Addressing the double burden of malnutrition in Egypt: do conditional cash transfers have a role?

Many developing countries are undergoing rapid socio-economic changes that impact on health and its social distribution. These changes can occur so rapidly that there is a resulting co-existence of diseases of affluence and diseases of poverty. Priority setting for nutritional programs has focused on the alleviation of undernutrition in low income settings. However, evidence shows that in many Low-and-Middle Income Countries the prevalence of obesity among women is increasing and can coexist with childhood stunting. This dual burden of poor nutrition contributes to worsening health inequity between the poor and the rich. Global and national policy makers are looking for novel programs to replace social protection mechanisms deemed inefficient. Conditional Cash Transfer (CCT) programs have emerged as an increasingly popular poverty alleviation strategy with some positive results. However, there is evidence they may have a negative impact if the complexity of transition settings is not taken into account. In this paper, we review the nutritional situation in Egypt and compare two CCT programs (Mexico and Colombia) in an attempt to identify features that would address both child undernutrition and adult overnutrition. We conclude with suggestions for design of an Egyptian CCT program that would help maximise benefit to its beneficiaries

Application of Rarebit Perimetry in Preperimetric Glaucoma

Цел: Да се определят диагностичните възможности на Rarebit периметрията за установяване на ранни функционални промени при първична откритоъгълна глаукома.Методи: Включени са общо 47 очи разпределени в две групи: 23 очи с предпериметрична глаукома (ППГ) и контролна група от 24 очи, изследвани чрез Rarebit периметрия (РБП) и стандартна автоматична периметрия (САП). За оценка на разликите между групите са използвани Kruskal Wallis Test, Mann-Whitney Test, Fisher's Exact Test. Чувствителността и специфичността на РБП за установяване на ранни глаукомни промени е оценена чрез ROC анализ с помощта на различни алгоритми.Резултати: Средните стойности за МНR за контролите и групата ППГ са съответно: 94.71% (SD 2.58); 87.61% (SD 4.80). Разликите в стойностите на МНR между групите са статистически значими (Мann-Whitney Test, р<О.ОО1 ). Най-висока стойността на AROC (0. 849) е постигната, когато за абнормен се приема Rarebit тест с МНR<90% при сравняване на здравите очи с тези с ППГ.Заключение: РБП е чувствителен метод спрямо дефекти в зрителното поле при препериметрична глаукома. Тестът е бърз и лесен за изпълнение.Aim: То determine the diagnostic capabilities of Rarebit perimetry for detection of early functional changes in primary open-angle glaucoma.Methods: А total of 47 eyes divided into two groups: 23 eyes with preperimetric glaucoma (PPG) and a control group of 24 eyes were examined with Rarebit perimetry (RBP) and standard automated perimetry (SAP). То evaluate the differences between the groups were used Kruskal Wallis Test, Mann-Whitney Test and Fisher's Exact Test. The sensitivity and specificity of the RBP for detection of early glaucomatous changes were evaluated by ROC analysis using different algorithms.Results: Average МНR for control and PPG group were respectively: 94.71% (SD 2.58); 87.61% (SD 4.80). Differences in МНR between the groups were statistically significant (Мann-Whitney Test, р <0.001). The highest value of AROC (0.849) was achieved when as abnormal was accepted Rarebit test with МНR <90% when comparing healthy eyes to those with PPG.Conclusion: RBP is sensitive method for visual field defects in preperimetric glaucoma. The test is quick and easy to perform

Expanding Method Choice in Africa with Long-Acting Methods: IUDs, Implants or Both?

The objective of this article is to review key components of LARC uptake in Sub-Saharan Africa with the aim of guiding policies and programs. We assess trends in access to the IUD and implant, including method knowledge and availability at facilities; examine trends in use, source of supply, discontinuation and characteristics of users; and discuss the prospects for expanding method choice by increasing the availability of LARCs in national programs and the policy implications of our results

Does women's age matter in the SDGs era: coverage of demand for family planning satisfied with modern methods and institutional delivery in 91 low- and middle-income countries.

