Predictors of Rehabilitation Service Utilisation among Children with Cerebral Palsy (CP) in Low- and Middle-Income Countries (LMIC): Findings from the Global LMIC CP Register

Background: We assessed the rehabilitation status and predictors of rehabilitation service utilisation among children with cerebral palsy (CP) in selected low- and middle-income countries (LMICs). Methods: Data from the Global LMIC CP Register (GLM-CPR), a multi-country register of children with CP aged <18 years in selected countries, were used. Descriptive and inferential statistics (e.g., adjusted odds ratios) were reported. Results: Between January 2015 and December 2019, 3441 children were registered from Bangladesh (n = 2852), Indonesia (n = 130), Nepal (n = 182), and Ghana (n = 277). The proportion of children who never received rehabilitation was 49.8% (n = 1411) in Bangladesh, 45.8% (n = 82) in Nepal, 66.2% (n = 86) in Indonesia, and 26.7% (n = 74) in Ghana. The mean (Standard Deviation) age of commencing rehabilitation services was relatively delayed in Nepal (3.9 (3.1) year). Lack of awareness was the most frequently reported reason for not receiving rehabilitation in all four countries. Common predictors of not receiving rehabilitation were older age at assessment (i.e., age of children at the time of the data collection), low parental education and family income, mild functional limitation, and associated impairments (i.e., hearing and/or intellectual impairments). Additionally, gender of the children significantly influenced rehabilitation service utilisation in Bangladesh. Conclusions: Child’s age, functional limitation and associated impairments, and parental education and economic status influenced the rehabilitation utilisation among children with CP in LMICs. Policymakers and service providers could use these findings to increase access to rehabilitation and improve equity in rehabilitation service utilisation for better functional outcome of children with CP

Evaluation of a surgical treatment algorithm for neglected clubfoot in low-resource settings

Purpose
Idiopathic clubfoot affects approximately 1/1000 alive-born infants, of whom 80–91% are born in low- or middle-income countries (LMICs). This retrospective study aimed to evaluate the morphological, functional, and social outcomes in patients with neglected clubfoot in rural Bangladesh, after receiving surgical treatment.

Methods
Patients received a posteromedial release (PMR) with or without an additional soft tissue intervention (group 1), a PMR with an additional bony intervention (group 2), or a triple arthrodesis (group 3) according to our surgical algorithm. Patients were followed until two year post-intervention. Evaluation was done using a modified International Clubfoot Study Group Outcome evaluation score and the Laaveg-Ponseti score.

Results
Twenty-two patients with 32 neglected clubfeet (ages 2–24 years) received surgical treatment. Nineteen patients with 29 clubfeet attended follow-up. At two year follow-up an excellent, good, or fair Laaveg-Ponseti score was obtained in 81% (group 1), 80% (group 2), and 0% (group 3) of the patients (p value 0.0038). Age at intervention is inversely correlated with the Laaveg-Ponseti score at two year follow-up (p < 0.0001). All patients attended school or work and were able to wear normal shoes.

Conclusion
Our treatment algorithm is in line with other surgical algorithms used in LMICs. Our data reconfirms that excellent results can be obtained with a PMR regardless of age. Our algorithm follows a pragmatic approach that takes into account the reality on the ground in many LMICs. Good functional outcomes can be achieved with PMR for neglected clubfoot. Further research is needed to investigate the possible role of triple arthrodesis.

Assessing service availability and readiness to manage cervical cancer in Bangladesh

Background
The second most common cancer among females in Bangladesh is cervical cancer. The national strategy for cervical cancer needs monitoring to ensure that patients have access to care. In order to provide accurate information to policymakers in Bangladesh and other low and middle income countries, it is vital to assess current service availability and readiness to manage cervical cancer at health facilities in Bangladesh.

Methods
An interviewer-administered questionnaire adapted from the World Health Organization Service Availability and Readiness Assessment Standard Tool was used to collect cross-sectional data from health administrators of 323 health facilities in Bangladesh. Services provided were categorized into domains and service readiness was determined by mean readiness index (RI) scores. Data analysis was conducted using STATA version 13.

