Gendered health systems biased against maternal survival : preliminary findings from Koppal, Karnataka, India

In this paper we outline the context of pregnant women’s lives and the plural health systems they encounter in Koppal, the most deprived district in the state of Karnataka, south India. We combine preliminary survey findings with qualitative work to illustrate the dynamics involved in seeking and receiving obstetric care. Despite high levels of poverty and scarce resources supporting primary health care in the region, women with obstetric complications do access a range of health providers. Yet they still die. Although addressing the technical and managerial capacity constraints to ensuring equitable access to emergency obstetric care is essential, we argue that maternal well-being and survival cannot be effectively ensured without confronting the gender biases that also constrain health systems from supporting women’s health and saving women’s lives. We analyse these biases as failures in acknowledgement and accountability for pregnant women’s needs and conclude with strategic steps to effectively respond to the situation that encompass technical, managerial and political action. Keywords: maternal health, maternal mortality, plural health systems, gender bias, acknowledgement, accountability

Unfree markets: socially embedded informal health providers in

a b s t r a c t The dynamics of informal health markets in marginalised regions are relevant to policy discourse in India, but are poorly understood. We examine how informal health markets operate from the viewpoint of informal providers (those without any government-recognised medical degrees, otherwise known as RMPs) by drawing upon data from a household survey in 2002, a provider census in 2004 and ongoing field observations from a research site in Koppal district, Karnataka, India. We find that despite their illegality, RMPs depend on government and private providers for their training and referral networks. Buffeted by unregulated market pressures, RMPs are driven to provide allopathic commodities regardless of need, but can also be circumspect in their practice. Though motivated by profit, their socially embedded practice at community level at times undermines their ability to ensure payment of fees for their services. In addition, RMPs feel that communities can threaten them via violence or malicious rumours, leading them to seek political favour and social protection from village elites and elected representatives. RMPs operate within negotiated quid pro quo bargains that lead to tenuous reciprocity or fragile trust between them and the communities in which they practise. In the context of this 'unfree' market, some RMPs reported being more embedded in health systems, more responsive to communities and more vulnerable to unregulated market pressures than others. Understanding the heterogeneity, nuanced motivations and the embedded social relations that mark informal providers in the health systems, markets and communities they work in, is critical for health system reforms

Identifying and assessing maternal risks : a handbook for healthcare providers

This handbook on maternal risks draws from research and activities of the Gender and Health Equity (GHE) project including its pregnancy tracking system and helpline in Koppal district (India). Findings showed that health personnel in Primary and Community Health Centres ignore or downplay obvious indications of risk. The project developed strategies to improve collective responsibility for maternal safety, and to strengthen access to health services. The handbook is based on work with pregnant women, their families, communities and healthcare providers. Maternal safety can be assured quite easily by every society with the available obstetric knowledge and technology, yet social and health system factors may still serve as barriers.Swedish International Development Cooperation Agency (Sida)the John D. and Catherine T. MacArthur Foundationthe Rockefeller Foundationthe Ford Foundatio

A summative content analysis of how programmes to improve the right to sexual and reproductive health address power.

Introduction Power shapes all aspects of global health. The concept of power is not only useful in understanding the current situation, but it is also regularly mobilised in programmatic efforts that seek to change power relations. This paper uses summative content analysis to describe how sexual and reproductive health (SRH) programmes in low-income and middle-income countries explicitly and implicitly aim to alter relations of power. Methods Content analysis is a qualitative approach to analysing textual data; in our analysis, peer-reviewed articles that describe programmes aiming to alter power relations to improve SRH constituted the data. We searched three databases, ultimately including 108 articles. We extracted the articles into a spreadsheet that included basic details about the paper and the programme, including what level of the social ecological model programme activities addressed. Results The programmes reviewed reflect a diversity of priorities and approaches to addressing power, though most papers were largely based in a biomedical framework. Most programmes intervened at multiple levels simultaneously; some of these were ‘structural’ programmes that explicitly aimed to shift power relations, others addressed multiple levels using a more typical programme theory that sought to change individual behaviours and proximate drivers. This prevailing focus on proximate behaviours is somewhat mismatched with the broader literature on the power-related drivers of SRH health inequities, which explores the role of embedded norms and structures. Conclusion This paper adds value by summarising what the academic public health community has chosen to test and research in terms of power relations and SRH, and by raising questions about how this corresponds to the significant task of effecting change in power relations to improve the right to SRH

Preoperative MRI-radiomics features improve prediction of survival in glioblastoma patients over MGMT methylation status alone

