Assessing the Regional and District Capacity for Operationalizing Emergency Obstetric Care through First Referral Units in Gujarat

Maternal mortality remains to be one of the very important public health problems in India. The maternal mortality estimates, is about (300-400/100,000 live births). There are diverse management issues, policy barriers to be overcome for improving maternal health. Especially, the operationalization of Emergency Obstetric Care (EmOC) and access to skilled care attendance during delivery. This study focuses on understanding the regional and district level capacity of the state government to operationalize First Referral Units for providing Emergency Obstetric care. This study is a part of a larger project for strengthening midwifery and Emergency Obstetric Care in India. The study apart from giving an in-depth insight into the functioning of various health facilities highlights the results from the basic to the more comprehensive level of EmOC services. It gives recommendation on various measures to rectify shortcomings noticed and make EmOC a more effective at different levels in the State of Gujarat. The study uses both primary and secondary data collection. The study was conducted in six regions of Gujarat -one district from each of these regions was selected. Out of these districts 27 health facilities were examined, which consists of seven district hospitals, eight designated as first referral units (FRU), four community health centers (CHC) and eight 24/7 primary health centers (PHC). Detailed field notes for individual facilities were prepared and analyzed subsequently for all facilities together. A common feature among all health centres were issues related to general infrastructure. Many times infrastructure planning (location, layout and maintenance) is left to engineers, who have limited knowledge about proper EmOC services. Poor infrastructure leads to poor quality of health services and wastage of resources. Through National Rural Health Mission (NRHM) and Rogi Kalyan Samiti funds major and minor repair/renovations are taking place to improve hospital buildings. In some health facilities from poor resource setting with high demand from patients were still able to deliver services. Human resources analysis suggests that there is shortage of specialists at FRUs, and committed nursing staff in labor room. As result of the Chiranjeevi initiative, the Below Poverty Line (BPL) population who earlier used to public health facilities are now accessing private facilities for delivery, and this has affected and decreased the workload of the public health facilities. Furthermore, there is lack of managerial skills at senior level hospital staff. Registers like birth, drug, Medical Termination of Pregnancy are maintained but not in standard format. Since complicated cases are not registered properly, maternal deaths are not reported. Even though the system of monitoring is well established at the state and district level, they are not properly followed. The funds for operationalization of First Referral Units come from department of family welfare. However, the administrative control is in the hands of department of medical services. Due to this factor monitoring system has become weak. The weak link between these two departments is the Regional Deputy Director who has only one administrative staff to take care of the issues in their region. The problem of monitoring the Primary Health Centres has become smooth with the appointment of new District Project Coordinators. Some facilities especially in district hospital reported that internal meetings and monitoring are happening because of the special interest of facility managers and newly appointed assistant hospitals administrators. In lower facilities this type of internal monitoring exists in a weak form. Underutilization of government facilities is a result of poor quality of services provided. In spite of reasonably developed health system, several problems of infrastructure, staffing, accountability and management capacity contribute to the poor functioning of facilities to act as an EmOC service delivery center. Some of the major bottlenecks in improving EmOC services are limited management capacity, lack of availability of blood in rural areas and poor registration of births and deaths and no monitoring of EmOC. District hospitals, FRUs, CHCs and Sub district hospitals come under the administrative control of the department of medical services. The clinical monitoring of these facilities lies with the department of health and family welfare. At the district level monitoring of these facilities are not properly done, therefore it effects directly the operationalization of the facilities. In the absence of adequate management capacity, the operationalization of EmOC is not well planned, executed or monitored, which results in delays in implementation and poor quality of care.

Tetanus trismus in a 2 year old child: Case report

Tetanus is still a major cause of mortality and morbidity in developing countries. It occurs in children mainly in the unimmunized, due to parental ignorance and objection to vaccination. This potentially fatal disease caused by a neurotoxin, tetanospasmin released from wounds infected with Clostridium tetani, an anaerobic gram–positive bacillus. As tetanus becomes less common, cases are likely to be misdiagnosed or go unrecognized. In this case report, we present a case of tetanus in a partially immunized 2 year old girl who presented with trismus. She was treated with the recent recommendations and adequate supportive care. Detection of tetanus at a very early stage can favor lifesaving interventions. Trismus, infected wound and partially immunized/unimmunized status of a child were the key features leading to the prompt diagnosis and early treatment

Managing Equipment for Emergency Obstetric Care in Rural Hospitals

In resource poor countries substantial sums of money, from governments and international donors, are used to purchase equipment for health facilities. WHO estimates that 50-80% of such equipment remains non-functional. This article is based on the experiences from various projects in developing countries in Asia and Africa. The key issues in the purchase, distribution, installation, management and maintenance of equipment for emergency obstetric care (EmOC) services are identified and discussed. Some positive examples are described to show how common equipment management problems are solved.

