South-South Knowledge Sharing for the Inclusion of the Urban Poor: India-South Africa Praxis

Shack/Slum Dwellers International (SDI) is a social movement of the urban poor which began in India, networked initially in Asia and then moved to South Africa, and to the other parts of Africa. SDI created knowledge and strategies to help communities of the poor to transform themselves from beneficiaries and consumers of aid and assistance into actors who demonstrated possible ways for city governments and international agencies committed to development to explore solutions. SDI which facilitated the first exchange of five South African township leaders to India formed the basis of the India-South Africa learning exchange programme. The engagement between the community federations from these countries grew, with many Asian and African slum federations at the centre of the learning process, designing possibilities, managing transnational relationship. The exchanges have not just included civil society actors, but also government officials. In 1996, Slum/Shack Dwellers International (SDI) was formed by the federations from eight countries from Asia, Africa and Latin America. To date, federations from 33 countries are the members of SDI

Inter-hospital obstetric referrals: public versus private sector to a tertiary care teaching hospital in South Kerala, India

Background: Inter-hospital Emergency obstetric transfers should be carried out effectively and efficiently to avoid maternal and fetal morbidity and mortality. Authors would like  to analyse the determinants ,patterns and reasons for referrals to tertiary hospital  for women with obstetric high-risk, complications and obstetric emergencies  from both public and private sectors and look into course in hospital and their feto-matermal morbidities.Methods: Descriptive study done at a tertiary care teaching hospital where 124 obstetrical referrals from nearby private and public health sectors were recruited.Results: Infertility treated obstetric referrals were at significant risk of referral (p value-0.002). Public sector referrals had past history of early pregnancy loss which was significant (p value-0.002). Public sector had statistically significant in -labour referrals (p value-0.04). All the obstetric referrals from public health sector reached within half an hour while one third of private sector referrals travelled more than an hour for emergency obstetric care (p value 0.001). Bronchial Asthma caused significant morbidity among public sector referrals (p value-0.001). Public sector referrals <31 weeks were nil while 55 % obstetric referrals were referred <31 weeks from various private hospitals seeked neonatal care with significant p value (0.016). NICU admissions were statistically significant in private sector referrals (p-value 0.001). Mean hospital stay in private sector referrals was 10.17 days and it was 7.62 days in government referrals.Conclusions: Specific guidelines for whom to refer, how to refer, when to refer and where to refer would be helpful in making timely referral. More stringent documentation in the referral slips and more co-ordination between the referral unit and the higher centers are required to build a strong health system

Incidence and risk factors for term low birth weight babies in a tertiary care hospital in Kerala

Background: Birth weight of <2.5 kg at birth is considered low birth weight and impacts the individual's health during their adult life. Babies are born with low birth weight, both in term and preterm deliveries. This study aims to find the incidence of term low birth weight babies (TLBW) and the maternal risk factors associated with the same.Methods: This case-control study was conducted on 166 pregnant women who had term live births during the study period July 2019 to December 2020. Inclusion criteria: Women with a live singleton TLBW (<2.5 kg) - cases (63) and normal birth weight babies - controls (103). Control group selection was 1:2 proportion as per the cases. Exclusion criteria consisted of women with multiple gestations. Binary and categorical variables were presented using counts and percentages. Independent sample t-test was used to compare two continuous variables, and the chi-square test/Fisher's exact test was used to find the association of categorical variables.Results: 1344 live births were reported during the study period, of which 63 cases were TLBW babies with an incidence of 4.68%. Among the baseline parameters, significant difference was observed only in body mass index (BMI). After assessing the common risk factors like anemia, urinary tract infection (UTI), genital tract infection, gestational diabetes mellitus (GDM), and gestational hypertension, only hypothyroidism showed significant association with TLBW (OR: 2.240, 95% CI:0.98-5.13, p=0.006).Conclusions: The incidence of TLBW babies was 4.68%, which is low compared with other studies. Hypothyroidism shows significant association with TLBW in this study which was not observed in previous literature

