Pattern of contraceptive use among reproductive-aged women with diabetes and/or hypertension: findings from Bangladesh Demographic and Health Survey

Background
The prevalence of chronic conditions such as diabetes and hypertension is increasing among reproductive-aged women in Bangladesh. However, the pattern of contraceptive use among this population remains unknown. We, therefore, explored the pattern of contraceptive use among reproductive-aged women with diabetes and/or hypertension in Bangladesh.

Methods
We extracted and analysed data of 3,947 women from the 2017/18 Bangladesh Demographic and Health Survey. Women’s pattern of contraceptive use was our outcome variable. We first classified the contraceptive using status as no method use, traditional method use (periodic abstinence, withdrawal, other traditional) and modern method use (pill, intra-uterine device, injections, male condom, female sterilization, male sterilization). We later classified these as (i) no contraceptive use vs any contraceptive use, (ii) traditional method or no use vs modern method use, (iii) traditional method vs modern method use. The explanatory variables were diagnosis of diabetes only, hypertension only or both diabetes and hypertension. The multilevel Poisson regression with robust variance was used to explore the associations.

Results
The overall prevalence of contraceptive use was 68.0% (95% CI 66.3–69.7). The corresponding prevalences were 69.4% (95% CI 61.8–76.1) in women with diabetes only, 67.3% (95% CI 63.5–70.9) with hypertension only, and 62.0% (95% CI 52.8–70.4) in women having both diabetes and hypertension. The prevalence of modern methods of contraceptive use was lower (46.4%, 95% CI 37.4–55.6) and traditional methods use was higher (16.6%, 95% CI 13.8–16.8) in women who had both diabetes and hypertension than in women who did not have these conditions. The fully adjusted regression model showed that the prevalence of traditional method use was 31% (Prevalence ratio: 1.31, 95% CI 1.02–2.01) higher in women having both diabetes and hypertension compared with their counterparts who had none of these conditions.

Conclusion
In Bangladesh, women with both diabetes and hypertension were more likely to use traditional contraception methods. These women are likely to experience increased risks of unwanted pregnancies and associated adverse maternal and child health outcomes. Targeted policies and programs should be undertaken to promote modern contraceptive use among women living with both chronic conditions.

A study of clinical and economic burden of surgical site infection in patients undergoing caesarian section at a tertiary care teaching hospital in India

Background
Caesarian section is one of the most commonly performed surgeries in India. Determination of the incidence as well as the clinical and financial burden of post caesarian surgical site infection (SSI) is of critical importance for all the stakeholders for rational and fair allocation of resources.

Methods
This study was a prospective observational case-control study. The mean direct and indirect cost of treatment for the cases were compared with the control patients. An unpaired t-test was used to compare the mean between the two groups.

Results
Out of 2024 patients, who underwent caesarian section during the study period, 114 had acquired incisional surgical site infection (ISSI), with the infection incidence being 5.63%. The total cost of illness due to post caesarian ISSI was almost three times higher compared to the non-infected matched control group. (P<0.0001). An average length of hospital stay in the ISSI patient group was 10 days longer than that in the control group (P<0.0001) and importantly total length of antimicrobial therapy(LOT) in patients with ISSI was also almost three times higher than the control group (P<0.0001).

Conclusion
The development of post caesarian SSI imposes a significant clinical as well as a financial burden. The study highlights the necessity of taking effective preventive measures to decrease the incidence of SSI.

How much do government and households spend on an episode of hospitalisation in India? A comparison for public and private hospitals in Chhattisgarh state

Background
Improvements in the financing of healthcare services are important for developing countries like India to make progress towards universal health coverage. Inpatient-care contributes to a big share of total health expenditure in India. India has a mixed health-system with a sizeable presence of private hospitals. Existing studies show that out-of-pocket expenditure (OOPE) incurred per hospitalisation in private hospitals was greater than public facilities. But, such comparisons have not taken into account the healthcare spending by government.