Results
There were seven tertiary and specialized hospitals, 118 secondary level health facilities, 124 primary level health facilities, and 74 NGO/private hospitals included in the study. Twenty-six per cent of the health facilities provided services to cancer patients. Among the 34 tracer items used to assess cancer management capacity of health facilities, four cervical cancer-specific tracer items were used to determine service readiness for cervical cancer. On average, tertiary and specialized hospitals surpassed the readiness index cutoff of 70% with adequate staff and training (100%), equipment (100%), and diagnostic facilities (85.7%), indicating that they were ready to manage cervical cancer. The mean RI scores for the rest of the health facilities were below the cutoff value, meaning that they were not prepared to provide adequate cervical cancer services.

Conclusion
The health facilities in Bangladesh (except for some tertiary hospitals) lack readiness in cervical cancer management in terms of guidelines on diagnosis and treatment, training of staff, and shortage of equipment. Given that cervical cancer accounts for more than one-fourth of all female cancers in Bangladesh, management of cervical cancer needs to be available at all levels of health facilities, with primary level facilities focusing on early diagnosis. It is recommended that appropriate standard operating procedures on cervical cancer be developed for each level of health facilities to contribute towards attaining sustainable developmental goals.

Global neurosurgery, Bangladesh and COVID-19 era

Background. COVID-19 has become an alarming pandemic for our earth. It has created panic not only in China but also in developing countries like Bangladesh. Bangladesh has adequate confinements to constrain the spread of the infection and in this circumstance, overall healthcare workers including neurosurgeons are confronting a ton of difficulties. The purpose of this paper is to depict the proficiency of Global neurosurgery in this COVID-19 time.

Method. Global neurosurgery offers the chance of fusing the best proof-based guidelines of care. This paper demonstrated that, in low to middle-income countries, Global medical procedure has been received to address the issues of residents who lack critical surgical care.

Results. Inappropriate and insufficient asset allotment has been a significant obstacle for the health system for decently giving security to the patients. The fundamental training process has been genuinely hampered in the current circumstance. Worldwide health activities have set to an alternate centre and Global neurosurgery as an assurance is slowed down.

Conclusion. This paper recommended that Global neurosurgical activities need to come forward and increase the workforce to emphasize surgical service.

Epidemiological characteristics of child injury in a tertiary paediatric surgical centre in Bangladesh

While high income countries (HICs) have reduced the mortality from child injury, it is increasing in the low- and middle-income countries (LMICs). However, injury registry and reporting are inconsistent and not well developed in the LMICs. This study aims at describing the epidemiology of child injury in a tertiary paediatric surgical centre in Bangladesh. We retrospectively analysed all patients of injury between 0 and 12 years of age admitted in the Department of Paediatric Surgery, Chattogram Medical College Hospital during January 2017 to June 2020. Analysis was done for the hospital prevalence, age and sex distribution, seasonal variations, mechanism of injury, site of involvement, and mortality from injury. There were a total of 538 patients and male to female ratio was 2.01:1. Hospital prevalence was 6.71%. Mean age was 6.60 ± 3.32 years. School age children were affected more (51.7%); and “6-10 years” age group had the highest number injuries (251 patients, 46.65%). The most common mechanisms of injuries were road-traffic accident (RTA, 35.32%), followed by fall (26.39%) and „stab or cut injury‟ (20.63%). Males experienced more abdominal injuries and females had more perineal injuries (P=0.00). RTA was the commonest mechanism in males (37.05%) and falls were the commonest mechanism in females (32.96%). „Stab or cut injury‟ was the commonest mechanism in infants and toddlers, and RTA was commonest among pre-school and school age children. There were no significant seasonal variations (P=0.09). There were 5.76% intentional injuries. Mortality was 2.60% and major causes of mortality were RTA and animal assaults. Injuries were more prevalent during the mid-childhood with an overall increasing trend with age. Mechanism of injury and site of involvement were different among different age groups and between sexes.