Determinants and outcomes of caesarean delivery: elective versus emergency in a tertiary care teaching institute in Kerala, India

Background: Globally, the caesarean delivery rate is rising continuously, making caesarean one of the most common surgical procedures. The purpose was to analyse the determinants and maternofoetal outcomes in elective versus emergency caesarean sections in a tertiary care centre.Methods: All women, who gave birth by Caesarean deliveries done over a period of 1 year (January 2018-December 2018), were studied in Travancore Medical College in Kerala, India. Indications of caesarean, whether emergency or elective, medical morbidities, Gestational age at decision, birthweights and extended hospital stay and new-borns needed to resuscitate were looked into. The data was collected and analysed from the hospital registry.Results: Out of the 378 selected patients, 95 patients in group of elective and 283 emergency caesarean section were studied. The indications of emergency caesarean sections were failed induction, non-progression of labour, CPD, Previous caesarean in labour, foetal distress. The most frequent indicator for elective lower segment caesarean section (LSCS) was patient with previous LSCS not willing for vaginal birth, followed by breech presentation and high risk pregnancy ( BOH and ART). Younger mothers, gestational age remote from term, low-birth weight, and extended hospital stay were statistically significant in mothers undergoing emergency caesarean delivery. Fever, urinary tract infections, need for maternal and neonatal ventilation, blood transfusion, scar dehiscence were more common in the emergency caesarean group.Conclusions: The antenatal morbidity, low birth weights, decision taken preterm for salvaging the baby, postoperative complications and extended stay were more in the emergency caesarean when compared to elective caesarean

Screening for perceived stress among pregnant women availing antenatal care at a tertiary care teaching institution in Kerala, India

Background: Stress during pregnancy can have serious adverse outcomes on the mother, the foetus and the new-born. It can lead to low-birth-weight, preterm births and neuro-psychological effects such as anxiety and depression during pregnancy and puerperium. This cross-sectional research aims to assess the severity of stress among postnatal women in Kerala. This study analysed socio-demographic, obstetric, family dynamics, neonatal characteristics and psychiatric determinants of postpartum stress using perceived stress scale (PSS) among postnatal women in a tertiary hospital in Kerala state, India.Methods: 119 women between 2 to 6 weeks of postpartum period were subjected to a pre-tested pre-structured standard questionnaire. Terminal illness, still birth delivery and comorbid psychiatric illness was excluded. Screening and diagnosis of postpartum stress was done based on perceived stress scale (PSS) and graded as mild 0-13, moderate 14-26, severe 27-40.Results: Study findings indicated a statistically significant association between postpartum stress and risk factors such as unplanned/unwanted pregnancy. The mean age of women was 27±4.8 years. Support from spouse and in-laws was a negative predictor of developing both postnatal stress and depression. Family income, education of couple and husbands’ occupations were non-determinant factors (p>0.05) in this study. Psychiatric illness in the family and past history of psychiatric illness also contributed to postnatal stress. The most important variable which influenced perceived stress during pregnancy was lengthier NICU stay. Even breastfeeding problems and associated neonatal issues worsened the stress scales significantly in the immediate postnatal period.Conclusions: This research concluded that stress detection and timely counselling along with mental and physical support will mitigate stress and postpartum depression

Prevalence and determinants of postnatal depression in a tertiary care teaching institute in Kerala, India

