Manisha Nair

CARRS Surveillance study: design and methods to assess burdens from multiple perspectives.

BackgroundCardio-metabolic diseases (CMDs) are a growing public health problem, but data on incidence, trends, and costs in developing countries is scarce. Comprehensive and standardised surveillance for non-communicable diseases was recommended at the United Nations High-level meeting in 2011.Aims: To develop a model surveillance system for CMDs and risk factors that could be adopted for continued assessment of burdens from multiple perspectives in South-Asian countries.MethodsDesign: Hybrid model with two cross-sectional serial surveys three years apart to monitor trend, with a three-year prospective follow-up of the first cohort.Sites: Three urban settings (Chennai and New Delhi in India; Karachi in Pakistan), 4000 participants in each site stratified by gender and age.Sampling methodology: Multi-stage cluster random sampling; followed by within-household participant selection through a combination of Health Information National Trends Study (HINTS) and Kish methods.Culturally-appropriate and methodologically-relevant data collection instruments were developed to gather information on CMDs and their risk factors; quality of life, health-care utilisation and costs, along with objective measures of anthropometric, clinical and biochemical parameters. The cohort follow-up is designed as a pilot study to understand the feasibility of estimating incidence of risk factors, disease events, morbidity, and mortality.ResultsThe overall participant response rate in the first cross-sectional survey was 94.1% (Chennai 92.4%, nu2009=u20094943; Delhi 95.7%, nu2009=u20094425; Karachi 94.3%, nu2009=u20094016). 51.8% of the participants were females, 61.6%u2009<u200945years, 27.5% 45–60years and 10.9% >60u2009years.DiscussionThis surveillance model will generate data on prevalence and trends; help study the complex life-course patterns of CMDs, and provide a platform for developing and testing interventions and tools for prevention and control of CMDs in South-Asia. It will also help understanding the challenges and opportunities in establishing a surveillance system across countries.

Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview.

Objective Conduct a global situational analysis to identify the current facilitators and barriers to improving quality of care (QoC) for pregnant women, newborns and children. Study design Metareview of published and unpublished systematic reviews and meta-analyses conducted between January 2000 and March 2013 in any language. Assessment of Multiple Systematic Reviews (AMSTAR) is used to assess the methodological quality of systematic reviews. Settings Health systems of all countries. Study outcome: QoC measured using surrogate indicators––effective, efficient, accessible, acceptable/patient centred, equitable and safe. Analysis Conducted in two phases (1) qualitative synthesis of extracted data to identify and group the facilitators and barriers to improving QoC, for each of the three population groups, into the six domains of WHOs framework and explore new domains and (2) an analysis grid to map the common facilitators and barriers. Results We included 98 systematic reviews with 110 interventions to improve QoC from countries globally. The facilitators and barriers identified fitted the six domains of WHOs framework––information, patient–population engagement, leadership, regulations and standards, organisational capacity and models of care. Two new domains, ‘communication’ and ‘satisfaction’, were generated. Facilitators included active and regular interpersonal communication between users and providers; respect, confidentiality, comfort and support during care provision; engaging users in decision-making; continuity of care and effective audit and feedback mechanisms. Key barriers identified were language barriers in information and communication; power difference between users and providers; health systems not accounting for user satisfaction; variable standards of implementation of standard guidelines; shortage of resources in health facilities and lack of studies assessing the role of leadership in improving QoC. These were common across the three population groups. Conclusions The barriers to good-quality healthcare are common for pregnant women, newborns and children; thus, interventions targeted to address them will have uniform beneficial effects. Adopting the identified facilitators would help countries strengthen their health systems and ensure high-quality care for all.

Factors associated with maternal death from direct pregnancy complications: a UK national case–control study