Evaluation of Morbidity and Mortality in Eclampsia: A Study in a Tertiary Care Hospital, Rajshahi, Bangladesh

Introduction: Eclampsia is a hypothetically life-threatening rare tricky situation of the hypertensive disorders of pregnancy, which is responsible for huge records in morbidity and deaths among women of reproductive age and their offspring. It is an occurrence of convulsion linked with pregnancy complicated by preeclampsia. The estimate of incidence and the burden of eclampsia is still a challenging pursuit worldwide; currently only seven countries have national data on the topic. Aim of the study: To assess the morbidity and mortality in eclampsia. Methods: This was a cross sectional observational study carried out in the Department of Obstetrics and Gynaecology in 250 Bedded General Hospital, Pabna, Bangladesh during the period from June 2016 and July 2016. Proper written consent form all the participants were obtained and the ethical committee of the hospital had approved the study before starting the
intervention. In total 178 pregnant women with eclampsia were finalized as the study population. Result: In our study we found in total 148 live births from total 178 mothers which were 83.15% against total study population. Among all the babies 139 were survived which was 93.91% among total live births. Death after birth was 9 in number which was 6.08% among total live births. Early neonatal death was 13 in number which was 7.3% against total mothers. Stillbirths were 16 in number which was 9% against total mothers. In perinatal complication analysis we found 42 babies with jaundice which was 28.38% among live births. Babies with septicemia were 28 (18.92%), with respiratory distress 25 (16.89%), with neonatal convulsion were 7(4.73%) and with no complication were 46 (31.08%). Conclusion: It was observed in our study that; lower income families have a worse performance in all obstetric health
care indicators among women with eclampsia. So, Proper health care and mental health facilities in order to get better obstetric and perinatal outcomes might be the faster route to reduce severe maternal outcome due to eclampsia.

Pattern of road traffic Accident and their consequences in Dhaka City

Road traffic injuries (RTIs) are one of the eight burning public health issues worldwide causing 1.3 million death every year. This study aimed to see the pattern of road traffic injuries, their consequences, and factors associated within Dhaka city. A cross-sectional study was conducted among Road Traffic Accident victims attended in three largest and tertiary care hospitals located inside the Dhaka metropolitan area through structured interviews between 25 January and 21 February 2017 with a sample size of 140. The majority of injured patients were between 18-37 years. More than 55% of injuries were severe, and intracranial injury (27.1%) was the most common type. T-junction (32.1%) and highways (31.4%) were most places for RTAs where half of the total victims were passengers. Our study indicates
age, gender, and educational status were significantly associated with consequences of RTAs (p<0.05). Moreover, among the RTAs related variables, type of vehicle, RTA type, injury place, and treatment approach found significantly associated with consequences of RTAs (P<0.05). The findings of this study could play an important role to build awareness on RTAs among policymakers and general peoples to reduce mortality due to RTIs.

Cost-effectiveness of inhaled oxytocin for prevention of postpartum haemorrhage: a modelling study applied to two high burden settings

Background: Access to oxytocin for prevention of postpartum haemorrhage (PPH) in resource-poor settings is limited by the requirement for a consistent cold chain and for a skilled attendant to administer the injection. To overcome these barriers, heat-stable, non-injectable formulations of oxytocin are under development, including oxytocin for inhalation. This study modelled the cost-effectiveness of an inhaled oxytocin product (IHO) in Bangladesh and Ethiopia.

Methods: A decision analytic model was developed to assess the cost-effectiveness of IHO for the prevention of PPH compared to the standard of care in Bangladesh and Ethiopia. In Bangladesh, introduction of IHO was modelled in all public facilities and home deliveries with or without a skilled attendant. In Ethiopia, IHO was modelled in all public facilities and home deliveries with health extension workers. Costs (costs of introduction, PPH prevention and PPH treatment) and effects (PPH cases averted, deaths averted) were modelled over a 12-month program. Life years gained were modelled over a lifetime horizon (discounted at 3%). Cost of maintaining the cold chain or effects of compromised oxytocin quality (in the absence of a cold chain) were not modelled.

