Women's experiences of mistreatment during childbirth: A comparative view of home- and facility-based births in Pakistan.

INTRODUCTION: Respectful and dignified healthcare is a fundamental right for every woman. However, many women seeking childbirth services, especially those in low-income countries such as Pakistan, are mistreated by their birth attendants. The aim of this epidemiological study was to estimate the prevalence of mistreatment and types of mistreatment among women giving birth in facility- and home-based settings in Pakistan in order to address the lack of empirical evidence on this topic. The study also examined the association between demographics (socio-demographic, reproductive history and empowerment status) and mistreatment, both in general and according to birth setting (whether home- or facility-based). MATERIAL AND METHODS: In phase one, we identified 24 mistreatment indicators through an extensive literature review. We then pre-tested these indicators and classified them into seven behavioural types. During phase two, the survey was conducted (April-May 2013) in 14 districts across Pakistan. A total of 1,334 women who had given birth at home or in a healthcare facility over the past 12 months were interviewed. Linear regression analysis was employed for the full data set, and for facility- and home-based births separately, using Stata version 14.1. RESULTS: There were no significant differences in manifestations of mistreatment between facility- and home-based childbirths. Approximately 97% of women reported experiencing at least one disrespectful and abusive behaviour. Experiences of mistreatment by type were as follows: non-consented care (81%); right to information (72%); non-confidential care (69%); verbal abuse (35%); abandonment of care (32%); discriminatory care (15%); and physical abuse (15%). In overall analysis, experience of mistreatment was lower among women who were unemployed (β = -1.17, 95% CI -1.81, -0.53); and higher among less empowered women (β = 0.11, 95% CI 0.06, 0.16); and those assisted by a traditional birth attendant as opposed to a general physician (β = 0.94, 95% CI 0.13, 1.75). Sub-group analyses for home-based births identified the same significant associations with mistreatment, with ethnicity included. In facility-based births, there was a significant relationship between women's employment and empowerment status and mistreatment. Women with prior education on birth preparedness were less likely to experience mistreatment compared to those who had received no previous birth preparedness education. CONCLUSION: In order to promote care that is woman-centred and provided in a respectful and culturally appropriate manner, service providers should be cognisant of the current situation and ensure provision of quality antenatal care. At the community level, women should seek antenatal care for improved birth preparedness, while at the interpersonal level strategies should be devised to leverage women's ability to participate in key household decisions

Prognostic indicators in cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVT) can affect all age groups, particularly women of childbearing age. Overall prognosis for survival and functional independence is better than it was believed. Mortality usually ranges from 6-15% and transtentorial herniation is the major cause of death. Approximately 80% of patients are functionally independent in the long term. Altered mental status and cerebral haemorrhage at presentation are the strongest predictors of death and disability. Patients with CVT related to pregnancy and puerperium generally do better than patients with other causes. Septic CVT carries a worse prognosis than aseptic CVT and of the latter, patients with syndrome of isolated intracranial hypertension have a better prognosis than those with focal deficits or encephalopathy. Anticoagulation is believed to improve outcome in CVT although robust data are lacking. Epilepsy, headaches, visual loss, pyramidal deficits and cognitive impairment are some of the long term sequelae. The risk of recurrence of CVT is low, particularly after the first 12 months of the first episode

Are underprivileged and less empowered women deprived of respectful maternity care: Inequities in childbirth experiences in public health facilities in Pakistan

Background: Attainment of healthcare in respectful and dignified manner is a fundamental right for every woman regardless of the individual status. However, social exclusion, poor psychosocial support, and demeaning care during childbirth at health facilities are common worldwide, particularly in low- and middle-income countries. We concurrently examined how women with varying socio-demographic characteristics are treated during childbirth, the effect of women\u27s empowerment on mistreatment, and health services factors that contribute to mistreatment in secondary-level public health facilities in Pakistan.Methods: A cross-sectional survey was conducted during August-November 2016 among 783 women who gave birth in six secondary-care public health facilities across four contiguous districts of southern Sindh. Women were recruited in health facilities and later interviewed at home within 42 days of postpartum using a WHO\u27s framework-guided 43-item structured questionnaire. Means, standard deviation, and average were used to describe characteristics of the participants. Multivariable linear regression was applied using Stata 15.1.Results: Women experiencing at least one violation of their right to care by hospital staff during intrapartum care included: ineffective communication (100%); lack of supportive care (99.7%); loss of autonomy (97.5%); failure of meeting professional clinical standards (84.4%); lack of resources (76.3%); verbal abuse (15.2%); physical abuse (14.8%); and discrimination (3.2%). Risk factors of all three dimensions showed significant association with mistreatment: socio-demographic: primigravida and poorer were more mistreated; health services: lesser-education on birth preparedness and postnatal care leads to higher mistreatment; and in terms of women\u27s empowerment: women who were emotionally and physically abused by family, and those with lack of social support and lesser involvement in joint household decision making with husbands are more likely to be mistreated as compared to their counterparts. The magnitude of relationship between all significant risk factors and mistreatment, in the form of β coefficients, ranged from 0.2 to 5.5 with p-values less than 0.05.Conclusion: There are glaring inequalities in terms of the way women are treated during childbirth in public health facilities. Measures of socio-demographic, health services, and women\u27s empowerment showed a significant independent association with mistreatment during childbirth. At the health system level, there is a need for urgent solutions for more inclusive care to ensure that all women are treated with compassion and dignity, complemented by psychosocial support for those who are emotionally disturbed and lack social support

