Thilini Chanchala Agampodi

Breastfeeding practices in a public health field practice area in Sri Lanka: a survival analysis

BackgroundExclusive breastfeeding up to the completion of the sixth month of age is the national infant feeding recommendation for Sri Lanka. The objective of the present study was to collect data on exclusive breastfeeding up to six months and to describe the association between exclusive breastfeeding and selected socio-demographic factors.MethodsA clinic based cross-sectional study was conducted in the Medical Officer of Health area, Beruwala, Sri Lanka in June 2006. Mothers with infants aged 4 to 12 months, attending the 19 child welfare clinics in the area were included in the study. Infants with specific feeding problems (cleft lip and palate and primary lactose intolerance) were excluded. Cluster sampling technique was used and consecutive infants fulfilling the inclusion criteria were enrolled. A total of 219 mothers participated in the study. The statistical tests used were survival analysis (Kaplan-Meier survival curves and Cox proportional Hazard model).ResultsAll 219 mothers had initiated breastfeeding. The median duration of exclusive breastfeeding was four months (95% CI 3.75, 4.25). The rates of exclusive breastfeeding at 4 and 6 months were 61.6% (135/219) and 15.5% (24/155) respectively. Bivariate analysis showed that the Muslim ethnicity (p = 0.004), lower levels of parental education (p < 0.001) and being an unemployed mother (p = 0.021) were important associations of early cessation of exclusive breastfeeding. At the time of the study, 62% (135/219) of infants were receiving feeds via a bottle and 23% (51/219) were receiving infant formula. Muslim ethnicity was significantly associated with bottle and formula feeding (p < 0.001). Bottle feeding was also significantly higher among mothers with a low level of education and among employed mothers.ConclusionThe rate of breastfeeding initiation and exclusive breastfeeding up to the fourth month is very high in Medical Officer of Health area, Beruwala, Sri Lanka. However exclusive breastfeeding up to six months is still low and the prevalence of inappropriate feeding practices is high.

Exclusive breastfeeding in Sri Lanka: problems of interpretation of reported rates

Accurate interpretation of reported breastfeeding rates is essential in understanding the true picture of a countrys breastfeeding status. In Sri Lanka, where the reported exclusive breastfeeding (EBF) rate among infants aged from 0 to 5 months is 75%, accurate understanding of this rate is of the utmost importance. The danger of misinterpreting the data and assuming that Sri Lanka has achieved a high EBF rate is that health workers begin to believe that no further effort should be made in this area. This is very dangerous as the potential to further improve rates of EBF will not be addressed. We discuss the interpretation of survey data and various definitions used in the relevant literature. We strongly recommend that interpretation of EBF rates should be done only after careful evaluation of the definitions and survey methods used.

Duration of exclusive breastfeeding; validity of retrospective assessment at nine months of age

BackgroundIn cross sectional, case control and retrospective cohort studies, duration of Exclusive Breastfeeding (EBF) usually depends on maternal recall. Retrospective data are often subjected to recall bias and could lead to a potential for exposure misclassification. The purpose of the present paper is to assess the validity of maternal recall of EBF duration during infancy, after cessation of EBF and to evaluate the two methods to collect retrospective data on EBF.MethodsA cohort study was carried out in Naula Medical Officer of Health (MOH) area. Study cohort included all infants born during the months of February to April 2008 and currently residing in Naula MOH area. Baseline data collection was carried out using the pregnancy record, the child health development record and by using an interviewer administered structured questionnaire. Data extraction from the pregnancy record and the child health development record were carried out by public health midwives. The interviewer administered structured questionnaire was administered by the MOH during the follow-up visits. Duration of EBF was assessed in three ways; based on prospective data since birth: Retrospective data based on an event calendar: and the Mother reported EBF duration.ResultsA total of 114 mother-infant pairs were recruited and followed up. Proportion of infants receiving EBF up to the completion of the sixth month by the three methods were; data since birth (actual EBF rate) - 23.9%; mother reported data - 77.7% and event calendar method - 41.3%. Median duration of EBF reported in the three methods was 5, 6, and 5 respectively. A statistically significant difference was observed in these differences from Kaplan-Meire Survival analysis (Log rank test - Chi square-63.4, p < 0.001). Validity of retrospective methods was analysed using data since birth as the gold standard. Sensitivity of both methods to detect exclusively breastfed babies were 100.0%. Specificity of mother recall data was 26.2% (95%CI-17.9, 36.8%) compared to 75.0% (95% CI-64.5, 83.2%) in the event calendar method.ConclusionsRetrospective evaluation methods systematically overestimate the duration of EBF. Maternal recall data provide highly unspecific data whereas use of an event calendar provided more valid data. Reporting of data accrual methods in breastfeeding studies will allow the readers to interpret findings accurately and the use of event calendars rather than direct questioning as a valid method of determining EBF is recommended.