Results: In Bangladesh, IHO was estimated to avert 18,644 cases of PPH, 76 maternal deaths and 1954 maternal life years lost. This also yielded a cost-saving, with the majority of gains occurring among home deliveries where IHO would replace misoprostol. In Ethiopia, IHO averted 3111 PPH cases, 30 maternal deaths and 767 maternal life years lost. The full IHO introduction program bears an incremental cost-effectiveness ratio (ICER) of between 2 and 3 times the per-capita Gross Domestic Product (GDP) ($1880 USD per maternal life year lost) and thus is unlikely to be considered cost-effective in Ethiopia. However, the ICER of routine IHO administration considering recurring cost alone falls under 25% of per-capita GDP ($175 USD per maternal life-year saved).

Conclusions: IHO has the potential to expand access to uterotonics and reduce PPH-associated morbidity and mortality in high burden settings. This can facilitate reduced spending on PPH management, making the product highly cost-effective in settings where coverage of institutional delivery is lagging.

Prevalence and Factors Associated With Caesarean Section in Four Hard-to-Reach Areas of Bangladesh: Findings From a Cross-Sectional Survey

Background: Caesarean section (C-section) is a major obstetric life-saving intervention for the prevention of pregnancy and childbirth related complications. Globally C-section is increasing, as well as in Bangladesh. This study identifies the prevalence of C-section and socio-economic and health care seeking related determinants of C-section among women living in hard-to-reach (HtR) areas in Bangladesh.

Methods: A cross-sectional survey was conducted using a structured questionnaire between August and December 2017 at four distinct types of HtR areas of Bangladesh, namely coastal, hilly, haor (wetland), and char areas (shallow land-mass rising out of a river). Total 2,768 women of 15-49 years of age and who had delivery within one year prior to data collection were interviewed. For the analysis of determinants of C- section, the explanatory variables were maternal age, educational status of women and their husbands, women’s religion, employment status and access to mobile phone, wealth index of the household, distance to the nearest health facility from the household, the number of ANC visits and presence of complications during pregnancy and the last childbirth. Logistic regression model was run among 850 women, who had facility delivery. Variables found significantly associated with the outcome (C-section) in bivariate analysis were included in the multivariable logistic model. A p-value <0.05 was considered as statistically significant in the analyses.

Results: Of the 2,768 women included in the study, 13% had C-sections. The mean (±SD) age of respondents was 25.4 (± 0.1) years. The adjusted prevalence of C-section was 13.1 times higher among women who had their delivery in private facilities than women who delivered in public facilities (Adjusted Odds Ratio, AOR: 13.1; 95% CI 8.6-19.9; p-value: <0.001). Women from haor area and coastal area had 4.7 times (AOR: 4.7; 95% CI 2.4-9.4; p value: <0.001) and 6.8 times (AOR: 6.8; 95% CI 3.6-12.8; p value: <0.001) more chance of having C-section, respectively, than women living in char area. Among women who reported complications during the last childbirth, the AOR of C-section was 3.6 times higher than those who did not report any complication (AOR: 3.6; 95% CI 2.4-5.4; p value: <0.001).

Conclusions: The study identifies that the prevalence of C-sections in four HtR areas of Bangladesh in substantially below the national average, although, the prevalence was higher in coastal areas than three other HtR regions. Both public and private health services for C-section should be made available and accessible in remote HtR areas for women with pregnancy complications. Establishment of an accreditation system for regulating private hospitals are needed to ensure rational use of the procedure.

Demand and capacity to integrate pelvic organ prolapse and genital fistula services in low-resource settings.

INTRODUCTION AND HYPOTHESIS:
There is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers.

METHODS:
Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services.

RESULTS:
Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts.

CONCLUSIONS:
Integration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.