Quality of caesarean delivery services and documentation in first-line referral facilities in Afghanistan: a chart review

<p>Abstract</p> <p>Background</p> <p>Increasing appropriate use and documentation of caesarean section (CS) has the potential to decrease maternal and perinatal mortality in settings with low CS rates. We analyzed data collected as part of a comprehensive needs assessment of emergency obstetric and newborn care (EmONC) facilities in Afghanistan to gain a greater understanding of the clinical indications, timeliness, and outcomes of CS deliveries.</p> <p>Methods</p> <p>Records were reviewed at 78 government health facilities expected to function as EmONC providers that were located in secure areas of the country. Information was collected on the three most recent CS deliveries in the preceding 12 months at facilities with at least one CS delivery in the preceding three months. After excluding 16 facilities with no recent CS deliveries, the sample includes 173 CS deliveries at 62 facilities.</p> <p>Results</p> <p>No CS deliveries were performed in the previous three months at 21% of facilities surveyed; all of these were lower-level facilities. Most CS deliveries (88%) were classified as emergencies, and only 12% were referrals from another facility. General anesthesia was used in 62% of cases, and spinal or epidural anesthesia in 34%. Only 28% of cases were managed with a partograph. Surgery began less than one hour after the decision for a CS delivery in just 30% of emergency cases. Among the 173 cases, 27 maternal deaths, 28 stillbirths, and 3 early neonatal deaths were documented. In cases of maternal and fetal death, the most common indications for CS delivery were placenta praevia or abruption and malpresentation. In 62% of maternal deaths, the fetus was stillborn or died shortly after birth. In 48% of stillbirths, the fetus had a normal heart rate at the last check. Information on partograph use was missing in 38% of cases, information on parity missing in 23% of cases and indications for cesareans missing in 9%.</p> <p>Conclusions</p> <p>Timely referral within and to EmONC facilities would decrease the proportion of CS deliveries that develop to emergency status. While the substantial mortality associated with CS in Afghanistan may be partly due to women coming late for obstetric care, efforts to increase the availability and utilization of CS must also focus on improving the quality of care to reduce mortality. Key goals should be encouraging use of partographs and improving decision-making and documentation around CS deliveries.</p

Essays on Sovereign Risk and Banking

This thesis consists of three essays on sovereign risk and banking. In the first essay, we examine the determinants of sovereign risk in the Eurozone focusing on the recent crisis episode and search for a self-fulfilling contagion link by using an exogenous ECB policy announcement for identification. our principal components analysis reveals that the perceived commonality in default risk among peripheral and core Eurozone countries increased after the announcement. An event study detects significant pre-announcement news transmission from Spain to Italy, Belgium, France and Austria that clearly dissipates post-announcement. Country-specific regressions of CDS spreads on systematic risk factors illustrate frequent days of large adverse shocks affecting simultaneously those same Eurozone countries during the pre-announcement period; but not afterwards. Altogether these findings support the view that market expectations during Eurozone crisis were at least partially self-fulfilling and ECB policy helped to contain such adverse dynamics. In the second essay we focus on European banks' sovereign bond exposures. By using a novel bank-level dataset covering the entire timeline of the Eurozone crisis, we first reconfirm that the crisi led to the reallocation of sovereign debt from foreign to domestic banks. This reallocation was only visible for banks as opposed to other domestic private agents and it cannot be explained by the banks' risk-shifting tendency. In contrast to the recent literature focusing only on sovereign debt. We show that the bank's private sector exposures were (at least) equally affected by a rise in home bias. Finally, we propose a new debt reallocation channel based on informational frictions and show that crisi-country debt was not only reallocated to domestic banks, but also to the informationally closer foreign banks. Our results imply that informational asymmetries among banks played a key role in the recent fragmentation across Eurozone debt markets. In the third essay, our investigation shifts towards political economy aspects of the relationship between sovereigns and domestic banks. We use date on the universe of credit extended over a 14 year period in Turkey to document a strong political lending cycle. We find that state-owned banks systemically adjust their provincial lending around local elections relative to the private banks in the same province. there is considerable tactical redistribution: state-pwned banks increase loans in politically competitive provinces with a current mayor aligned with the ruling party but reduce it in similar provinces with a current mayor from opposition.this effect only exists in corporate lending as opposed to consumer loans, suggesting that tactical redistribution targets job creation to increase electoral success. Such political lending also seems to influence real outcomes as the credit constrained opposition areas suffer a drop in economic output as measured by local construction activity

Categorising interventions to levels of inpatient care for small and sick newborns: Findings from a global survey.