Antenatal Depression in Anuradhapura, Sri Lanka and the Factor Structure of the Sinhalese Version of Edinburgh Post Partum Depression Scale among Pregnant Women

Background Mental health problems among women of reproductive age group contribute to 7% of Global Burden of Diseases of women of all ages. Purpose of this study was to determine the prevalence and correlates of antenatal depression among pregnant women in Anuradhapura, Sri Lanka, and to explore the factor structure of EPDS. Methods Pregnant women with gestational age of 24–36 weeks and residing in Anuradhapura district, Sri Lanka were recruited to the study using a two stage cluster sampling procedure. Sinhalese version of Edinburgh Post Partum Depression Scale (EPDS) and an interviewer administered questionnaire was use to collect data. A cut off value of 9 was used for the Sinhalese version of EPDS. Results A total of 376 pregnant women were studied. Median EPDS score among pregnant women was 5 (IQR 2–8). Prevalence of antenatal depression in this study sample was 16.2% (n = 61). Thought of self harming (item number 10) was reported by 26 pregnant women (6.9%). None of the socio-demographic factors were associated with depression in this study sample. Having heart burn was significantly associated with depressive symptoms (p = 0.041). Sri Lankan version of EPDS showed a two factor solution. Anxiety was not emerged as a separate factor in this analysis. Conclusions Prevalence of antenatal depression in Anuradhapura, Sri Lanka was relatively low. Anxiety was not emerged as a separate factor in the Sinhalese version of the EPDS.

Family planning prevalence among postpartum mothers attending child welfare clinics - a Sri Lankan experience.

Sir, One of the main reasons for seeking abortion in Sri Lanka is insufficient spacing between births.(1) This could be partly due to deficit in postpartum contraceptive services. A hospital-based study reported that at the time they leave the hospital, knowledge on the appropriate time to start a contraceptive method was poor among Sri Lankan mothers.(2) Even among those who are knowledgeable, the actual practices are unknown. Studies have demonstrated that antenatal programs that promote contraception are not effective to improve postpartum contraceptive prevalence.(3,4) The purpose of this study was to assess the prevalence of modern Family Planning (FP) methods among postpartum mothers in order to improve maternal and child healthcare service provision. A clinic-based, cross-sectional, descriptive study was conducted in the area of the medical officer of health, Beruwala. We interviewed all infant-mother pairs where infants were two months of age, attending child welfare clinics for the first dose of Diphtheria-Tetanus-Pertussis (DTP) during a period of two months. A cluster sampling technique was used to obtain the sample from 19 child welfare clinics. An interviewer administered questionnaire was used for data collection. Authors collected data during routine clinic visits. Ethical and administrative clearance was obtained from the National Institute of Health Sciences, Kalutara. All together 129 mothers were interviewed. Mean age of the study sample was 27 years with a standard deviation of 4.6. Median duration of the postpartum period was eight weeks. Sixty-four of the study sample were having their first child. The sample consisted of 58 (45%) Muslim mothers and 71 (55%) Sinhalese mothers. Family Planning (FP) prevalence among study participants was 41.1% (53). Out of the mothers who were not on FP, 22 (28.9%) had already decided on an FP method. Fifty-four mothers, 41.9%, neither used a family planning method nor had they decided on a method or when to start. All these 75 mothers who had already started and decided on an FP method had received domiciliary care (postpartum home visits by the public health midwife) and FP advice through the area public health midwife. Among those who had not decided on a method, 40 (74.1%) had no specific reasons for noncommencement, while 12 (22.2%) had not decided because of the inaccurate information received on FP. Nine mothers (16.7%) did not receive domiciliary care at all and only 33 (61.1%) received family planning advice from the area public health midwife. Use of an FP method was significantly associated with domiciliary postpartum care (Fishers exact test P = 0.009) and FP counseling (χ2 = 17.5, P < 0.001). Maternal age, ethnicity or number of children was not significantly associated with postpartum FP prevalence. The prevalence of modern methods used among the reproductive age group in Sri Lanka was 49.5% in 2000.(5) The prevalence of modern FP methods used among postpartum mothers in our study sample was below this national average. The study shows that all mothers who received domiciliary care had not received FP counseling. Divisional level health care managers should pay more attention to improve the quality of postpartum care in order to improve maternal and child health status.

