCR knowledge and practices was used for the interviews. The results were analyzed by means of the Chi-square test, and a binary logistic regression model was used to determine the factors influencing BPCR. RESULTS: The overall response rate was 94.6%, with a low BPCR status. Out of 770 participants, only 163 (21.2%) were well prepared, while 607 (78.8%) were not prepared for safe childbirth and its complications. A small proportion of women knew about the serious warning signs of pregnancy, labour, childbirth and the postpartum period (16.2%), (15.3%) and (22.7%) respectively. Antenatal care (ANC) checkup (P < 0.001), cost of ANC checkup (p = 0.016), place of birth (p = 0.014), awareness of serious warning signs during pregnancy (p = 0.001) and awareness of serious warning signs during the postpartum period (p < 0.001) were found to be significant predictors of BPCR. CONCLUSION: The proportion of women who were well prepared for birth and its complications was low. It is recommended to organize community-based education campaigns and improve the quality of MNCH services at every level to increase BPCR among women in Sindh.

Prevalence of anxiety and depression in high school students of Karachi, Pakistan.

Objectives: Anxiety and depression are commonly occurring mental disorders in school-going students and if not considered can result in a worse outcome. The objective of our study was to determine the prevalence, risk factors and relationship of anxiety and depression with different variables among high school students of Karachi. Methods: This cross-sectional study was conducted in October - November 2020 in government and private high schools of four districts of Karachi. Two stage cluster sampling was used to select study sites with 400 students inducted. Data was collected by using Aga Khan University Scale of anxiety and depression. Relationship of outcome with predictor variables was examined by applying univariate and multivariate logistic regression analysis. Results: Overall 53.2% participants reported anxiety and depression out of which 78.8% were females. Participants who were studying in private schools (OR 0.39, CI 0.21-0.69 at 95%, p=0.002) and had mothers who were housewives (OR 0.28, CI 0.09-0.83 at 95%, p=0.022) were less likely to develop anxiety and depression. Participants whose fathers and mothers had a history of anxiety and depression were three times more likely to develop anxiety and depression (OR 3.12, CI 1.52-6.41 at 95%, p=0.002) and (OR 3.02, CI 1.39-6.59 at 95%, p=0.005) respectively. Conclusion: The study found a high prevalence of anxiety and depression among high school students. Female students of public sector school and those who had a family history of anxiety and depression were more likely to develop it. Early detection and management of anxiety and depression by screening are necessary to overcome this burden.

Quality of labor and birth care in Sindh Province, Pakistan: Findings from direct observations at health facilities.

This study presents data from the first observation of labor, childbirth and immediate newborn care in a clinical setting in Sindh, the second most populous province of Pakistan. Trained midwives observed 310 births at 126 district level referral facilities and primary health care facilities in 10 districts of Sindh where the USAID-funded Maternal Child Health Integrated Program (MCHIP) was implemented. The facility participation rate was 78%. The findings show that monitoring vital signs during the initial examination was conducted for less than one-in-ten women. Infection prevention practices were only observed for one-in-four women. Modesty was preserved for less than half of women. In spite of an absence of monitoring during the first and second stages of labor, providers augmented labor with oxytocin in two-thirds of births. To prevent post-partum hemorrhage, oxytocin was administered within a minute of birth in 51% of cases. Immediate drying of the baby was nearly universal and eight out of ten babies were wrapped in a dry towel. Newborn vital signs and the baby's weight were taken in one-in-ten cases. Breastfeeding was initiated during the first hour of birth in 18% of cases. A support-person was present during labor and birth for 90% of women. While quality of care is poor across all facilities, the provision of care at district-level referral facilities was even lower quality than at primary health care facilities. This is because dais or assistants without formal training provided labor, birth, and newborn care for 40% of deliveries during night shifts at referral facilities. This study found many examples of suboptimal practice by skilled birth attendants across all levels of health facilities. There remains an urgent need to improve quality of service provision among skilled birth attendants in Pakistan.

Barriers and enablers for practicing kangaroo mother care (KMC) in rural Sindh, Pakistan.

