Shiyam Sunder Tikmani

Health Care Use Patterns for Diarrhea in Children in Low-Income Periurban Communities of Karachi, Pakistan

Diarrhea causes 16% of all child deaths in Pakistan. We assessed patterns of healthcare use among caretakers of a randomly selected sample of 959 children ages 0–59 months in low-income periurban settlements of Karachi through a cross-sectional survey. A diarrheal episode was reported to have occurred in the previous 2 weeks among 298 (31.1%) children. Overall, 280 (80.3%) children sought care. Oral rehydration solution and zinc were used by 40.8% and 2%, respectively; 11% were admitted or received intravenous rehydration, and 29% sought care at health centers identified as sentinel centers for recruiting cases of diarrhea for a planned multicenter diarrheal etiology case-control study. Odds ratios for independent predictors of care-seeking behavior were lethargy, 4.14 (95% confidence interval = 1.45–11.77); fever, 2.67 (1.27–5.59); and stool frequency more than six per day, 2.29 (1.03–5.09). Perception of high cost of care and use of home antibiotics were associated with reduced care seeking: odds ratio = 0.28 (0.1–0.78) and 0.29 (0.11–0.82), respectively. There is a need for standardized, affordable, and accessible treatment of diarrhea as well as community education regarding appropriate care in areas with high diarrheal burden.

A prospective cause of death classification system for maternal deaths in low and middle-income countries: Results from the Global Network Maternal Newborn Health Registry

To describe the causes of maternal death in a population‐based cohort in six low‐ and middle‐income countries using a standardised, hierarchical, algorithmic cause of death (COD) methodology.

Trends and determinants of stillbirth in developing countries: results from the Global Network’s Population-Based Birth Registry

BackgroundStillbirth rates remain high, especially in low and middle-income countries, where rates are 25 per 1000, ten-fold higher than in high-income countries. The United Nations’ Every Newborn Action Plan has set a goal of 12 stillbirths per 1000 births by 2030 for all countries.MethodsFrom a population-based pregnancy outcome registry, including data from 2010 to 2016 from two sites each in Africa (Zambia and Kenya) and India (Nagpur and Belagavi), as well as sites in Pakistan and Guatemala, we evaluated the stillbirth rates and rates of annual decline as well as risk factors for 427,111 births of which 12,181 were stillbirths.ResultsThe mean stillbirth rates for the sites were 21.3 per 1000 births for Africa, 25.3 per 1000 births for India, 56.9 per 1000 births for Pakistan and 19.9 per 1000 births for Guatemala. From 2010 to 2016, across all sites, the mean stillbirth rate declined from 31.7 per 1000 births to 26.4 per 1000 births for an average annual decline of 3.0%. Risk factors for stillbirth were similar across the sites and included maternal ageu2009<u200920xa0years and ageu2009>u200935xa0years. Compared to parity 1–2, zero parity and parity >u20093 were both associated with increased stillbirth risk and compared to women with any prenatal care, women with no prenatal care had significantly increased risk of stillbirth in all sites.ConclusionsAt the current rates of decline, stillbirth rates in these sites will not reach the Every Newborn Action Plan goal of 12 per 1000 births by 2030. More attention to the risk factors and treating the causes of stillbirths will be required to reach the Every Newborn Action Plan goal of stillbirth reduction.Trial registrationNCT01073475.

The project to understand and research preterm pregnancy outcomes and stillbirths in South Asia (PURPOSe): A protocol of a prospective, cohort study of causes of mortality among preterm births and stillbirths

BackgroundIn South Asia, where most stillbirths and neonatal deaths occur, much remains unknown about the causes of these deaths. About one-third of neonatal deaths are attributed to prematurity, yet the specific conditions which cause these deaths are often unclear as is the etiology of stillbirths. In low-resource settings, most women are not routinely tested for infections and autopsy is rare.MethodsThis prospective, cohort study will be conducted in hospitals in Davengere, India and Karachi, Pakistan. All women who deliver either a stillbirth or a preterm birth at one of the hospitals will be eligible for enrollment. With consent, the participant and, when applicable, her offspring, will be followed to 28-days post-delivery. A series of research tests will be conducted to determine infection and presence of other conditions which may contribute to the death. In addition, all routine clinical investigations will be documented. For both stillbirths and preterm neonates who die ≤u200928xa0days, with consent, a standard autopsy as well as minimally invasive tissue sampling will be conducted. Finally, an expert panel will review all available data for stillbirths and neonatal deaths to determine the primary and contributing causes of death using pre-specified guidance.ConclusionThis will be among the first studies to prospectively obtain detailed information on causes of stillbirth and preterm neonatal death in low-resource settings in Asia. Determining the primary causes of death will be important to inform strategies most likely to reduce the high mortality rates in South Asia.Trial registrationClinicaltrials.gov (NCT03438110) Clinical Trial Registry of India (CTRI/2018/03/012281).