BACKGROUND: The Sustainable Development Goals (SDGs) include specific targets for family planning (SDG 3.7) and birth attendance (SDG 3.1.2), and require analyses disaggregated by age and other dimensions of inequality (SDG 17.18). We aimed to describe coverage with demand for family planning satisfied with modern methods (DFPSm) and institutional delivery in low- and middle-income countries across the reproductive age spectrum. We attempted to identify a typology of patterns of coverage by age and compare their distribution according to geographic regions, World Bank income groups and intervention coverage levels. METHODS: We used Demographic and Health Survey and Multiple Indicator Cluster Surveys. For DFPSm, we considered the woman's age at the time of the survey, whereas for institutional delivery we considered the woman's age at birth of the child. Both age variables were categorized into seven groups of 5 year-intervals, 15-19 up to 45-49. Five distinct patterns were identified: (a) increasing coverage with age; (b) similar coverage in all age groups; (c) U-shaped; (d) inverse U-shaped; and (e) declining coverage with age. The frequency of the five patterns was examined according to UNICEF regions, World Bank income groups, and coverage at national level of the given indicator. RESULTS: We analyzed 91 countries. For DFPSm, the most frequent age patterns were inverse U-shaped (53%, 47 countries) and increasing coverage with age (41%, 36 countries). Inverse-U shaped patterns for DFPSm was the commonest pattern among lower-middle income countries, while low- and upper middle-income countries showed a more balanced distribution between increasing with age and U-shaped patterns. In the first and second tertiles of national coverage of DFPSm, inverse U-shaped was observed in more than half of countries. For institutional delivery, declining coverage with age was the prevailing pattern (44%, 39 countries), followed by similar coverage across age groups (39%, 35 countries). Most (79%) upper-middle income countries showed no variation by age group while most low-income countries showed declining coverage with age (71%). CONCLUSION: Large inequalities in DFPSm and institutional delivery were identified by age, varying from one intervention to the other. Policy and programmatic approaches must be tailored to national patterns, and in most cases older women and adolescents will require special attention due to lower coverage and because they are at higher risk for maternal mortality and other poor obstetrical outcomes

A mediation approach to understanding socio-economic inequalities in maternal health-seeking behaviours in Egypt.

BACKGROUND: The levels and origins of socio-economic inequalities in health-seeking behaviours in Egypt are poorly understood. This paper assesses the levels of health-seeking behaviours related to maternal care (antenatal care [ANC] and facility delivery) and their accumulation during pregnancy and childbirth. Secondly, it explores the mechanisms underlying the association between socio-economic position (SEP) and maternal health-seeking behaviours. Thirdly, it examines the effectiveness of targeting of free public ANC and delivery care. METHODS: Data from the 2008 Demographic and Health Survey were used to capture two latent constructs of SEP: individual socio-cultural capital and household-level economic capital. These variables were entered into an adjusted mediation model, predicting twelve dimensions of maternal health-seeking; including any ANC, private ANC, first ANC visit in first trimester, regular ANC (four or more visits during pregnancy), facility delivery, and private delivery. ANC and delivery care costs were examined separately by provider type (public or private). RESULTS: While 74.2% of women with a birth in the 5-year recall period obtained any ANC and 72.4% delivered in a facility, only 48.8% obtained the complete maternal care package (timely and regular facility-based ANC as well as facility delivery) for their most recent live birth. Both socio-cultural capital and economic capital were independently positively associated with receiving any ANC and delivering in a facility. The strongest direct effect of socio-cultural capital was seen in models predicting private provider use of both ANC and delivery. Despite substantial proportions of women using public providers reporting receipt of free care (ANC: 38%, delivery: 24%), this free-of-charge public care was not effectively targeted to women with lowest economic resources. CONCLUSIONS: Socio-cultural capital is the primary mechanism leading to inequalities in maternal health-seeking in Egypt. Future studies should therefore examine the objective and perceived quality of care from different types of providers. Improvements in the targeting of free public care could help reduce the existing SEP-based inequalities in maternal care coverage in the short term