BACKGROUND: More than 2.5 million newborns die each year, accounting for 47% of children dying worldwide before their age of five years. Complications of preterm birth are the leading cause of death among newborns. Pakistan is amongst the top ten countries with highest preterm birth rate per 1000 live births. Globally, Every Newborn Action Plan (ENAP) has emphasized on Kangaroo Mother Care (KMC) as an essential component of neonatal health initiatives. MATERIALS AND METHODS: We conducted this qualitative study with 12 in-depth interviews (IDIs) and 14 focus group discussion (FGD) sessions, in two health facilities of Sindh, Pakistan during October-December 2016, to understand the key barriers and enablers to a mother's ability to practice KMC and the feasibility of implementing and improving these practices. RESULTS: The findings revealed that community stakeholders were generally aware of health issues especially related to maternal and neonatal health. Both the health care providers and managers were supportive of implementing KMC in their respective health facilities as well as for continuous use of KMC at household level. In order to initiate KMC at facility level, study respondents emphasized on ensuring availability of equipment, supplies, water-sanitation facility, modified patient ward (e.g., curtain, separate room) and quality of services as well as training of health providers as critical prerequisites. Also in order to continue practicing KMC at household level, engaging the community and establishing functional referral linkage between community and facilities were focused issues in facility and community level FGDs and IDIs. CONCLUSION: The study participants considered it feasible to initiate KMC practice at health facility and to continue practicing at home after returning from facility. Ensuring facility readiness to initiate KMC, improving capacity of health providers both at facility and community levels, coupled with focusing on community mobilization strategy, targeting specific audiences, may help policy makers and program planners to initiate KMC at health facility and keep KMC practice continued at household level.

Factors associated with the use of antenatal care in Sindh province, Pakistan: A population-based study.

BACKGROUND: Antenatal care (ANC) is critical to decrease maternal and neonatal mortality. However, little is known about the utilization of ANC services in Pakistan. This study assessed the utilization of ANC in Sindh province, Pakistan, and identified the factors that affect its use. METHODS: We analysed a subset of data from Maternal and Child Health (MCH) Program Indicator Surveys conducted in Sindh province, Pakistan in 2013 and 2014. Respondents included 10,200 women who had given birth in the past two years. The outcome measure was making at least four ANC visits. Logistic regression models were used to identify demographic, socioeconomic, characteristics of ANC, and informational factors associated with ANC use. RESULTS: Most women (83.5%) received one or more ANC, mostly by doctors (95%), but only 57.3% of them made the recommended four or more visits, and just 53.7% received their initial ANC care during the first trimester. Making four or more ANC visits was associated with: fewer household occupants (odds ratio [OR] = 0.98; 95% confidence interval [CI] = [0.97, 0.99]), large city residence (OR = 1.92; 95% CI = [1.57, 2.35]), higher women's education (OR = 1.70; 95% CI = [1.33, 2.15]), greater household wealth (OR = 5.66; 95% CI = [4.22, 7.60]), and receiving MCH information from lady health worker (OR = 1.17; 95% CI = [1.00, 1.37]), mother-in-law (OR = 1.17; 95% CI = [1.01, 1.36]), other relatives/friends (OR = 1.19; 95% CI = [1.03, 1.38]), or nurse/midwife (OR = 1.31; 95% CI = [1.06, 1.61]). CONCLUSIONS: This study demonstrates that both socioeconomic factors and health information sources are associated with women's use of ANC. Therefore, programs should target socially disadvantaged and vulnerable groups, particularly rural, less educated, and poor women, to improve utilization of ANC. In addition, strategies to increase exposure to MCH information sources should be a priority in Sindh, Pakistan.

Treatment response to iron and folic acid alone is the same as with multivitamins and/or anthelminthics in severely anemic 6- to 24-month-old children.

We assessed the effectiveness of iron+folic acid for the treatment of severe anemia [hemoglobin (Hb) <70 g/L] and the efficacy of added multivitamins and/or anthelminthics among children aged 6-24 mo in periurban Karachi, Pakistan. The study design was a double blind, placebo-controlled, randomized trial of currently recommended daily iron (25 mg) and folic acid (100 microg) for 90 d with daily multivitamins [vitamin A (300 microg, as retinol palmitate), vitamin E (6 mg tocopherol equivalents), vitamin B-12 (0.9 microg), vitamin C (15 mg), riboflavin (0.5 mg)] and/or anthelminthics (100 mg mebendazole twice daily for 3 d) compared with placebos. Treatment response was defined as reaching a Hb concentration > or =100 g/L at the end of 90 d. The prevalence of severe anemia in the 9518 children screened was 5.7% and a total of 462 severely anemic children were enrolled in the study. Adherence to treatment was approximately 70% for iron+folic acid, approximately 80% for multivitamins, and almost 100% for mebendazole. Children receiving iron+folic acid alone had a response rate of 38.7% at 90 d. The additional treatment with mebendazole or multivitamins did not significantly improve cure rates or change the Hb concentration over and above iron+folic acid treatment alone. Adherence to iron+folic acid of higher than the median resulted in a better treatment response rate of 50%. High-dose daily iron+folic acid performed as well as iron+folic acid with anthelminthics and multivitamins in the treatment of severe anemia in this setting. Higher adherence may be important in enhancing treatment impact.