Methods
For a valid comparison between public and for-profit private providers, this study in Indian state of Chhattisgarh assessed the combined spending by government and households per episode of hospitalisation. The supply-side and demand-side spending from public and private sources was taken into account. The study used two datasets: a) household survey for data on hospital utilisation, OOPE, cash incentives received by patients and claims raised under publicly funded health insurance (PFHI) schemes (n = 903 hospitalisation episodes) b) survey of public facilities to find supply-side government spending per hospitalisation (n = 64 facilities).

Results
Taking into account all relevant demand and supply side expenditures, the average total spending per day of hospitalisation was INR 2833 for public hospitals and INR 6788 for private hospitals. Adjusted model for logarithmic transformation of OOPE while controlling for variables including case-mix showed that a hospitalisation in private hospitals was significantly more expensive than public hospitals (coefficient = 2.9, p < 0.001). Hospitalisations in private hospitals were more likely to result in a PFHI claim (adjusted-odds-ratio = 1.45, p = 0.02) and involve a greater amount than public hospitals (coefficient = 0.27, p < 0.001). Propensity-score matching models confirmed the above results.

Overall, supply-side public spending contributed to 16% of total spending, demand-side spending through PFHI to 16%, cash incentives to 1% and OOPE to 67%. OOPE constituted 31% of total spending per episode in public and 86% in private hospitals.

Conclusions
Government and households put together spent substantially more per hospitalisation in private hospitals than public hospitals in Chhattisgarh. This has important implications for the allocative efficiency and the desired public-private provider-mix. Using public resources for purchasing inpatient care services from private providers may not be a suitable strategy for such contexts.

Sexual and Reproductive Health and Rights (SRHR) and Maternal, Neonatal and Child Health (MNCH) in Bangladesh: Impacts of the Covid-19 Pandemic

The Covid-19 pandemic has exacerbated and drawn fresh attention to long-standing systemic weaknesses in health and economic systems. The virus – and the public health response – has wrought significant disruption on sexual and reproductive health and rights (SRHR) and maternal, neonatal and child health (MNCH) in Bangladesh. Known negative health outcomes include increased domestic and gender-based violence, child marriage, negative mental health, and adverse child health outcomes. This scoping paper for the Covid-19 Learning, Evidence and Research Programme for Bangladesh (CLEAR) aims to inform future research and policy engagement to support response, recovery, progress, and future health system resilience for SRHR and MNCH in Bangladesh, following the Covid-19 crisis. We present what is known on disruptions and impacts, as well as evidence gaps and priority areas for future research and engagement.

EMR adoption in Dhaka, Bangladesh: a template to index pediatric central nervous system tumor care and a review of preliminary neuro-oncologic observations

Purpose
To describe the design, implementation, and adoption of a simplified electronic medical record (EMR) and its use in documenting pediatric central nervous system (CNS) tumors at a tertiary care referral hospital in South-East Asia.

Methods
A novel EMR, cataloguing pediatric CNS tumors was used to collect data from August 2017 to March 2020 at National Institute of Neurosciences and Hospital (NINS&H) in Dhaka, Bangladesh.

Results
Two hundred forty-nine pediatric patients with a CNS tumor were admitted to NINS&H. Fifty-eight percent of patients were male, and the median age was 8 years. A total of 188/249 patients (76%) underwent surgery during their index admission. Radiographic locations were known for 212/249 (85%) of cases; the most common radiographic locations were infratentorial (81/212; 38%), suprasellar (45/212; 21%), and supratentorial (29/212; 14%). A histopathological classification was reported on 156/249 (63%) of patients’ cytology. The most common infratentorial pathologies were medulloblastoma (22/47; 47%) and pilocytic astrocytoma (14/47; 30%). The median time between admission and surgery was 36 days, while the median post-operation stay was 19.5 days.

Conclusions
The feasibility of a basic EMR platform for a busy pediatric neurosurgery department in a lower-middle income country is demonstrated, and preliminary clinical data is reviewed. A wide variety of pediatric CNS tumors were observed, spanning the spectrum of anatomic locations and histopathologic subtypes. Surgical intervention was performed for the majority of patients. Barriers to care include limited molecular diagnostics and unavailable data on adjuvant therapy. Future targets include improvement of clinical documentation in the pre-operative and post-operative period.