Erbium-doped fiber ring laser tuning using an intra-cavity Fabry-Perot filter

A tunable erbium-doped fiber ring laser using an intra-cavity Fabry-Perot filter as the tuning element is investigated. Tuning is achieved by varying the applied voltage which controls the FP cavity length. The laser's wavelength is monitored using an optical spectrum analyzer to determine the laser's spectral characteristics under static conditions at different wavelengths over its tuning range of approximately 50nm. When the laser is tuned rapidly, the frequency versus time characteristic is determined using a fiber Fabry-Perot interferometer with a photodetector to convert the optical signal to an electrical signal. The core of the research is to determine the degree of spectral broadening of the laser as a function of the spectral tuning rate. The fringe contrast of fiber Fabry-Perot interferometer transmittance curves decreases with increase in the tuning frequency. The gain at a certain wavelength becomes a function of time putting an upper limit on the tuning frequency of the system. The carrier lifetime of erbium ions dictates the maximum achievable tuning speed

Stroke in Pakistan

Stroke is the most common cause of disability and a leading cause of mortality world wide. Though the incidence is falling in West but probably is rising in Asia. The burden of stroke risk factors in Pakistan is enormous e.g. by 2020 Pakistan will be 4th most populous country in terms of diabetic patients. Similarly every 3rd person above age of 45 years has hypertension. Ironically a great majority of these patients are unaware of their diagnosis. This is further complicated by the fact that most of diagnosed patients have uncontrolled hypertension, as a result of poor compliance on patients part and poor updated knowledge on physicians part. Data on stroke incidence and prevalence from Pakistan is scarce, however, there are several reported case series in literature highlighting significant differences in terms of stroke epidemiology, risk factors and stroke subtypes/patterns. Considering a high population, absolute number of stroke in our country would be in millions. Its consequences are myriad ranging form physical disability to death, to psychologic, social and economic consequences. These consequences do not only affect the individual or his/her family but also society as a whole. We reviewed available literature on stroke and its risk factors from Pakistan

Compliance to antihypertensive therapy

Objective: To determine compliance, factors affecting compliance to antihypertensive therapy and to compare compliant and non-compliant groups, in a tertiary care setting.Study Design: Analytical (cross-sectional) study.Place and Duration of Study: The outpatient clinics at the Aga Khan University from May 2004 to February 2005.Patients and Methods: Two hundred patients presenting to the outpatients clinic were included. All patients 18 years and above, who had stage 1 and 2 hypertension, had one clinic visit to a medicine clinic, 6 months prior to presentation and started on antihypertensive medicines, were included.Results: Sixty six percent were males and 33.5 % were females. Mean age was 58.1(+/-12) years and mean duration of hypertension was 7.2 (+/- 6.7) years. Fifty-seven percent were compliant and 43 % were noncompliant. In the noncompliant group, 53.4 % had mild noncompliance, 24.4 % had severe non-compliance, while 22% had moderate noncompliance. Factors of noncompliance were 56.8% missed doses due to forgetfulness, 12.7% deliberately missed their doses, 11.6% could not take the medicine due to side effects, 10.4% did not take the dose due to increased number of tablets, 4.6% were not properly counseled by the physician and 3.48% did not take medicines due to cost issues. The mean systolic blood pressure was 126 +/- 19.2 mmHg in the compliant group while it was 133 +/-16.5 mmHg in the noncompliant group p-value 0.004). The mean diastolic blood pressure in the compliant group was 76 +/- 11.9 mmHg, while in the noncompliant group it was 81.9 +/-10.9 mmHg (p-value 0.001).Conclusion: Compliance to antihypertensive therapy in a tertiary care center is significantly good. Forgetfulness was the major reason for noncompliance. The mean blood pressure control was better in the compliant group

