Gunnar Tschudi Bondevik

Maternal hematological status and risk of low birth weight and preterm delivery in Nepal

Background. Our aim was to investigate associations between maternal characteristics, with emphasis on hematological status, and risk of low birth weight and preterm delivery among pregnant Nepali women.

Homocysteine and methylmalonic acid levels in pregnant Nepali women. Should cobalamin supplementation be considered

Objective: The aim of this study was to investigate homocysteine and methylmalonic acid levels as markers of functional cobalamin and folate status in pregnant Nepali women.Design: Cross-sectional study.Setting: Patan Hospital, Kathmandu, Nepal.Subjects: A sub-sample (n=382) of all pregnant women (n=2856) coming for their first antenatal visit in a 12 month period, 1994–1995. The selection of the sub-sample was based on maternal haematocrit values, categorised into three groups: severely, moderately and non-anaemic women. As serum levels of total homocysteine (s-tHcy) and methylmalonic acid (s-MMA) were similar in the three groups, pooled data are presented. Women who had already received micronutrient supplementation (n=54) were excluded. The remaining women (n=328) were included in the statistical analysis.Results: Overall mean values (±s.d.) of s-tHcy and s-MMA were 9.5 (±4.2) µmol/l and 0.39 (±0.32) µmol/l, respectively. Elevated s-tHcy (>7.5 µmol/l) was found in 68% of the women, while 61% had elevated s-MMA (>0.26 µmol/l). Low s-cobalamin values (<150 pmol/l) were observed in 49% of the women, while only 7% had low s-folate values (≤4.5 nmol/l). s-tHcy was significantly correlated with s-MMA (r=0.28, P<0.001), s-cobalamin (r=−0.30, P<0.001) and s-folate (r=−0.24, P<0.001). s-MMA was significantly associated with s-cobalamin (r=−0.40, P<0.001), but not with s-folate.Conclusions: Functional cobalamin deficiency was very common in the study population, while functional folate deficiency was rather uncommon. We suggest considering cobalamin supplementation to pregnant Nepali women.Sponsorship: The Norwegian Research Council and the Norwegian Universities Committee for Development, Research and Education.European Journal of Clinical Nutrition (2001) 55, 856–864

Factors associated with depressive symptoms among postnatal women in Nepal

Background. Depression after childbirth affects both the mother and her infant. In South‐Asia, maternal depression might also contribute to poor infant growth. Knowledge of risk factors could improve the health workers’ recognition of depression. Aim. To examine possible risk factors for depression in the postnatal period among women in one clinical, one urban and one rural population in Lalitpur district, Nepal. Method. A total of 426 postnatal women were included in a cross‐sectional structured interview study, 5–10 weeks after delivery. Depressive symptoms were measured by the Edinburgh Postnatal Depression Scale [EPDS]. Results. Multivariate analysis showed that depression (EPDS >12) was strongly associated with husbands alcoholism, polygamy and previous depression. Other significant factors were stressful life events, multiparity, smoking and depression during pregnancy. There was a non‐significant trend of lower depressive scores among women living in arranged marriages, and among women practicing the tradition of staying in their maternal home after delivery. Conclusions. In addition to previously documented risk factors, traditional family structures may influence the risk of depression among postnatal women in Nepal.

Anaemia in pregnancy: possible causes and risk factors in Nepali women

Objective: The aim of this study was to investigate the importance of nutritional deficiencies and infections in the development of anaemia in pregnant Nepali women.Design: Case-control study.Setting: Patan Hospital, Kathmandu, Nepal.Subjects: A sub-sample (n=479) of all pregnant women (n=2856) coming for their first antenatal visit in a 12 month period, 1994–1995. Women who had already received any micronutrient supplementation (n=82), and those whose serum samples showed macroscopic haemolysis (n=7) were excluded. The remaining women (n=390) were included in the statistical analysis. They were divided into three groups; a non-anaemic control group, haematocrit (Hct)>33% (n=82), and two case-groups: moderately anaemic, Hct 25–33% (n=254), and severely anaemic, Hct<25% (n=54).Results: We found high prevalences of nutritional deficiencies and intestinal infections, both among cases and controls. The prevalence of low s-ferritin was high, especially among the severely anaemic women (55.6%). In a multiple logistic regression model, the presence of low s-vitamin A, elevated s-C-reactive protein or hookworm infection was associated with a significantly increased risk of severe anaemia. The adjusted odds ratios (95% CI) were 8.38 (1.99, 35.30), 4.91 (1.22, 19.67) and 5.43 (1.20, 24.61), respectively.Conclusions: In addition to the present routine iron and folate supplementation to pregnant Nepali women, vitamin A supplementation needs to be considered. Prevention and treatment of infections should, together with dietary advice, be emphasized more strongly in the antenatal care.Sponsorship: The Norwegian Research Council and the Norwegian Universities Committee for Development, Research and Education.European Journal of Clinical Nutrition (2000) 54, 3–8

Anemia in pregnancy in rural Tanzania: associations with micronutrients status and infections