Sir, We refer to the article ‘Factors associated with maternal death from direct pregnancy complications: aUKnational casecontrol study’ published in BJOG. This study highlights the significant contribution of medical co-morbidities to deaths arising from obstetric causes (direct deaths). Surprisingly, no mention is made of preconception care and its possible value. The importance of preconception care has been stated and re-iterated in the two most recent confidential enquiries into maternal deaths and we are concerned that there appears to be a lack of implementation of this key aspect of women’s health. Of the six risk factors associated with maternal death from direct pregnancy complications identified in the study, we believe preconception counselling could have affected at least four of these— inadequate use of antenatal care, substance misuse, medical co-morbididties and previous pregnancy problems. Did any of these women receive advice before becoming pregnant? In a recent survey of 100 pregnant and newly delivered women in our unit, 26 had received some form of preconception advice from a health care professional. More concerning was that only one-third of women with medical disorders received advice before getting pregnant. Women were asked what would help to raise awareness and they suggested social media, advertising with posters, and introduction of such awareness as part of secondary school education. As a result we have developed a local initiative (babySAFER) to raise awareness of smoking, alcohol, folic acid, exercise and eating, and rubella vaccination. The information presented as a smart card also refers to the importance of existing medical conditions and medications. This has been widely circulated, for example in pharmacies and GP surgeries, and is under evaluation. Although limited evidence exists in the form of randomised controlled trials to confirm the impact of preconception awareness on maternal and child health, it seems obvious that all women should be encouraged to seek advice before they conceive. Messages from previous maternal mortality reports do not seem to have been taken up by health services. We feel a collective approach from health care professionals involved in the care of women of reproductive age is essential to promote preconception awareness. There is unlikely to be a change in the profile of maternal mortalities before this happens.&

Education for health professionals in the emerging market economies: a literature review.

Medical Education 2010: 44: 856–863

Health professionals' migration in emerging market economies: patterns, causes and possible solutions

BACKGROUNDnAbout a third of the countries affected by shortage of human resources for health are the emerging market economies (EMEs). The greatest shortage in absolute terms was found to be in India and Indonesia leading to health system crisis. This review identifies the patterns of migration of health workers, causes and possible solutions in these EMEs.nnnMETHODSnA qualitative synthesis approach based on the critical review and realist review approaches to the literature review was used.nnnRESULTSnThe patterns of migration of health professionals in the EMEs have led to two types of discrepancies between health needs and healthcare workers: (i) within country (rural-urban, public-private or government healthcare sector-private sector) and (ii) across countries (south to north). Factors that influence migration include lack of employment opportunities, appropriate work environment and wages in EMEs, growing demand in high-income countries due to demographic transition, favourable country policies for financial remittances by migrant workersxa0and medical education system of EMEs. A range of successful national and international initiatives to address health workforce migration were identified.nnnCONCLUSIONSnMeasures to control migration should be country specific and designed in accordance with the push and pull factors existing in the EMEs.

Ethnic Variations in Severe Maternal Morbidity in the UK– A Case Control Study

Background Previous studies showed a higher risk of maternal morbidity amongst black and other minority ethnic (BME) groups, but were unable to investigate whether this excess risk was concentrated within specific BME groups in the UK. Our aim was to analyse the specific risks and to investigate reasons for any disparity. Methods Unmatched case-control analysis using data from the United Kingdom Obstetric Surveillance System (UKOSS), February 2005-January 2013. Cases were 1,753 women who experienced severe morbidity during the peripartum period. Controls were 3,310 women who delivered immediately before the cases in the same hospital. Multivariable logistic regression modelling was used to adjust for known confounders and to understand their effects. Results Compared with white European women, the odds of severe maternal morbidity were 83% higher among black African women (adjusted odds ratio (aOR)u200a=u200a1.83; 95% Confidence Interval (CI)u200a=u200a1.39–2.40), 80% higher among black Caribbean (aORu200a=u200a1.80; 95% CIu200a=u200a1.14–2.82), 74% higher in Bangladeshi (aORu200a=u200a1.74; 95% CIu200a=u200a1.05–2.88), 56% higher in other non-whites (non-Asian) (aORu200a=u200a1.56; 95% CIu200a=u200a1.05–2.33) and 43% higher among Pakistani women (aORu200a=u200a1.43; 95% CIu200a=u200a1.07–1.92). There was no evidence of substantial confounding. Anaemia in current pregnancy, previous pregnancy problems, inadequate utilisation of antenatal care, pre-existing medical conditions, parity>3, and being younger and older were independent risk factors but, the odds of severe maternal morbidity did not differ by socioeconomic status, between smokers and non-smokers or by BMI. Discussion This national study demonstrates an increased risk of severe maternal morbidity among women of ethnic minority backgrounds which could not be explained by known risk factors for severe maternal morbidity.