Minor Ailments in Pregnancy Are Not a Minor Concern for Pregnant Women: A Morbidity Assessment Survey in Rural Sri Lanka

Background Although maternal mortality has become a major focus on global public health agenda, maternal morbidity is a neglected area of research. The purpose of this paper is to present the burden of acute maternal illness during pregnancy. Methods A cross sectional study was carried out in Anuradhapura district, Sri Lanka. Pregnant women residing in the Anuradhapura district with a gestational age more than 24 weeks through 36 weeks were recruited to the study using a two-stage cluster sampling technique. All pregnant women who consented participated in a detailed interview using a structured questionnaire. Self reported episodes of acute illness during pregnancy were the main outcome measures. Secondary outcomes were utilization of medical services and frequency of hospitalizations. Results Nausea and vomiting during pregnancy (NVP) was experienced by 325 (69.7%) of the 466 pregnant women studied. Other common symptoms were backache (152, 32.6%), dizziness (112, 24.0%) and heartburn/regurgitation (107, 23.0%). Of the 421 pregnant women who reported ill health conditions 260 (61.8%) women sought medical treatment for these illnesses. Total number of episodes that needed treatment seeking were 373. Hospitalizations were reported by 83 (17.8%) pregnant women and the total number of hospitalizations was 109. The leading cause of hospitalization was NVP which accounted for 43.1% of total admissions and 49.1% of total days spent in hospitals. Conclusions Minor maternal ill health conditions affecting day-to-day life have a major burden on pregnancy period. Evidence based management guidelines and health promotion strategies are needed to control and prevent these conditions, in order to provide comprehensive, good quality maternal health care.

Productivity Cost Due to Maternal Ill Health in Sri Lanka

Background The global impact of maternal ill health on economic productivity is estimated to be over 15 billion USD per year. Global data on productivity cost associated with maternal ill health are limited to estimations based on secondary data. Purpose of our study was to determine the productivity cost due to maternal ill health during pregnancy in Sri Lanka. Methods and Findings We studied 466 pregnant women, aged 24 to 36 weeks, residing in Anuradhapura, Sri Lanka. A two stage cluster sampling procedure was used in a cross sectional design and all pregnant women were interviewed at clinic centers, using the culturally adapted Immpact tool kit for productivity cost assessment. Of the 466 pregnant women studied, 421 (90.3%) reported at least one ill health condition during the pregnancy period, and 353 (83.8%) of them had conditions affecting their daily life. Total incapacitation requiring another person to carry out all their routine activities was reported by 122 (26.1%) of the women. In this study sample, during the last episode of ill health, total number of days lost due to absenteeism was 3,356 (32.9% of total loss) and the days lost due to presenteeism was 6,832.8 (67.1% of the total loss). Of the 353 women with ill health conditions affecting their daily life, 280 (60%) had coping strategies to recover loss of productivity. Of the coping strategies used to recover productivity loss during maternal ill health, 76.8% (n = 215) was an intra-household adaptation, and 22.8% (n = 64) was through social networks. Loss of productivity was 28.9 days per episode of maternal ill health. The mean productivity cost due to last episode of ill health in this sample was Rs.8,444.26 (95% CI-Rs.6888.74-Rs.9999.78). Conclusions Maternal ill health has a major impact on household productivity and economy. The major impact is due to, generally ignored minor ailments during pregnancy.