Implementing the WHO Labour Care Guide to reduce the use of Caesarean section in four hospitals in India: protocol and statistical analysis plan for a pragmatic, stepped-wedge, cluster-randomized pilot trial

BACKGROUND
The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO’s latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women’s experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: 1) develop and optimise a strategy for implementing the LCG (formative phase); and 2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase).

METHODS
In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women’s experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness.

DISCUSSION
Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally.

TRIAL REGISTRATION:
CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022)

Clinical profile, outcomes and predictors of mortality in neonates operated for gastrointestinal anomalies in a tertiary neonatal care unit- An observational study

Background: Gastrointestinal (GI) malformations have varied short-term and long-term outcomes reported across various neonatal units in India.
Methods: This descriptive study was done to study the clinical profile, outcomes and predictors of mortality in neonates operated for congenital GI malformations in a tertiary neonatal care unit in South India between years 2011 and 2020. Details were collected by retrospective review of the case sheets.
Results: Total of 68 neonates were included with esophageal atresia (EA) in 10, infantile hypertrophic pyloric stenosis (IHPS) in 9, duodenal atresia (DA) in 10, ileal atresia in 8, jejunal atresia in 5, anorectal malformations (ARM) in 11, meconium ileus/peritonitis in 9, malrotation in 2, and Hirschsprung’s disease (HD) in 4. Antenatal diagnosis was highest in DA (80%). Associated anomalies were maximum in EA (50%), the most common being vertebral, anal atresia, cardiac defects, tracheoesophageal fistula, renal and radial abnormalities, and limb abnormalities association (VACTERL). Overall mortality was 15%. IHPS, DA, Malrotation, HD and ARM had 100 % survival while ileal atresia had the least survival (38%). Gestational age <32 weeks (odds ratio [OR] 12.77 [1.96, 82.89]) and outborn babies (OR 5.55 [1.01, 30.33]) were significant predictors of mortality in babies operated for small intestinal anomalies. None of the surviving infants were moderately or severely underweight at follow-up.
Conclusion: Overall survival of surgically correctable GI anomalies is good. Among the predictors for mortality, modifiable factors such as in-utero referral of antenatally diagnosed congenital anomalies need attention. One-fifth had associated anomalies highlighting the need to actively look for the same. Although these neonates are vulnerable for growth failure, they had optimal growth on follow-up possibly due to standardized total parenteral nutritional policy during neonatal intensive care unit stay.

Comparative evaluation of robot-assisted and conventional urology surgeries in India

There is dearth of evidence on patients’ perspective, their knowledge and understanding about robot-assisted surgeries, especially in Low- and Middle-Income countries such as India. The aim of this prospective study was to analyze inpatients’ and surgeon’s perspectives towards robot-assisted and conventional urological surgeries. A total of 136 patients (94 robot-assisted surgery cases and 42 conventional surgery cases) were enrolled in the study. A performa (with details such as sociodemographic details of patient, patient’s view point on surgery opted and doctor’s perspective on advising robot-assisted or conventional surgery) was used for data collection. Of 136 patients, 135 (99.3%) responded that their reason for opting the surgery (either robot-assisted or open laparoscopy) depended on the advice provided by the surgeon. 78 (83.3%) patients mentioned they opted for robot-assisted surgeries because of aesthetics (cosmetically better) in comparison to 07 (16.7%) patients who opted for conventional surgeries. Only 1.1% of surgeons reported robot-assisted surgeries to be technically easy. A few surgeons (1.1%) who operated with robot-assisted surgeries mentioned it to be time-consuming than 71.4% (30) surgeons in open/lap group. All the surgeons who treated patients with robot-assisted surgeries mentioned to have no of complications in comparison to 35.75% surgeons in open/lap group. The reason for choosing robot-assisted surgeries among both patients and surgeons were patient’s compatibility, cosmetically better, less-time consuming and less hospital stay. In addition, the surgeons also believed the robot-assisted surgeries to have fewer complications for their patients and therefore, recommended it.