Prognostic Indicators in Patients with Primary Intraventricular Haemorrhage

Objectives: Primary intraventricular haemorrhage (PIVH) is a rare clinical entity. We sought to evaluate risk factors, clinical and radiological features, and outcome of patients with PIVH. Materials and Methods: Cases of PIVH were identified from cohort of patients with non traumatic intracerebral haemorrhage (ICH) by reviewing the radiological data. Their charts were reviewed and demographic, clinical, radiological and laboratory data was recorded and analyzed. Chi square and t test were used to determine predictors of poor outcome. Results: Fifteen of 677 (2%) patients with ICH had PIVH. Nine (60%) were men. Median age was 56 years. Predisposing factors included hypertension in twelve (80%), coagulopathy in five (33%) and vascular malformations in two (13%) patients. Eleven (73%) patients developed hydrocephalus. Two patients died. Univariate analysis identified diabetes mellitus, blood in all ventricles and coagulopathy as predictors of death during initial hospital stay and hydrocephalus as predictor of poor outcome (death and disability combined) (p\u3c0.05). Conclusion: Hypertension is most common associated risk factor for primary intraventricular haemorrhage followed by coagulopathy. Hydrocephalus is a common complication, associated with poor outcome. Diabetes mellitus, coagulopathy and panventricular blood predict early mortalit

Dual Wavelength Polarimetry for Glucose Sensing in the Anterior Chamber of the Eye

Clinical guidelines dictate that frequent blood glucose monitoring in diabetic patients is critical towards proper management of the disease. Although, several different types of glucose monitors are now commercially available, most of these devices are invasive, thereby adversely affecting patient compliance. To this end, optical polarimetric glucose sensing through the eye has been proposed as a potential noninvasive means to aid in the control of diabetes. Arguably, the most critical and limiting factor towards successful application of such a technique is the time varying corneal birefringence due to eye motion artifact. In the first part of this research, we describe a birefringent ocular model along with a geometric ray tracing scheme to serve as a tool towards better understanding of the cornea’s birefringence properties. The simulations show that index-unmatched coupling of light is spatially limited to a smaller range when compared to index-matched situation. Polarimetric measurements on rabbits’ eyes indicate relative agreement between the modeled and experimental values of corneal birefringence. In addition, the observed rotation in the plane of polarized light for multiple wavelengths demonstrates the potential for using a dual-wavelength polarimetric approach to overcome the noise due to time-varying corneal birefringence. These results will ultimately aid in the development of an appropriate eye coupling mechanism for in vivo polarimetric glucose measurements. The latter part of the dissertation focuses on design and development of a dual wavelength optical polarimeter. The described system utilizes real-time closed-loop feedback based on proportional-integral-derivative (PID) control, which effectively reduced the time taken by the system to stabilize while minimizing the effect of motion artifact, which appears as common noise source for both the wavelengths. Glucose measurements performed in both in vitro and ex vivo conditions demonstrate the sensitivity of the current system. Finally, in vivo results in rabbits indicate that dual-wavelength polarimetry has the potential to noninvasively probe glucose through the anterior chamber of the eye

Occult cervical spinal dural arteriovenous fistula masquerading as acute spinal cord ischemia

Acute presentation of upper and lower extremity motor weakness is commonly attributed to intracerebral ischemic infarct upon initial examination. For those that exhibit acute onset of bilateral weakness, it is important to expand the differential diagnosis to include spinal cord ischemic involvement. One cause of ischemic lesions is spinal dural arteriovenous (AV) fistulas which are generally found in the thoraco-lumbar region. They present with progressive paraplegia or quadriplegia due to changes in the spinal venous pressure and eventual myelopathy. We present a 60 year old gentleman with bilateral upper extremity weakness and right lower extremity weakness preceded by upper back and neck pain. Initial studies included both Magnetic resonance imagine (MRI) of the brain and also the cervical spine that demonstrated abnormal signal intensity within the anterior cervical cord from C3-C7 levels concerning for spinal cord infarct. In our case there were no flow voids to suggest dilated perimedullary vessels that usually prompt further diagnostic evaluation through a spinal angiogram. However, given the clinical suspicion, a spinal angiogram was obtained that demonstrated a cervical dural AV fistula supplied by a dural branch vessel originating from the left vertebral artery. We will highlight the importance of recognizing the clinical presentation of spinal dural AV fistulas; the usual findings on imaging, the value of considering further diagnostic tests if clinical suspicion is high, and provide an overview of the spinal dural AV treatment

Age estimation of a sample of pakistani population using coronal pulp cavity Index in molars and premolars on orthopantomogram

The aim of the present study was to assess the validity of tooth-coronal index (TCI) in the age estimation. This retrospective charts review was conducted at the Aga Khan University Hospital, Karachi from January 2016 to March 2016, and comprised 315 teeth of 80 individuals. The teeth were analysed on Orthopantomogram. TCI was calculated for unrestored mandibular premolars and molars. Pearson\u27s correlation was applied to assess correlation between chronological age and TCI. Besides, 30(37.5%) subjects were male and 50(62.5%) female, and 140(44.4%) teeth were of male subjects and 175(55.6%) were of females. The mean correlation coefficient between chronological age and TCI was -0.27. The highest negative correlation was observed for tooth No.47 in males (r=-0.72) whereas among females the highest negative correlation was noted for tooth No.36 (r=- 0.61).There was very weak correlation between age and TCI of a tooth. Therefore, TCI index could not be predictably used for age estimation in the studied population