Background: Glioblastoma (GBM) is the most common malignant central nervous system tumor, and MGMT promoter hypermethylation in this tumor has been shown to be associated with better prognosis. We evaluated the capacity of radiomics features to add complementary information to MGMT status, to improve the ability to predict prognosis. Methods: 159 patients with untreated GBM were included in this study and divided into training and independent test sets. 286 radiomics features were extracted from the magnetic resonance images acquired prior to any treatments. A least absolute shrinkage selection operator (LASSO) selection followed by Kaplan-Meier analysis was used to determine the prognostic value of radiomics features to predict overall survival (OS). The combination of MGMT status with radiomics was also investigated and all results were validated on the independent test set. Results: LASSO analysis identified 8 out of the 286 radiomic features to be relevant which were then used for determining association to OS. One feature (edge descriptor) remained significant on the external validation cohort after multiple testing (p=0.04) and the combination with MGMT identified a group of patients with the best prognosis with a survival probability of 0.61 after 43 months (p=0.0005). Conclusion: Our results suggest that combining radiomics with MGMT is more accurate in stratifying patients into groups of different survival risks when compared to with using these predictors in isolation. We identified two subgroups within patients who have methylated MGMT: one with a similar survival to unmethylated MGMT patients and the other with a significantly longer OS

Technical note: Extension of CERR for computational radiomics: a comprehensive MATLAB platform for reproducible radiomics research

PurposeRadiomics is a growing field of image quantitation, but it lacks stable and high-quality software systems. We extended the capabilities of the Computational Environment for Radiological Research (CERR) to create a comprehensive, open-source, MATLAB-based software platform with an emphasis on reproducibility, speed, and clinical integration of radiomics research. MethodThe radiomics tools in CERR were designed specifically to quantitate medical images in combination with CERR's core functionalities of radiological data import, transformation, management, image segmentation, and visualization. CERR allows for batch calculation and visualization of radiomics features, and provides a user-friendly data structure for radiomics metadata. All radiomics computations are vectorized for speed. Additionally, a test suite is provided for reconstruction and comparison with radiomics features computed using other software platforms such as the Insight Toolkit (ITK) and PyRadiomics. CERR was evaluated according to the standards defined by the Image Biomarker Standardization Initiative. CERR's radiomics feature calculation was integrated with the clinically used MIM software using its MATLAB((R)) application programming interface. ResultsThe CERR provides a comprehensive computational platform for radiomics analysis. Matrix formulations for the compute-intensive Haralick texture resulted in speeds that are superior to the implementation in ITK 4.12. For an image discretized into 32 bins, CERR achieved a speedup of 3.5 times over ITK. The CERR test suite enabled the successful identification of programming errors as well as genuine differences in radiomics definitions and calculations across the software packages tested. ConclusionThe CERR's radiomics capabilities are comprehensive, open-source, and fast, making it an attractive platform for developing and exploring radiomics signatures across institutions. The ability to both choose from a wide variety of radiomics implementations and to integrate with a clinical workflow makes CERR useful for retrospective as well as prospective research analyses

Solid Organ Transplantation During COVID-19 Pandemic: An International Web-based Survey on Resources’ Allocation

Background. Solid organ transplants (SOTs) are life-saving interventions, recently challenged by coronavirus disease 2019 (COVID-19). SOTs require a multistep process, which can be affected by COVID-19 at several phases. Methods. SOT-specialists, COVID-19-specialists, and medical ethicists designed an international survey according to CHERRIES guidelines. Personal opinions about continuing SOTs, safe managing of donors and recipients, as well as equity of resources' allocation were investigated. The survey was sent by e-mail. Multiple approaches were used (corresponding authors from Scopus, websites of scientific societies, COVID-19 webinars). After the descriptive analysis, univariate and multivariate ordinal regression analysis was performed. Results. There were 1819 complete answers from 71 countries. The response rate was 49%. Data were stratified according to region, macrospecialty, and organ of interest. Answers were analyzed using univariate- multivariate ordinal regression analysis and thematic analysis. Overall, 20% of the responders thought SOTs should not stop (continue transplant without restriction); over 70% suggested SOTs should selectively stop, and almost 10% indicated they should completely stop. Furthermore, 82% agreed to shift resources from transplant to COVID-19 temporarily. Briefly, main reason for not stopping was that if the transplant will not proceed, the organ will be wasted. Focusing on SOT from living donors, 61% stated that activity should be restricted only to "urgent"cases. At the multivariate analysis, factors identified in favor of continuing transplant were Italy, ethicist, partially disagreeing on the equity question, a high number of COVID-19- related deaths on the day of the answer, a high IHDI country. Factors predicting to stop SOTs were Europe except-Italy, public university hospital, and strongly agreeing on the equity question. Conclusions. In conclusion, the majority of responders suggested that transplant activity should be continued through the implementation of isolation measures and the adoption of the COVID-19-free pathways. Differences between professional categories are less strong than supposed