HbA1c values for defining diabetes and impaired fasting glucose in Asian Indians

AIMnTo determine the glycosylated haemoglobin (HbA(1c)) cut-points for diabetes and impaired fasting glucose (IFG) among Asian Indians.nnnMETHODSnParticipants (n=525) were a random sample selected from the India Health Study. Based on history and fasting plasma glucose (FPG), participants were classified into known diabetes, newly diagnosed diabetes (NDD), impaired fasting glucose (IFG) [ADA and WHO criteria] or normal fasting glucose (NFG). Receiver Operating Characteristic curves were used to identify the optimum sensitivity and specificity for defining HbA(1c) cut-points for NDD and IFG against the FPG criteria.nnnRESULTSnThere were 64 participants with a known history of diabetes. Of the remaining 461, IFG was present in 44.7% (ADA) and 18.2% (WHO), and 10.4% were NDD. Mean HbA(1c) were 5.4 (±0.04)% for NFG; 5.7 (±0.06)% among IFG-ADA, 5.8 (±0.09)% among IFG-WHO; 7.5 (±0.33)% for NDD and 8.4 (±0.32)% for known diabetes. Optimal HbA(1c) cut-point for NDD was 5.8% (sensitivity=75%, specificity=75.5%, AUC=0.819). Cut-point for IFG (ADA) was 5.5% (sensitivity=59.7%, specificity=59.9%, AUC=0.628) and for IFG (WHO) was 5.6% (sensitivity=60.7%, specificity=65.1%, AUC=0.671).nnnCONCLUSIONnIn this study population from north and south regions of India, the HbA(1c) cut-point that defines NDD (≥5.8%) was much lower than that proposed by an international expert committee and the American Diabetes Association (≥6.5%). A cut-point of ≥5.5% or ≥5.6% defined IFG, and was slightly lower than the ≥5.7% for high risk proposed, but accuracy was less than 70%.

Why Do South Asians Have High Risk for CAD

South Asians have a higher risk for coronary artery disease (CAD) due to both pathophysiological and life course-related risk factors. We performed a literature search and used qualitative synthesis to present evidence for CAD risk factors among South Asians. A large proportion of the higher risk of South Asians for CAD can be explained by conventional risk factors. However, several conditioning factors such as education, socioeconomic status, and fetal programming, and early life influences may contribute to excess CAD risk in South Asians, suggesting the need for a life course approach. Evidence on unconventional risk factors is provocative but comes from small studies. Large-scale, well-designed epidemiological studies are needed for an in-depth understanding of the CAD risk among South Asians.

Association between maternal anaemia and pregnancy outcomes: a cohort study in Assam, India

Objectives To examine the association between maternal anaemia and adverse maternal and infant outcomes, and to assess the feasibility of conducting epidemiological studies through the Indian Obstetric Surveillance System–Assam (IndOSS-Assam). Design Retrospective cohort study using anonymised hospital records. Exposure: maternal iron deficiency anaemia; outcomes: postpartum haemorrhage (PPH), low birthweight, small-for-gestational age babies, perinatal death. Setting 5 government medical colleges in Assam. Study population 1007 pregnant women who delivered in the 5 medical colleges from January to June 2015. Main outcome measures ORs with 95% CIs to estimate the association between maternal iron deficiency anaemia and the adverse maternal and infant outcomes. Potential interactive roles of infections and induction of labour on the adverse outcomes were explored. Results 35% (n=351) pregnant women had moderate–severe anaemia. Women with severe anaemia had a higher odds of PPH (adjusted OR (aOR) =9.45; 95% CI 2.62 to 34.05), giving birth to low birthweight (aOR=6.19; 95% CI 1.44 to 26.71) and small-for-gestational age babies (aOR=8.72; 95% CI 1.66 to 45.67), and perinatal death (aOR=16.42; 95% CI 4.38 to 61.55). Odds of PPH increased 17-fold among women with moderate–severe anaemia who underwent induction of labour, and 19-fold among women who had infection and moderate–severe anaemia. Conclusions Maternal iron deficiency anaemia is a major public health problem in Assam. Maternal anaemia was associated with increased risks of PPH, low birthweight, small-for-gestational age babies and perinatal death. While the best approach is prevention, a large number of women present with severe anaemia late in pregnancy and there is no clear guidance on how these women should be managed during labour and delivery.

Risk factors and newborn outcomes associated with maternal deaths in the UK from 2009 to 2013: a national case-control study.

To identify the risk factors for and adverse newborn outcomes associated with maternal deaths from direct and indirect causes in the UK.