Rates of IUCD discontinuation and its associated factors among the clients of a social franchising network in Pakistan

Background: Modern Intrauterine contraceptive device (IUCD) is very safe, highly effective reversible and inexpensive family planning method which offers 5-10 years of protection against pregnancy. The contraceptive use in Pakistan has been merely 30% for over a decade with IUCD being the least used method. Higher discontinuation rates are documented in developing countries; however no such data is available for Pakistan. Marie Stopes Society (MSS) established a social franchise outlets network branded as \u27SURAJ\u27 (Sun) in Pakistan to provide quality family planning services. This study attempts to determine IUCD discontinuation rates and its associated risk factors. Using a semi-structured questionnaire, a cross-sectional study was conducted with 3000 clients who availed IUCD services from Suraj provider 6, 12 and 24 month back,. Data were analyzed in SPSS 17.0; adjusted prevalence ratios were calculated to see associations between discontinuation and its risk factors.Case presentation: We found that 22.7% of the IUCD acceptors experienced some health problem; while the overall discontinuation rate was 18.9% with average time of usage of 7.4 (SD ± 5.8) months before discontinuation. Half of them showed health concerns (49.8%); of which a majority (70.2%) returned to Suraj provider for IUCD removal. Women living in Punjab, residing at a travelling time of 30-60 minutes and no previous use of contraceptive are more likely to discontinue IUCD. However, among total women 81.7% still expressed willingness to avail IUCD services from Suraj provider in future, if needed.Conclusion: The findings suggest a need for training the providers and field workers to prevent early discontinuation of IUCD among the Suraj clients and by addressing the health concerns through proper counseling, continued follow-up and immediate medical aid/referral in case of complications

Cross-Sector Review of Drivers and Available 3Rs Approaches for Acute Systemic Toxicity Testing

Acute systemic toxicity studies are carried out in many sectors in which synthetic chemicals are manufactured or used and are among the most criticized of all toxicology tests on both scientific and ethical grounds. A review of the drivers for acute toxicity testing within the pharmaceutical industry led to a paradigm shift whereby in vivo acute toxicity data are no longer routinely required in advance of human clinical trials. Based on this experience, the following review was undertaken to identify (1) regulatory and scientific drivers for acute toxicity testing in other industrial sectors, (2) activities aimed at replacing, reducing, or refining the use of animals, and (3) recommendations for future work in this area

Relationship between household wealth inequality and chronic childhood under-nutrition in Bangladesh

BACKGROUND: Household food insecurity and under-nutrition remain critically important in developing countries struggling to emerge from the scourge of poverty, where historically, improvements in economic conditions have benefited only certain privileged groups, causing growing inequality in health and healthcare among the population. METHODS: Utilizing information from 5,977 children aged 0-59 months included in the 2004 Bangladesh Demographic and Health Survey , this study examined the relationship between household wealth inequality and chronic childhood under-nutrition. A child is defined as being chronically undernourished or whose growth rate is adversely stunted, if his or her z-score of height-for-age is more than two standard deviations below the median of international reference. Household wealth status is measured by an established index based on household ownership of durable assets. This study utilized multivariate logistic regressions to estimate the effect of household wealth status on adverse childhood growth rate. RESULTS: The results indicate that children in the poorest 20% of households are more than three time as likely to suffer from adverse growth rate stunting as children from the wealthiest 20% of households (OR=3.6; 95% CI: 3.0, 4.3). The effect of household wealth status remain significantly large when the analysis was adjusted for a child's multiple birth status, age, gender, antenatal care, delivery assistance, birth order, and duration that the child was breastfed; mother's age at childbirth, nutritional status, education; household access to safe drinking water, arsenic in drinking water, access to a hygienic toilet facility, cooking fuel cleanliness, residence, and geographic location (OR=2.4; 95% CI: 1.8, 3.2). CONCLUSION: This study concludes that household wealth inequality is strongly associated with childhood adverse growth rate stunting. Reducing poverty and making services more available and accessible to the poor are essential to improving overall childhood health and nutritional status in Bangladesh