Perceptions of parents and healthcare professionals regarding minimal invasive tissue sampling to identify the cause of death in stillbirths and neonates: a qualitative study protocol

BackgroundGlobally, around 2.6 million neonatal deaths occur world-wide every year and the numbers of stillbirths is almost similar. Pakistan is ranked among the highest countries in the world for neonatal mortality. In 2016, for every 1000 babies born in Pakistan, 46 died before the end of the first month of life. Also, Pakistan had the highest rate of stillbirths (43.1/1000 births) in 2015. To meet sustainable development (SDG) targets of reducing neonatal mortality and stillbirths, it is essential to gain understanding about the causes of neonatal death and stillbirths. In Pakistan, full autopsies are conducted only in medico-legal cases and are very rarely performed to identify a definitive cause of death (CoD) and because of cost and insufficient staff are generally not feasible. Recently, minimally invasive tissue sampling (MITS) has been used to determine CoD in neonates and stillbirths as it addresses some of the socio-cultural and religious barriers to autopsy. However, it is not known how families and communities will perceive this procedure; therefore, exploring family and healthcare professionals’ perceptions regarding MITS is essential in determining acceptable and feasible approaches for Pakistan.MethodsThe study will employ an exploratory qualitative research design. The study will be conducted at the National Institute of Child Health (NICH) hospital of Karachi. The data collection method will consist of key-informant interviews (KIIs) and focus group discussions (FGDs). FGDs will be conducted with the families and relatives of newborns who are visiting the outpatient department (OPD) and well-baby clinics of NICH hospital. KIIs will be conducted with the NICH - medical director, healthcare providers, professionals involved in proceedings related to death and dying, religious leaders, health sector representatives from the government, public health experts, maternal and child health (MCH) specialists, obstetricians and neonatologists and experts from the bioethics committee. Study data will be analyzed using NVivo 10 software.DiscussionThe research will help explore specific cultural, religious and socio-behavioral factors that may increase or decrease the acceptability of MITS for identifying COD in neonates and stillbirths. The findings of the qualitative study will provide a better understanding of parents’ and healthcare professionals’ attitudes towards the use of MITS on neonatal deaths and stillborns.

Monitoring of birth registry coverage and data quality utilizing lot quality assurance sampling methodology: A pilot study

Background: Effectively monitoring the coverage and quality of data in low-resource settings is challenging. Lot quality assurance sampling (LQAS) is a method to classify coverage as adequate or inadequate. The aim of this pilot study is sought to determine the coverage and quality of a birth registry in a rural district in Pakistan. Methods: This survey was conducted in 14 clusters of Thatta, Pakistan. LQAS methodology was used to monitor the birth registry from December 2015 to February 2016. We randomly selected 19 villages from each cluster. We used a short questionnaire to review the quality of data collection for select variables. Frequency and percentages were reported for categorical variables. For data validation, Kappa statistics (κ) were applied to assess the agreement between categorical observations, and the Bland–Altman test was used to assess agreement for continuous data. Results: Of the 14 clusters sampled, 12 clusters had adequate coverage. Agreement of hemoglobin performance between the womens response and information in birth registry data was good (κ = 0.718) (95% confidence interval [CI]: 0.58–0.82); agreement on birth outcome recorded by the workers in the registry and as mentioned by women was very good (κ = 1.0); and agreement whether birth weight was assessed within 48 h of delivery was good (κ = 0.648) (0.37–0.92). Conclusion: LQAS is a powerful tool to monitor coverage and data quality of the birth registry maintained by the global network for womens and childrens health in Pakistan and potentially for data from other surveillance systems.