Background: Pregnancy and childbirth produce a variety of physiological, psychological and social consequences. Attitudes toward pregnancy and childbirth vary from culture to culture. Prevalence estimates range from 13 to 19% in resource-rich settings and 11 to 42% in resource- limited settings PND has a significant impact on the mother, the family, her partner and mother-infant interaction. This research aims to aid the early diagnosis of postnatal depression and the socio-demographic, obstetric, family dynamics, neonatal characteristics and psychiatric determinants of depression using EPDS among postnatal women in a tertiary hospital in Kerala state, India.Methods: 119 women between 2 to 6 weeks of postpartum period were subjected to a pre-tested pre-structured standard questionnaire. Diagnosis of depression was made using the Edinburgh postnatal depression scale. Possible depression is values >13 or more are invariably associated with depression.Results: Young age at marriage (p-value 0.022), love marriage (p-value 0.040) and low social support inadequate relationship with the in-laws was significantly associated with PND (p-0.003). Low birth weight was a significant determinant of PND (p-value-0.018). Gender of the new-born, fear and preference towards any particular gender and order of female child in multiparous woman had no association in determining postnatal depression. Childcare stress (p-value-0.011), psychiatry history in family and personal history of depression and mothers with low self-esteem (p-value-0.001) had odds of developing postnatal depression in the study.Conclusions: Early screening of the women and counselling of women and their family will reduce the maternal morbidity and adverse child outcomes

Analysis of caesarean delivery using Robson ten group classification system at a tertiary care teaching institute in Kerala, India

Background: Globally, the caesarean delivery rate is rising continuously, making caesarean one of the most common surgical procedures. The Robson classification, appreciated by WHO in 2014 and FIGO in 2016 is widely accepted, risk-based, ten-group classification system (TGCS) developed specifically to assess caesarean section rates. The aim of this study was to know the rate of Caesarean section in present hospital, to analyse the Caesarean sections based on Robson’s classification and to determine the contribution and significance of each group on the overall number of Caesarean sections.Methods: All women, who gave birth by Caesarean deliveries done over a period of 1 year (January 2018-December 2018) in Travancore Medical College Hospital in South Kerala India.Results: Group 5 (previous LSCS, single, cephalic >37 weeks) made the greatest contribution to the Caesarean section rate (27.24%). The second highest contributor was Group 2 (Nulliparous, singleton, cephalic, >37 weeks induced labour or caesarean section before labour followed by Group 10 (all single cephalic <36 weeks including previous CS) 18.78%.Conclusions: Limiting the CS rate in low-risk pregnancies is key to lowering the trend of increased CS. If TGCS is used uniformly, CS rates can be compared over time and between units, both nationally and internationally

Maternal risk factors and perinatal outcomes in fetal growth restriction using obstetric Doppler in South Kerala, India

Background: Fetal Growth Restriction (FGR) is the single largest contributing factor to perinatal morbidity in non-anomalous foetuses. Synonymous with Intrauterine Growth Restriction (IUGR), it is defined as an estimated fetal weight less than the10th percentile. Obstetric Doppler has helped in early detection and timely intervention in babies with FGR with significant improvements in perinatal outcomes.  Hence, authors evaluated the maternal risk factors and diagnosis-delivery intervals and perinatal outcomes in FGR using Doppler.Methods: This research conducted in a tertiary care hospital in South Kerala included 82 pregnant women who gave birth to neonates with birth weight less than the 10th percentile over a period of1 year (Jan 1, 2017-Dec 31, 2017). Socio-demographic, maternal risk, Diagnosis- delivery interval in FGR and neonatal morbidities were studied.Results: Mean GA at diagnosis in weeks was 34.29 and 35.19 respectively for abnormal and normal Doppler respectively (p value-0.032). The mean birthweight in Doppler abnormal FGR was 272.34 g lesser than in Doppler normal group (p value-0.001). Growth restricted low birth weight neonates had Doppler   pattern abnormalities (p value-0.0009). FGR <3rd percentile and AFI <5 had abnormal Doppler (OR:6.7). Abnormal biophysical profile (OR:14) and Non-Reactive NST (OR:3.5) correlated with abnormal Doppler. Growth restricted with normal Doppler had shorter NICU stays than with abnormalities (p value-0.003). Term FGR went home early than early preterm. (p value-0.001).Conclusions: Abnormal Doppler velocimetry is significantly associated with earlier FGR detection, shorter decision- delivery interval, reduction in the mean birthweight and longer NICU stay. Hence, Umbilical artery Doppler and Cerebroplacental index is an integral part of in-utero fetal surveillance to identify impending fetal hypoxia, appropriate management, optimising the timing of delivery and improve perinatal health in FGR