BACKGROUND: In 2017, 2.5 million newborns died, mainly from prematurity, infections, and intrapartum events. Preventing these deaths requires health systems to provide routine and emergency care at birth, and quality inpatient care for small and sick newborns. Defined levels of emergency obstetric care (EmOC) and standardised measurement of "signal functions" has improved tracking of maternal care in low- and middle-income countries (LMICs). Levels of newborn care, particularly for small and sick newborns, and associated signal functions are still not consistently defined or tracked. METHODS: Between November 2016-November 2017, we conducted an online survey of professionals working in maternal and newborn health. We asked respondents to categorise 18 clinical care interventions that could act as potential signal functions for small and sick newborns to 3 levels of care they thought were appropriate for health systems in LMICs to provide: "routine care at birth", "special care" and "intensive care". We calculated the percentage of respondents that classified each intervention at each level of care and stratified responses to look at variation by respondent characteristics. RESULTS: Six interventions were classified to specific levels by more than 50% of respondents as "routine care at birth," three interventions as "special care" and one as "intensive care". Eight interventions were borderline between these care levels. Responses were more consistent for interventions with relevant WHO clinical care guidelines while more variation in respondents' classification was observed in complex interventions that lack standards or guidelines. Respondents with experience in lower-income settings were more likely to assign a higher level of care for more complex interventions. CONCLUSIONS: Results were consistent with known challenges of scaling up inpatient care in lower-income settings and underline the importance of comprehensive guidelines and standards for inpatient care. Further work is needed to develop a shortlist of newborn signal functions aligned with emergency obstetric care levels to track universal health coverage for mothers and their newborns

Gestational diabetes in rural East Africa: A call to action

The number of cases of diabetes worldwide has increased significantly in the last decade. Characteristically, the incidence of gestational diabetes (GDM) reflects the incidence of type 2 diabetes mellitus (T2DM) in the background population, which is a warning that a rapid increase in the incidence is to be expected concomitant with the already observed increase in the incidence of T2DM. Although the majority of all deliveries worldwide take place in the so-called developing world, little is known about the prevalence of diabetes in pregnancy in rural areas of East Africa. Diabetes in pregnancy has effects on prospects for marriage, motherhood, and the role of women in East African society. Furthermore, intrauterine exposure to the metabolic environment of maternal diabetes, or GDM, is associated with increased risk of altered glucose homeostasis in the offspring, beginning in childhood and producing a higher prevalence of GDM in the next generation with all burdens and complications being associated with this disease. It is reasonable to conclude that more newborn infants each year are being exposed to the metabolic environment of diabetes during intrauterine development as a result of changing incidence and demographics of diabetes and pregnancy. We believe that programs and policies have to be established, including organization of the health system to provide care, medicines, and other tools necessary for diabetes in pregnancy management, consideration of accessibility and affordability of care, education for healthcare workers, and education of pregnant and nonpregnant women of reproductive age

Management of Diabetes in Pregnancy: Comparison of Guidelines with Current Practice at Austrian and Australian Obstetric Center

Aim To compare Austrian and Australian national guidelines for gestational and pre-gestational diabetes and estimate the level to which physicians comply with their country's guidelines

A Semantic Field: The Camel

The article presents a study to discover the role of the camel in the life of Somali people from at least two points of view: the linguistic one, exploring the semantic field represented by the camel in Somali language, and the literary one, providing songs of cameleers, proverbs and poems.Maqaalku wuxuu muujinayaa daraasaad lagu xiriira dowrka uu geela ku leeyahay nolosha bulshada soomaaliyeed, gaar ahaan xagga afka iyo suugaanta la xiriirta geela, sida heesaha geela, maahmaahyada iyo maansada.L'articolo presenta uno studio per approfondire il ruolo del cammello nella vita del popolo somalo da almeno due punti di vista: quello linguistico, esplorando il campo semantico relativo al cammello in lingua somala, e quello letterario, fornendo canzoni di cammellieri, proverbi e poesie.Thomas Labahn (ed.