Treatment response to standard of care for severe anemia in pregnant women and effect of multivitamins and enhanced anthelminthics.

BACKGROUND: Severe anemia (hemoglobin < 70 g/L) in pregnancy may increase the risk of maternal and perinatal mortality. OBJECTIVES: We assessed response to standard treatment with high-dose iron-folic acid for 90 d and single-dose (500 mg) mebendazole among severely anemic pregnant women in periurban Karachi, Pakistan. In addition, we evaluated the efficacy of 2 enhanced treatment regimens. DESIGN: We screened pregnant women (n = 6288) for severe anemia and provided them all with the standard treatment. To test the efficacy of 2 additional treatments, women were randomly assigned to standard treatment alone (control) or with 100 mg mebendazole twice daily for 3 d or 90 d of daily multivitamins or both using a 2 x 2 factorial design. RESULTS: Prevalence of severe anemia was high (10.5%) during pregnancy. Prevalence of geohelminths and malaria was low. Treatment response was defined as hemoglobin > 100 g/L at the 90-d or > or = 25 g/L at the 60-d follow-up visit. The standard-of-care treatment resulted in a response rate of 49% at follow-up, although an adherence of > or = 85% elicited a higher response (67%). The effect of the additional treatments was weak. Although response was higher in the enhanced groups than for the standard treatment at the final assessment, the differences were not statistically significant. However, hemoglobin concentration increased significantly in all groups and was higher in the enhanced mebendazole group compared with the standard group (P < 0.05). CONCLUSIONS: Iron deficiency was high in this population, and the standard-of-care treatment resulted in a treatment response of 50%, although better treatment adherence showed a higher response. Multivitamins and the enhanced mebendazole regimen had a modest benefit over and above the standard treatment.

Zinc during and in convalescence from diarrhea has no demonstrable effect on subsequent morbidity and anthropometric status among infants <6 mo of age.

BACKGROUND: Preventing illness and improving growth in the first 6 mo of life is critical to reducing infant mortality. Zinc given for 14 d at the start of diarrhea has been shown to decrease the incidence and prevalence of diarrhea and pneumonia and improve growth in the 2-3 mo after, but no trial has been done in infants <6 mo of age. OBJECTIVE: This study sought to assess the effect of 14 d of zinc supplementation on subsequent morbidity and growth among infants 1-5 mo of age living in Pakistan, India, and Ethiopia. DESIGN: Infants with acute diarrhea were randomly assigned to receive zinc (10 mg/d; n = 538) or placebo (n = 536) for 2 wk. Weekly follow-up visits were conducted for 8 wk after the diarrhea episode. Incidence and prevalence of diarrhea and prevalence of respiratory infections including pneumonia were compared between the groups. Changes in weight, length, and corresponding z scores during the 8 wk of follow-up were also compared. RESULTS: One thousand seventy-four infants were enrolled at the start of follow-up. The groups did not differ significantly in the proportion of infants with at least one episode of diarrhea or respiratory infections. Infants who received zinc had more days of diarrhea (rate ratio = 1.20) than did the infants who received placebo. The groups had similar prevalences of pneumonia and overall respiratory infections. No significant differences in the mean changes in weight-for-age, length-for-age, and weight-for-length z scores were observed between the groups overall or in stratified analyses. CONCLUSION: Young infants do not appear to benefit from 2 wk of zinc, unlike what has been observed among older children.

Zinc supplementation for the treatment of diarrhea in infants in Pakistan, India and Ethiopia.

OBJECTIVE: This randomized, placebo controlled trial was designed to assess the safety and efficacy of 10-mg zinc supplementation for the treatment of acute diarrhea in infants. METHODS: A total of 1110 infants aged 28 days to 5 months with acute diarrhea were enrolled and randomized to receive either zinc (n = 554) or placebo (n = 556) for 14 days. Diarrhea history, anthropometric status, breast-feeding status and socioeconomic indicators were assessed at baseline. The homes of all infants were visited every 3 days until the diarrhea episode was over. The number of stools, presence of blood and additional illnesses were recorded daily. RESULTS: The geometric mean duration of the diarrhea episode was 0.21 days longer among infants receiving zinc versus those receiving placebo, but this was not statistically significant and no difference was observed after controlling for sex, exclusive breast-feeding and length for age Z score. There were no differences in any subgroup (ie, sex, baseline length for age Z score, exclusive breast-feeding or site after controlling for the remaining subgroup variables). There were no differences in reported stool frequency or among the proportion of episodes lasting longer than 7 days. Rates of vomiting were similar in the zinc and placebo groups. CONCLUSIONS: Young infants do not appear to benefit from zinc supplementation for the treatment of diarrhea.