Differentials of fertility in North and South Gondar zones, northwest Ethiopia: A comparative cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Ethiopia is one of the most densely populated countries in Africa with an estimated population of 77.1 million in mid-2007. Uncontrolled fertility has adversely influenced the socio-economic, demographic and environmental situations of the country. It is one of the largest and poorest countries that, even in the midst of crisis, has maintained high levels of fertility. This study was aimed at investigating the most important factors influencing fertility behavior in Northwest Ethiopia.</p> <p>Methods</p> <p>A comparative cross-sectional study which included 2424 women aged 25 years and above was undertaken in the Amhara region of Northwest Ethiopia. The study subjects were grouped into high fertile and low fertile categories. There were 1011 and 1413 women in the high and low fertile groups, respectively. A multi-stage cluster sampling stratified by place of residence was employed to select the required study subjects. Both bivariate and multivariate logistic regression techniques were used to analyze the data.</p> <p>Results</p> <p>Among the 25 variables considered in this study, only 9 of them were found significantly and independently associated with the level of fertility. Women with at least secondary education were at a lower risk of high fertility with OR = 0.37 (95% CI: 0.21 to 0.64) compared to those with no formal education. However, women with primary education did not show any significant difference when compared with the same baseline group. Age at first marriage was inversely associated with the number of children ever born alive. Place of residence, household expenditure, number of children who have died, attitude towards using contraceptives, women's knowledge on the safe period, and current marital status were the other variables that showed significant associations with the level of fertility.</p> <p>Conclusion</p> <p>Female education beyond the primary level, reduced infant and child mortality, delayed marriage and correct knowledge on the safe period during the menstrual cycle were amongst the main factors that had a bearing on high fertility.</p

The Influence of Mediators on the Relationship Between Antenatal Opioid Agonist Exposure and the Severity of Neonatal Opioid Withdrawal Syndrome

OBJECTIVES: (1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity. METHODS: This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors. RESULTS: A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS. CONCLUSIONS FOR PRACTICE: MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy

Identification and Description of the Uncertainty, Variability, Bias and Influence in Quantitative Structure-Activity Relationships (QSARs) for Toxicity Prediction

Improving regulatory confidence in, and acceptance of, a prediction of toxicity from a quantitative structure-activity relationship (QSAR) requires assessment of its uncertainty and determination of whether the uncertainty is acceptable. Thus, it is crucial to identify potential uncertainties fundamental to QSAR predictions. Based on expert review, sources of uncertainties, variabilities and biases, as well as areas of influence in QSARs for toxicity prediction were established. These were grouped into three thematic areas: uncertainties, variabilities, potential biases and influences associated with 1) the creation of the QSAR, 2) the description of the QSAR, and 3) the application of the QSAR, also showing barriers for their use. Each thematic area was divided into a total of 13 main areas of concern with 49 assessment criteria covering all aspects of QSAR development, documentation and use. Two case studies were undertaken on different types of QSARs that demonstrated the applicability of the assessment criteria to identify potential weaknesses in the use of a QSAR for a specific purpose such that they may be addressed and mitigation strategies can be proposed, as well as enabling an informed decision on the adequacy of the model in the considered context

Unhealthy Snack Food and Beverage Consumption Is Associated with Lower Dietary Adequacy and Length-for-Age z-Scores among 12-23-Month-Olds in Kathmandu Valley, Nepal.