Feto-maternal outcome in patients with couvelaire uterus: a 3 year study in a tertiary care hospital in rural Karnataka, India

Background: Couvelaire uterus also known as uteroplacental apoplexy is a life threatening condition where abruptio placenta causes bleeding that penetrates into the uterine myometrium. It can only be diagnosed on direct visualization. Therefore, its occurrence is perhaps under reported and underestimated in the literature. The objective of this study was to determine the risk factors for couvelaire uterus and feto-maternal outcomes associated with couvelaire uterus in comparison with patients who presented with abruption without couvelaire uterus in a tertiary care hospital in rural Karnataka.Methods: All women who had abruptio placenta who were delivered by cesarean section were included in the study. Cases were women with couvelaire uterus and controls were women without couvelaire uterus observed intraoperatively during cesarean section.Results: Patients without couvelaire uterus had significantly more vaginal bleeding (22.2% vs 75%). However, patients with couvelaire uterus had a higher incidence of PPH (66.7% vs 28.6%), need for blood transfusion (5.9±3.2 pints vs 1.6±1.8 pints), DIC (22.2% vs 14.3%), maternal mortality (5.6% vs 0) and adverse neonatal outcome.Conclusions: We conclude that patients with couvelaire uterus had an increased risk of maternal complications such as postpartum hemorrhage and disseminated intravascular coagulation which resulted in increased need for blood transfusion, prolonged hospital stay and maternal morbidity and mortality. Present study further highlights that adverse neonatal outcomes such as low birth weight, low Apgar score and neonatal death were more frequently associated with couvelaire uterus. Thus, the presence of couvelaire uterus may be considered as a severe form of abruption and such patients should be anticipated for higher incidence and risk for maternal and neonatal morbidity

Doppler patterns in growth restricted foetuses: determinants and outcome in a tertiary hospital in South Kerala, India

Background: Foetal growth restriction refers to a condition in which the foetus is unable to achieve its genetically determined growth potential. Doppler velocimetry in FGR not only decides the optimum time of delivery but also the optimum mode of delivery and so authors evaluated the Doppler patterns in growth restricted fetuses.Methods: Nested case-control study conducted among normal and abnormal Doppler groups at a tertiary care teaching hospital in the year 2017.Results: Among 82 growth restricted foetuses, 54 of them had normal Doppler patterns (65.85%) and 28 had abnormal Doppler patterns (34.15%).13(46.5%) had umbilical S/D elevation,2 (7.14%) had AEDV,1(3.57%) with REDV and 12 (42.8%) with CPR<1. Mean maternal age was slightly higher in the abnormal Doppler group. FGR babies with abnormal velocity waveforms had shorter diagnosis to delivery interval than those with normal Doppler and decision for delivery was taken at a lower gestational age. (p value-0.001). Mothers of FGR babies with abnormal Doppler studies underwent emergency caesarean section for non-reassuring foetal heart patterns. (p value-0.001) The mean birth weight was higher (2201.80gm) in Doppler normal FGR and it was 1929.46grams in abnormal umbilical Doppler group and 1363.33gm in AREDV (pvalue-0.001). Growth restricted with normal Doppler had shorter NICU stays than with abnormalities (p value-0.003). Term FGR went home early than early preterm. (p value-0.001).Conclusions: Growth restricted foetuses with normal umbilical velocimetry are at a lower risk than those with abnormal velocimetry in terms of prolonged diagnosis-delivery interval and shorter NICU days. The need for neonatal resuscitation at birth was more in babies with abnormal Doppler velocimetry and absent diastole /reversed diastolic flow of umbilical artery velocimetry