Initiation and continuity of maternal healthcare: examining the role of vouchers and user-fee removal on maternal health service use in Kenya

This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health voucher programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the voucher programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women's timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum

Action leveraging evidence to reduce perinatal mortality and morbidity (ALERT): study protocol for a stepped-wedge cluster-randomised trial in Benin, Malawi, Tanzania and Uganda

Background: Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions during this period has the potential to avert at least 2.5 million deaths in mothers and their offspring annually. This paper describes a study protocol for implementing and evaluating a multi-faceted health care system intervention to strengthen the implementation of evidence-based interventions and responsive care during this crucial period. Methods: This is a cluster randomised stepped-wedge trial with a nested realist process evaluation across 16 hospitals in Benin, Malawi, Tanzania and Uganda. The ALERT intervention will include four main components: i) end-user participation through narratives of women, families and midwifery providers to ensure co-design of the intervention; ii) competency-based training; iii) quality improvement supported by data from a clinical perinatal e-registry and iv) empowerment and leadership mentoring of maternity unit leaders complemented by district based bi-annual coordination and accountability meetings. The trial\u27s primary outcome is in-facility perinatal (stillbirths and early neonatal) mortality, in which we expect a 25% reduction. A perinatal e-registry will be implemented to monitor the trial. Our nested realist process evaluation will help to understand what works, for whom, and under which conditions. We will apply a gender lens to explore constraints to the provision of evidence-based care by health workers providing maternity services. An economic evaluation will assess the scalability and cost-effectiveness of ALERT intervention. Discussion: There is evidence that each of the ALERT intervention components improves health providers\u27 practices and has modest to moderate effects. We aim to test if the innovative packaging, including addressing specific health systems constraints in these settings, will have a synergistic effect and produce more considerable perinatal mortality reductions

Evaluating the impact of a maternal health voucher programme on service use before and after the introduction of free maternity services in Kenya: a quasi-experimental study

INTRODUCTION: From 2006 to 2016, the Government of Kenya implemented a reproductive health voucher programme in select counties, providing poor women subsidised access to public and private sector care. In June 2013, the government introduced a policy calling for free maternity services to be provided in all public facilities. The concurrent implementation of these interventions presents an opportunity to provide new insights into how users adapt to a changing health financing and service provision landscape. METHODS: We used data from three cross-sectional surveys to assess changes over time in use of 4+ antenatal care visits, facility delivery, postnatal care and maternal healthcare across the continuum among a sample of predominantly poor women in six counties. We conducted a difference-in-differences analysis to estimate the impact of the voucher programme on these outcomes, and whether programme impact changed after free maternity services were introduced. RESULTS: Between the preintervention/roll-out phase and full implementation, the voucher programme was associated with a 5.5% greater absolute increase in use of facility delivery and substantial increases in use of the private sector for all services. After free maternity services were introduced, the voucher programme was associated with a 5.7% higher absolute increase in use of the recommended package of maternal health services; however, disparities in access to facility births between voucher and comparison counties declined. Increased use of private sector services by women in voucher counties accounts for their greater access to care across the continuum. CONCLUSIONS: Our findings show that the voucher programme is associated with a modest increase in women’s use of the full continuum of maternal health services at the recommended timings after free maternity services were introduced. The greater use of private sector services in voucher counties also suggests that there is need to expand women’s access to acceptable and affordable providers

Study on the Effect of Cold Plasma on the Germination and Growth of Durum Wheat Seeds Contaminated with Fusarium Graminearum