BACKGROUND: Consumption of unhealthy snack foods and beverages (USFBs) in low- and middle-income countries (LMICs) is rising, with global awareness increasing about risks of overnutrition. However, little is known about the relation between USFB consumption and young children's diet/nutritional outcomes in contexts where nutrient density of complementary foods is often low. OBJECTIVES: This study assessed the association of high USFB consumption, compared with low consumption, with nutrient intakes, dietary adequacy, iron status, and growth in young children in Kathmandu Valley, Nepal. METHODS: A cross-sectional survey was conducted in a representative sample of 745 primary caregivers of children aged 12-23 mo. Food consumption was measured through quantitative 24-h recalls, and child anthropometric measurements and capillary blood samples were collected. Using adjusted linear/logistic regression models, nutrient intakes, dietary adequacy, length-for-age and weight-for-length z-scores (LAZ and WLZ, respectively), and iron status were compared between lowest and highest tertiles of consumption based on the contribution of USFBs to total energy intakes (TEIs). Mediation of the relation between USFB consumption and LAZ via lowered dietary adequacy was explored using structural equations modeling. RESULTS: On average, USFBs contributed 46.9% of TEI among the highest tertile of consumers, compared with 5.2% of TEI among the lowest. Compared with low-USFB consumers, high-USFB consumers had lower nutrient intakes and a greater proportion were at risk of inadequate intakes for 8 nutrients. Mean LAZ was nearly 0.3 SD lower among high-USFB consumers than low consumers (P = 0.003), with this relationship partially mediated through dietary adequacy. No associations were found with stunting prevalence or iron status. Prevalence of overweight/obesity was low. CONCLUSIONS: In this LMIC context, high USFB consumption among young children was associated with inadequate micronutrient intakes, which can contribute to poor growth outcomes. Addressing increased availability of USFBs in LMIC food systems should be a priority for policies and programs aiming to safeguard child nutrition

Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency

BACKGROUND: Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997–2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices. METHODS: Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%). RESULTS: Only 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25–0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37–0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66–0.99 when comparing low to high SES). CONCLUSION: In Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account

Site-Level Variation in the Characteristics and Care of Infants With Neonatal Opioid Withdrawal

BACKGROUND AND OBJECTIVES: Variation in pediatric medical care is common and contributes to differences in patient outcomes. Site-to-site variation in the characteristics and care of infants with neonatal opioid withdrawal syndrome (NOWS) has yet to be quantified. Our objective was to describe site-to-site variation in maternal-infant characteristics, infant management, and outcomes for infants with NOWS. METHODS: Cross-sectional study of 1377 infants born between July 1, 2016, and June 30, 2017, who were ≥36 weeks\u27 gestation, with NOWS (evidence of opioid exposure and NOWS scoring within the first 120 hours of life) born at or transferred to 1 of 30 participating hospitals nationwide. Site-to-site variation for each parameter within the 3 domains was measured as the range of individual site-level means, medians, or proportions. RESULTS: Sites varied widely in the proportion of infants whose mothers received adequate prenatal care (31.3%-100%), medication-assisted treatment (5.9%-100%), and prenatal counseling (1.9%-75.5%). Sites varied in the proportion of infants with toxicology screening (50%-100%) and proportion of infants receiving pharmacologic therapy (6.7%-100%), secondary medications (1.1%-69.2%), and nonpharmacologic interventions including fortified feeds (2.9%-90%) and maternal breast milk (22.2%-83.3%). The mean length of stay varied across sites (2-28.8 days), as did the proportion of infants discharged with their parents (33.3%-91.1%). CONCLUSIONS: Considerable site-to-site variation exists in all 3 domains. The magnitude of the observed variation makes it unlikely that all infants are receiving efficient and effective care for NOWS. This variation should be considered in future clinical trial development, practice implementation, and policy development

Ravaged landscapes and climate vulnerability: The challenge in achieving food security and nutrition in post-conflict Timor-Leste

Food insecurity and malnutrition are prevalent in post-conflict countries. Climate change poses further challenges to their food production. Timor-Leste is an agrarian society that won independence in 2002 and is struggling to achieve food security and reduce undernutrition as the country modernizes. The economy depends on fossil fuel revenues and oil reserves are dwindling. A review of climate, agricultural, and nutrition data reveals high weather vulnerability, low agricultural productivity, and slow dietary and nutritional progress. But solutions exist. Agricultural sector actions can make important contributions to poverty reduction, food security, dietary diversity, micronutrient sufficiency, and overall nutrition. Agriculture can be made to be more nutrition- and gender-sensitive with a focus on mixed farming systems, biodiversity, climate-smart practices, and access to inputs, training, and technologies for farmers to enable sustainable and healthy rural livelihoods. Ultimately, productivity levels must improve to support the availability of sufficient and nutritious foods