Prevalence of Mental Health Problems in Adolescent Schoolchildren in Galle District, Sri Lanka Eight Months After Tsunami

The present study was conducted to assess the prevalence and associations of mental health problems (MHPs) among adolescent schoolchildren in Sri Lanka 8 months after the tsunami disaster. A descriptive cross-sectional study was carried out in the Galle Municipality area, Sri Lanka. The study instrument consisted of a self-administered questionnaire and the validated Sinhalese version of the Strengths and Difficulties Questionnaire. The prevalence of MHPs in the study population was 32.2% (confidence interval [CI] = 28.44% to 35.96%). Direct experience of the tidal wave (odds ratio [OR] = 2.93, P = .013), perception of being affected by tsunami (OR = 1.79, P = .0014), and impact of rumors (OR = 1.85, P < .001) were significantly associated with MHPs. Not having a close friend (OR = 1.79, P = .04), being criticized by teachers (OR = 1.66, P = .008), and adolescents being not satisfied with their academic achievements (OR = 2.42, P = .02) were also significantly associated with MHPs. Even 8 months after the tsunami, MHPs among adolescent schoolchildren in the affected areas are still very high.

Effect of low cost public health staff training on exclusive breastfeeding

ObjectiveTo assess the effectiveness and feasibility of on the job staff training and supportive supervision to improve six months Exclusive Breastfeeding (EBF).MethodsA longitudinal study was conducted in a public health field practice area-Sri Lanka in 2006–2007. Three breastfeeding counseling sessions were conducted for public health midwives. Supportive supervision and on the job training were done by two public health physicians. Pre and post intervention independent cross sectional studies were conducted to assess the effectiveness of the programme. The study sample consisted of mother-infant pairs where infants were aging 6 to 12 months, attending child welfare clinics. Primary outcome measure was the proportion of infants who received EBF up to 6 months. Logistic regressing model was used for analysis of predictors of EBF.ResultsStudy sample consisted of 336 mother-infant pairs (pre 139, post 197). Proportion of mothers who breastfed their infants exclusively for six months improved from 19% to 70% after the intervention. The median duration of EBF increased from 4 months to 6 months (inter-quartile range 2–6 and 5–6 months respectively). Unconfounded effect of intervention on 6 months EBF in logistic regression model was highly significant (OR=13.67. p<0.001). Intervention significantly reduced the bottle feeding rate (OR=0.212, p<0.001) but not formula feeding (OR=1.146. p=0.642). Of potential predictors assessed. Sinhalese mothers than Muslim mothers (OR=3.37, p<0.001) and employed mothers compared to housewives (OR=4.45. p=0.014) were more likely to breastfeed their infants upto six months. Parity, maternal education and maternal age were not significantly associated with six months EBF.ConclusionsThe existing public health infrastructure can be used effectively to improve six months EBF in places where the care is given primarily by public health system.

Dermatoglyphics in hypertension: a review.

Hypertension is a major contributor to the global burden of disease and mortality. A major medical advancement would be a better means to ascertain which persons are at higher risk for becoming hypertensive beforehand. To that end, there have been a number of studies showing that certain dermatoglyphic markers are associated with hypertension. This association could be explained if the risk toward developing hypertension later on in life is somehow connected with fetal development of dermatoglyphics. It would be highly valuable from a clinical standpoint if this conjecture could be substantiated since dermatoglyphic markers could then be used for screening out individuals who might be at an elevated risk of becoming hypertensive. The aim of this review was to search for and appraise available studies that pertain to the association between hypertension and dermatoglyphics.A systematic literature search conducted using articles from MEDLINE (PubMed), Trip, Cochran, Google scholar, and gray literature until December 2014. Of the 37 relevant publications, 17 were included in the review. The review performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement.This review showed a fairly consistent finding of an increased frequency of whorl patterns along with a higher mean total ridge count in digital dermatoglyphic results in hypertensive samples compared to controls. However, it was imperative to discuss several limitations found in the studies that could make this association as yet unsettled.