Extractability and characteristics of proteins deriving from wheat DDGS

Wheat Distillers’ Dried Grains with Solubles (DDGS) and in-process samples were used for protein extraction. Prolamins were the predominant protein components in the samples. The absence of extractable α- and γ-gliadins in DDGS indicated protein aggregation during the drum drying processing stage. Prolamin extraction was performed using 70% (v/v) ethanol or alkaline-ethanol solution in the presence of reducing agent. DDGS extracts had relatively low protein contents (14-44.9%, w/w), regardless of the condition applied. The wet solids were the most suitable raw material for protein extraction, with recovery yields of ~ 55% (w/w) and protein content of ~58% (w/w) in 70% (v/v) ethanol. Protein extracts from wet solids were significantly rich in glutamic acid and proline. Mass balance calculations demonstrated the high carbohydrate content (~ 50%, w/w) of solid residues. Overall, the feasibility of utilising in-process samples of DDGS for protein extraction with commercial potential was demonstrated

Building the Infrastructure to Reach and Care for the Poor: Trends, Obstacles and Strategies to overcome them

Infrastructure forms a critical part of health service delivery in any country. Availability, Accessibility, Affordability, Equity, Efficiency and Quality of MNH services highly depend on the distribution, functionality and quality of infrastructure. Most developing countries have invested substantially in developing health infrastructure in rural areas which provides a base for extending MNH services to the poor. Still, there is clear evidence that in many countries there are gaps and inadequacies in health infrastructure. The functionality and utilization of health infrastructure has been sub-optimal or poor due to a variety of reasons. This paper reviews available literature and assesses the coverage and gaps in infrastructure for MNH. It also identifies critical issues in management of infrastructure and analysis their causes and impact on services delivery to the poor. The paper also reviews impacts of reforms on infrastructure and provides some recommendations for improvement of infrastructure management so as to ensure better services to the poor.

IL-33 stimulates expression of the GPR84 (EX33) fatty acid receptor gene and of cytokine and chemokine genes in human adipocytes

Expression of GPCR fatty acid sensor/receptor genes in adipocytes is modulated by inflammatory mediators, particularly IL-1β. In this study we examined whether the IL-1 gene superfamily member, IL-33, also regulates expression of the fatty acid receptor genes in adipocytes. Human fat cells, differentiated from preadipocytes, were incubated with IL-33 at three different dose levels for 3 or 24 h and mRNA measured by qPCR. Treatment with IL-33 induced a dose-dependent increase in GPR84 mRNA at 3 h, the level with the highest dose being 13.7-fold greater than in controls. Stimulation of GPR84 expression was transitory; the mRNA level was not elevated at 24 h. In contrast to GPR84, IL-33 had no effect on GPR120 expression. IL-33 markedly stimulated expression of the IL1B, CCL2, IL6, CXCL2 and CSF3 genes, but there was no effect on ADIPOQ expression. The largest effect was on CSF3, the mRNA level of which increased 183-fold over controls at 3 h with the highest dose of IL-33; there was a parallel increase in the secretion of G-CSF protein into the medium. It is concluded that in human adipocytes IL-33, which is synthesised in adipose tissue, has a strong stimulatory effect on the expression of cytokine and chemokine genes, particularly CSF3, and on the expression of GPR84, a pro-inflammatory fatty acid receptor

The platelet-surface thiol isomerase enzyme ERp57 modulates platelet function

Background: Thiol isomerases are a family of endoplasmic reticulum enzymes which orchestrate redox-based modifications of protein disulphide bonds. Previous studies have identified important roles for the thiol isomerases PDI and ERp5 in the regulation of normal platelet function. Objectives: Recently, we demonstrated the presence of a further five thiol isomerases at the platelet surface. In this report we aim to report the role of one of these enzymes - ERp57 in the regulation of platelet function. Methods/Results: Using enzyme activity function blocking antibodies, we demonstrate a role for ERp57 in platelet aggregation, dense granule secretion, fibrinogen binding, calcium mobilisation and thrombus formation under arterial conditions. In addition to the effects of ERp57 on isolated platelets, we observe the presence of ERp57 in the developing thrombus in vivo. Furthermore the inhibition of ERp57 function was found to reduce laser-injury induced arterial thrombus formation in a murine model of thrombosis. Conclusions: These data suggest that ERp57 is important for normal platelet function and opens up the possibility that the regulation of platelet function by a range of cell surface thiol isomerases may represent a broad paradigm for the regulation of haemostasis and thrombosis

Development and characterisation of protein films derived from dried distillers’ grains with solubles and in-process samples

Polymer films were developed utilising proteins extracted from wheat distillers’ dried grains with solubles (DDGS) and in-process samples (wet solids), both by-products of bioethanol production process. Structural characterisation of DDGS and wet solids films indicated a change in the secondary structure of the proteins, reflecting the impact of DDGS production process such as effect of enzyme on protein properties and consequently on the film properties; whereas the developed films exhibited a rough surface with voids. Determination of moisture sensitivity indicated that DDGS films exhibited more hydrophilicity than wet solids films, with the same trend being observed for their water solubility and water uptake. The moisture content and solubility of DDGS films ranged from 10.2-14.2 % and 32.3-41.8 % respectively whereas those for wet solids’ film ranged from 18.9-19.8 % and 23.8-24.2 % respectively. The mechanical properties of DDGS and wet solids (ranging from 0.27-0.32 MPa) were comparatively lower than commercial wheat gluten film (0.6 MPa). The poor mechanical properties and high water vapour permeability of DDGS and the wet solids films limit their application as biodegradable packaging materials. However, based on their hydrophilicity, the developed films have potential applications in agriculture and horticulture as controlled release matrices and soil conditioners