Frequency of bloodstream infection in febrile neutropenic patients, experience from a developing country

Introduction About 20% of febrile neutropenic patients are presented with bloodstream infection which is a leading cause of mortality among these patients. Awareness of the locally prevalent pathogens and their susceptibility pattern is important for proper treatment of infection which improves survival in these patients. The objective of this study was to determine the frequency of bloodstream infection in patients with febrile neutropenia admitted in Abbasi Shaheed Hospital. Methods This cross-sectional study was conducted in the Medical wards in Abbasi Shaheed Hospital, Karachi from 21-2-2016 to 20-8-2017. Patients of over 15 years of age of either gender with severe neutropenia were included in this study. Patients with noninfectious cause of fever, or fever prior to neutropenia were excluded. Patients meeting inclusion criteria were enrolled after taking informed consent. About 2–5u202fml blood was collected under aseptic measures in Bactac culture bottles. Blood samples were sent to lab within 30u202fmin of collection. Antimicrobial sensitivity testing of all isolates was performed on diagnostic Sensitivity test plates by Kerby – Bauer Method. Patients were referred back to treating physician if blood culture is positive. The data was analyzed using SPSS version 20. Results Of 200 patients, the mean age was 25.8u202f±u202f5.7 years, 120 (60%) were male with male to female ratio of 1.5:1, 89 (44.5%) had low grade fever (Temp. ≤102u202f°C) and 111 (55.5%) had high grade fever(Temp. >102u202f°C). The frequency of staphylococcus aureus was 16%, E. coli was 14.5%, Pseudomonas 8.5% and Klebsiella 15.5% Conclusions It is concluded that the frequency of staphylococcus aureus was 16%, E. coli was 14.5%, Pseudomonas 8.5% and Klebsiella 15.5%

Vaccination Status and Factors for Non- Vaccination in Children at a Tertiary Care Hospital

Immunization is a very effective strategy to prevent against common infectious disease. The objectives of the study were to determine the immunization status and reasons for non-vaccination of children coming to Civil Hospital Sukkur. This cross-sectional study was conducted pediatric OPD at Civil Hospital Sukkur from January 1, 2013, to June 30, 2013. Parents of children under five years of age brought their child to Outpatient Department of Civil Hospital Sukkur for any illness were asked to participate in the study. Parents who gave informed consent were included in the study. Data were collected using a small questionnaire by the researcher himself. A total of 500 parents gave consent to participate in the study. The average age of children was 20.4±16.3 months, 257 (51.4%) were males and 243 (48.6%) were females. Four hundred and four (80.4%) children were fully vaccinated and 98 (19.6%) were not vaccinated. Parents don’t know about immunization, busy parents, illness of a child, fear of immunization and parents who are not considering immunization as important are independent factors of non-vaccination.

Prevalence and determinants of unintended pregnancy: systematic review

Background: Unplanned pregnancy is one of the leading causes of maternal mortality and morbidity in the world. The objective of this systematic review was to synthesize the findings of various studies regarding prevalence and determinates of unintended pregnancy. Data sources: A range of electronic databases was searched for studies conducted in developing countries and published between 1990 and 2015. English-language publications were searched using relevant keywords, and reference lists were hand searched. Review methods: A systematic review was carried out for all the quantitative studies which met the inclusion criteria. The quality of selected studies was assessed using Newcastle-Ottawa Scale. Results: Twenty-two papers were included in the review. Average prevalence of unintended pregnancy was estimated to be 35% ranging from 13% to 82%. The predictors of unintended pregnancy were found to be, socio-demographic factors include women’s age, women’s education, parity, birth order and interval, previous pregnancy intention, age at the time of marriage, socioeconomic status, marital status, religion, caste, and ethnicity. Conclusion: Main correlates were found to be age, parity, educational and economic status. This means that undertaking outreach in poor countries might be helpful in fulfilling the needs of Family planning for these women. Furthermore, community-based distribution of family planning methods or counseling should be targeted to the illiterate older aged women of reproductive age with poor socioeconomic status.

Frequency of Birth Defects and its Relationship to Parents Having InterfamilyMarriages at a Tertiary Care Hospital

Background: Inter family cousin marriages carries a risk of increased birth defects. The exact contribution of interfamily to birth defects risk is controversial. The aims of this study were to determine the frequency of birth defects in in relation to interfamily or outside family marriages. Methods: This cross sectional study was conducted in the Civil hospital Sukkur from 9th November 2013 to 13th December 2015. Mothers giving birth to babies married in interfamily or outside family with their consent obtained were included in the study. Mothers not giving consent for study and having any known major illnesses were excluded from this study. Data was analyzed using SPSS version 21.0. Results: The mean age of enrolled participants is 26.72 ± 7.07 years, the mean years of marriage was 5.95 ± 6 years and 49.4% were residents of urban area. Overall 89.9% were Muslims, 8.4% Christians and 2.8% Hindus, 60.7% infant had gestational age of <37 weeks. Overall 11.4% of newborns have congenital malformations. Frequency of congenital malformations among interfamily marriages was 15.6% compared to outside family marriages accounted for 3.7% cases (p=0.021). Conclusion: It was concluded from this study that congenital malformations are common among participants of interfamily marriages.