Safe and Standard Thyroid Cancer Surgery, or Lack Thereof: Patterns and Correlates of Patient Referral to Tertiary Care Centre for Revision Thyroid Surgery in a LMIC

Background A surgeon’s characteristics such as volume and practice setup are essential elements in outcome of thyroid cancer. However, little information is available from the developing world regarding qualities of primary surgeon, such as level of knowledge, skill, and proper documentation while referring to higher center.

Methods Records of 164 patients of differentiated thyroid cancer (DTC) from January 1990 to December 2018 undergoing revision thyroid surgery following primary surgery elsewhere were retrospectively analyzed.

Results Out of 164 patients with postoperative diagnosis of DTC, referral patterns were as follows: low volume (LV) to high volume (HV) (n = 120, 73.2%), followed by HV to HV (n = 44, 26.8%). The primary surgery assessed by the extent of residual disease was in agreement with the documentation in only 55%. The type of thyroidectomy performed was not mentioned in 9.8%. The status of the parathyroid glands was mentioned only in 15.8% and recurrent laryngeal nerve in 12.2%. Less than recommended surgery was performed in 52.5% patients. Despite less than recommended surgery, 44.5% patients were directly referred for radioactive iodine ablation (RAIA). Thirty two percent patients were referred for RAIA after hemithyroidectomy. Central or lateral compartment lymphadenectomy, even after indication, was less likely at LV centers (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.64–0.77). Similarly, for DTC patients, the relationship between LV center surgery and subsequent referral for RAIA was RR, 0.71 (95% CI, 0.48–1.02).

Conclusions Most patients referred from LV surgeons are less likely to have proper thyroidectomy, have inadequate documentation of the primary surgery, and are referred for RAIA after less than total thyroidectomy. Our study highlights the lacunae in the approach to and understanding of thyroid cancer surgery by secondary care physicians in our country. We believe that there is an urgent necessity of educational reform and training to rectify this problem.

Evaluation of an Artificial Intelligence System for Retinopathy of Prematurity Screening in Nepal and Mongolia

Objective
The purpose of this study is to evaluate the performance of a deep learning algorithm for retinopathy of prematurity (ROP) screening in Nepal and Mongolia.

Design
This was a retrospective analysis of prospectively collected clinical data.

Subjects
Clinical information and fundus images were obtained from infants in two ROP screening programs in Nepal and Mongolia.

Methods
Fundus images were obtained using the Forus 3nethra neo in Nepal and RetCam® Portable in Mongolia. The overall severity of ROP was determined from the medical record using the International Classification of ROP (ICROP). The presence of plus disease was independently determined in each image using a reference standard diagnosis. The Imaging and Informatics for ROP (i-ROP) deep learning (DL) algorithm, which was trained on images from the RetCam® was used to classify plus disease, as well as assign a vascular severity score (VSS) from 1-9.

Main outcome measures
The main outcome measures were area under the receiver operating characteristic (AUC-ROC) and area under the precision recall curve (AUC-PR) for the presence of plus disease or type 1 ROP, and association between VSS and ICROP disease category.

Results
The prevalence of type 1 ROP was found to be higher in Mongolia (14.0%) than in Nepal (2.2%, p < 0.001) in these data sets. In Mongolia (Retcam images), the AUC-ROC for exam-level plus disease detection was 0.968 and AUC-PR was 0.823. In Nepal (Forus images), the AUC-ROC for exam-level plus disease detection was 0.999 and AUC-PR was 0.993. The ROP vascular severity score was associated with ICROP classification in both datasets (p < 0.001). At the population level, the median [interquartile range] VSS was found to be higher in Mongolia (2.7 [1.3–5.4]) as compared to Nepal (1.9 [1.2–3.4], p < 0.001). Conclusions These data provide preliminary evidence of the effectiveness of the i-ROP DL algorithm for ROP screening in neonatal populations in Nepal and Mongolia, using multiple camera systems, and provide useful data for consideration in future clinical implementation of AI-based ROP screening in low- and middle-income countries.