Cold plasmais a potentially new method of controlling diseases caused by fungal pathogens. In this investigation the effect of treatment with cold plasma of durum wheat seeds contaminated with Fusarium graminearum on the germination and growth of plants was studied. Plants of 6 durum wheat varieties were pre-contaminated with spore suspension of Fusarium graminearum. The harvested seeds were treated with cold plasma in 4 variants%253A 1ndash%253B direct treatment with Argon plasma torch sustained by travelling electromagnetic wave%253B 2 ndash%253B treatment with the same plasma torch of seeds in 20 ml distilled water%253B 3 ndash%253B underwater diaphragm discharge treatment in the container with applied voltage of 15 kV electrode, denoted by %2B%253B 4 ndash%253B underwater diaphragm discharge treatment in the container with grounded electrode, denoted by ndash%253B. Two control variants were used ndash%253B dry not treated contaminated seeds and wet not treated contaminated seeds. After the treatment the seeds were placed in petri dishes for germination. Sprouted seeds were planted in pots with soil mixture and cultivated to maturity in green house conditions in Field Crops Institute ndash%253BChirpan, Bulgaria in 2017%252F2018 year. The effect of the treatment on the following traits were studied%253A germination rate, days to heading, plant high, parameters of chlorophyll fluorescence during the grain filling, spike length, kernel number per spike, kernel weight per spike, TKW and obtained ill (Fusarium graminearum) and healthy seeds. The results received were processed statistically via two-way ANOVA and Duncans multiple range test. The analysis of variance reveals that the genotype, treatment with cold plasma and the interactions between them have a statistically significant effect on the variation of the germination rate. The best germination rate (means from all genotypes) was obtained by treatment with cold plasma variant 1 - direct treatment with Argon plasma torch sustained by travelling electromagnetic wave and variant 3 - underwater diaphragm discharge treatment in the container with applied voltage of 15 kV electrode, denoted by %2B. After the germination the number of seeds contaminated with Fusarium graminearum was the lowest after variant 4 in the treatment of three of the studied varieties. Stimulating effect of the cold plasma treatment on the plant growth was found in 4 genotypes. Varieties Elbrus, Progres, Deni and Zvezdica were with higher PH during the grain filling. The results from the influence of cold plasma on the other studied traits will be processed after the plant maturation and will be included in the final version of the paper. Acknowledgments%253A This work was supported by Bulgarian National Science Fund under Grant No DH08%252F8, 2016

Length of Stay After Childbirth in 92 Countries and Associated Factors in 30 Low- and Middle-Income Countries: Compilation of Reported Data and a Cross-sectional Analysis from Nationally Representative Surveys

Background: Following childbirth, women need to stay sufficiently long in health facilities to receive adequate care. Little is known about length of stay following childbirth in low- and middle-income countries or its determinants. Methods and Findings: We described length of stay after facility delivery in 92 countries. We then created a conceptual framework of the main drivers of length of stay, and explored factors associated with length of stay in 30 countries using multivariable linear regression. Finally, we used multivariable logistic regression to examine the factors associated with stays that were “too short” (<24 h for vaginal deliveries and <72 h for cesarean-section deliveries). Across countries, the mean length of stay ranged from 1.3 to 6.6 d: 0.5 to 6.2 d for singleton vaginal deliveries and 2.5 to 9.3 d for cesarean-section deliveries. The percentage of women staying too short ranged from 0.2% to 83% for vaginal deliveries and from 1% to 75% for cesarean-section deliveries. Our conceptual framework identified three broad categories of factors that influenced length of stay: need-related determinants that required an indicated extension of stay, and health-system and woman/family dimensions that were drivers of inappropriately short or long stays. The factors identified as independently important in our regression analyses included cesarean-section delivery, birthweight, multiple birth, and infant survival status. Older women and women whose infants were delivered by doctors had extended lengths of stay, as did poorer women. Reliance on factors captured in secondary data that were self-reported by women up to 5 y after a live birth was the main limitation. Conclusions: Length of stay after childbirth is very variable between countries. Substantial proportions of women stay too short to receive adequate postnatal care. We need to ensure that facilities have skilled birth attendants and effective elements of care, but also that women stay long enough to benefit from these. The challenge is to commit to achieving adequate lengths of stay in low- and middle-income countries, while ensuring any additional time is used to provide high-quality and respectful care