Objective: We studied the association between anemia in pregnancy and characteristics related to nutrition and infections.Design: Cross-sectional study.Setting: Four antenatal clinics in rural northern Tanzania.Subjects/methods: A total of 2547 women were screened for hemoglobin (Hb) and malaria plasmodia in capillary blood and for infections in urine. According to their Hb, they were assigned to one of five groups and selected accordingly, Hb<70 g/l (n=10), Hb=70–89 g/l (n=61), Hb=90–109 g/l (n=86), Hb=110–149 g/l (n=105) and Hb≥150 g/l (n=50). The 312 selected subjects had venous blood drawn, were interviewed, and their arm circumference was measured. The sera were analyzed for ferritin, iron, total iron binding capacity (TIBC), cobalamin, folate, vitamin A, C-reactive protein (CRP), and lactate dehydrogenase (LD). Transferrin saturation (TFsat) was calculated. Urine was examined by dipsticks for nitrite.Main outcome measures: Unadjusted and adjusted odds ratio (OR and AOR) of anemia with Hb<90 g/l.Results: Anemia (Hb<90 g/l) was associated with iron deficiency (low s-ferritin; AOR 3.4). The association with vitamin deficiencies were significant in unadjusted analysis (low s-folate; OR 3.1, low s-vitamin A; OR 2.6). Anemia was also associated with markers of infections (elevated s-CRP; AOR 3.5, urine nitrite positive; AOR 2.4) and hemolysis (elevated s-LD; AOR 10.1). A malaria positive blood slide was associated with anemia in unadjusted analysis (OR 2.7). An arm circumference less than 25 cm was associated with anemia (AOR 4.0). The associations with less severe anemia (Hb 90–109 g/l) were similar, but weaker.Conclusions: Anemia in pregnancy was associated with markers of infections and nutritional deficiencies. This should be taken into account in the management of anemia at antenatal clinics.Sponsorship: The study was supported by the Norwegian Research Council (NFR) and the Centre for International Health, University of Bergen.

Subjective and objective sleep among depressed and non-depressed postnatal women.

Objective:  Women sleep less in the postnatal period and it has been suggested that mothers diagnosed with depression alternatively could be suffering from the effects of chronic sleep deprivation.

The prevalence of anemia in pregnant Nepali women--a study in Kathmandu.

Background. Anemia in pregnancy is associated with maternal and perinatal morbidity and mortality. The World Health Organization has suggested that where up‐to‐date information is not available, prevalence studies should be undertaken.

The prevalence of depressive symptoms in the postnatal period in Lalitpur district, Nepal

Background. Mental disorders are highly prevalent across different cultures and are often associated with serious role impairment. In developing countries, more than three‐quarters of people with serious mental disease do not receive any treatment. Identifying and treating maternal depression is important also in Nepal, where suicide is the second largest cause of deaths among women of reproductive age. The emotional, cognitive, and physical development of the infant is also negatively influenced by maternal depression.

EurOOHnet—the European research network for out-of-hours primary health care

Abstract Background and rationale: European countries face similar challenges in the provision of health care. Demographic factors like ageing, population growth, changing patient behaviour, and lack of work force lead to increasing demands, costs, and overcrowding of out-of-hours (OOH) care (i.e. primary care services, emergency departments (EDs), and ambulance services). These developments strain services and imply safety risks. In the last few decades, countries have been re-organizing their OOH primary health care services. Aim and scope of the network: We established a European research network for out-of-hours primary health care (EurOOHnet), which aims to transfer knowledge, share experiences, and conduct research. Combining research competencies and integrating results can generate a profound information flow to European researchers and decision makers in health policy, contributing towards feasible and high-quality OOH care. It also contributes to a more comparable performance level within European regions. Conducted research projects: The European research network aims to conduct mutual research projects. At present, three projects have been accomplished, among others concerning the diagnostic scope in OOH primary care services and guideline adherence for diagnosis and treatment of cystitis in OOH primary care. The future: Future areas of research will be organizational models for OOH care; appropriate use of the OOH services; quality of telephone triage; quality of medical care; patient safety issues; use of auxiliary personnel; collaboration with EDs and ambulance care; and the role of GPs in OOH care.

The safety attitudes questionnaire – ambulatory version: psychometric properties of the Norwegian translated version for the primary care setting

BackgroundPatient safety culture is how leader and staff interaction, attitudes, routines and practices protect patients from adverse events in healthcare. The Safety Attitudes Questionnaire is the most widely used instrument to measure safety attitudes among health care providers. The instrument may identify possible weaknesses in clinical settings, and motivate and guide quality improvement interventions and reductions in medical errors. The Safety Attitudes Questionnaire – Ambulatory Version was developed for measuring safety culture in the primary care setting. The original version includes six major patient safety factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, Working conditions and Stress recognition. We describe the results of a validation study using the Norwegian translation of the questionnaire in the primary care setting, and present the psychometric properties of this version.MethodsThe study was done in seven Out-of-hours casualty clinics and 17 regular GP practices employing a total of 510 primary health care providers (194 nurses and 316 medical doctors). In October and November 2012, the translated Safety Attitudes Questionnaire – Ambulatory Version was distributed by e-mail. Data were collected electronically using the program QuestBack, whereby the participants responded anonymously. SPSS was used to estimate the Cronbach’s alphas, item-to-own-factor correlations, intercorrelations of factors and item-descriptive statistics. The confirmatory factor analysis was done by AMOS.ResultsOf the 510 invited health care providers, 266 (52%) answered the questionnaire - 72% of the registered nurses (n = 139) and 39% of the medical doctors (n = 124). In the confirmatory factor analysis, the following five factor model was shown to have acceptable goodness-of-fit values in the Norwegian primary care setting: Teamwork climate, Safety climate, Job satisfaction, Working conditions and Perceptions of management.ConclusionsThe results of our study indicate that the Norwegian translated version of the Safety Attitudes Questionnaire – Ambulatory Version, with the five confirmed factors, might be a useful tool for measuring several aspects of patient safety culture in the primary care setting. Further research should investigate whether there is an association between patient safety culture in primary care, as measured by the Safety Attitudes Questionnaire – Ambulatory Version, and occurrence of medical errors and negative patient outcome.