Rates and indications of caesarean section deliveries in Bhutan 2015–2019: a national review

Background Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan. Methods This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015–2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital. Results For the period 2015–2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were ‘past caesarean section’ (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%). Conclusion Bhutan’s caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan’s efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.

Relative Incidence of Office Visits and Cumulative Rates of Billed Diagnoses Along the Axis of Vaccination

We performed a retrospective analysis spanning ten years of pediatric practice focused on patients with variable vaccination born into a practice, presenting a unique opportunity to study the effects of variable vaccination on outcomes. The average total incidence of billed office visits per outcome related to the outcomes were compared across groups (Relative Incidence of Office Visit (RIOV)). RIOV is shown to be more powerful than odds ratio of diagnoses. Full cohort, cumulative incidence analyses, matched for days of care, and matched for family history analyses were conducted across quantiles of vaccine uptake. Increased office visits related to many diagnoses were robust to days-of-care-matched analyses, family history, gender block, age block, and false discovery risk. Many outcomes had high RIOV odds ratios after matching for days-of-care (e.g., anemia (6.334), asthma (3.496), allergic rhinitis (6.479), and sinusitis (3.529), all significant under the Z-test). Developmental disorders were determined to be difficult to study due to extremely low prevalence in the practice, potentially attributable to high rates of vaccine cessation upon adverse events and family history of autoimmunity. Remarkably, zero of the 561 unvaccinated patients in the study had attention deficit hyperactivity disorder (ADHD) compared to 0.063% of the (partially and fully) vaccinated. The implications of these results for the net public health effects of whole-population vaccination and with respect for informed consent on human health are compelling. Our results give agency to calls for research conducted by individuals who are independent of any funding sources related to the vaccine industry. While the low rates of developmental disorders prevented sufficiently powered hypothesis testing, it is notable that the overall rate of autism spectrum disorder (0.84%) in the cohort is half that of the US national rate (1.69%). The practice-wide rate of ADHD was roughly half of the national rate. The data indicate that unvaccinated children in the practice are not unhealthier than the vaccinated and indeed the overall results may indicate that the unvaccinated pediatric patients in this practice are healthier overall than the vaccinated.

Pencegahan Penyakit Demam Berdarah Dengue (DBD) dengan Pembuatan Bio Spray Pengusir Nyamuk di Kelurahan Taman Sari, Ampenan, NTB

Dengue hemorrhagic fever (DHF) in West Nusa Tenggara in 2017 has an incidence rate per 100,000 population of 26.86 above the national rate of 22.55% and a Case Fatality Rate of 0.15%. Prevention of mosquitoes with insecticides is the main choice for people to avoid mosquito bites. Insecticide products circulating in the community include combustion, electricity, spray, burn, and lotion. The chemicals contained in mosquito repellent insecticides include organochlorines, organophosphates, carbamates, pyrethroids, and DEET. The synthetic active ingredients pose a threat to human health. This underlies the implementation of Community Service Program from Undergraduate Programm in Pharmacy STIKES Nasional for the development of safer insecticide products use natural potentials such as lemongrass, cloves, and lime leaves. The method used is to provide education about dengue disease, the Aedes Aegypti mosquito, and a workshop by making bio spray. The results show that there is an increase in the knowledge of the people of Taman Sari, Ampenan, West Nusa Tenggara about the efforts to prevent DHF, as indicated by an increase in all correct post-test answers, In addition, the results of evaluations of overall community service satisfaction programs are very interesting.

Core Cities’ strong growth in the 2010s: Were they ‘leaving behind’ the rest of their regions?

Second-order cities are generally seen as disadvantaged places in the literature on globalisation, but in recent years they have staged a revival in several countries. This article uses two data sources to examine the employment change recorded by Britain’s Core Cities between 2012 and 2017, breaking it down by type of worker, occupation and industry. It aims, firstly, to identify which elements of their growth are distinctive compared to the country as a whole and, secondly, to see how far their growth has been emulated by the areas around them that contain the majority of Britain’s ‘left-behind’ places. The article demonstrates the great strides made by the nine provincial cities combined, substantially exceeding the national rate of increase for male, female, full-time, part-time, employee and self-employed work, notably in the three highest status occupational groups and in all industrial sectors apart from manufacturing and transport, especially business services. It is also found that their growth outstripped that of their local, regional and EU comparators, underlining the importance of direct policy intervention for ‘left-behind’ places rather than relying on ‘trickle-down’ processes, especially given uncertainties about the sustainability of Core City growth in the wake of COVID-19 and Brexit.

Impact of Mother-to-Mother Support Groups in Promoting Exclusive Breastfeeding in a Low-Resource Rural Community in Kenya: A Randomized Controlled Trial

Breastfeeding is the single most effective intervention for growth, health, development and survival of infants. Exclusive breastfeeding (EBF) for 6 months alone can reduce under-five child mortality by up to 13%. Community-based strategies such as Mother-to-Mother Support Groups (MTMSGs) have improved the rates of EBF by increasing the length of maternal support before and after delivery. The rate of EBF in the study area was 18.6%, which was lower than national rate of 32% at the time of the study. Currently, the Kenyan national rate is 61% but with high regional variability. This study was designed to assess the impact of community-based MTMSGs with or without income generating activities in promoting EBF in low socio-economic rural setting in Kenya. This was a cluster randomized controlled trial in which 3 health centres in Igembe South Sub-County in Meru County, Kenya were randomly allocated to three study groups, on a ratio of 1:1:1; to two treatment groups and a control group. The target population was pregnant mothers in their third trimester (33-37 weeks) and registered at ante-natal clinics in any of the 3 health centres. Total sample size was 249. Mothers in the first treatment group received breastfeeding education and support during seven monthly meetings by trained breastfeeding peer educators. Mothers in the second treatment group received breastfeeding education and support at the same frequency as those in first group in addition to conducting income generating activities facilitated by the research team. Mothers in the control group received no breastfeeding education. Infant feeding practices were determined based on 24–hour recall. Data was collected on monthly basis for 6 months postpartum by interviewers blinded to the study hypotheses. The primary outcome was EBF prevalence at six months while secondary outcome was cumulative EBF at six months. Mothers in the first and second treatment groups were two times more likely to exclusively breastfed at 6 months compared to mothers in the control group [RR=2.42;CI 1.36-4.28;(p=0.004] and [RR=1.89;CI 1.02-3.49;(p=0.033)] respectively. There was no significant difference in the EBF rates at 6 months in the 2 treatment groups. Median duration of cumulative EBF for the control group was significantly lower at 0.7 months compared with first treatment group at 2.8 months (p<0.001) and second treatment group at 3.4 months (p<0.001). Mother-to-mother support groups is an effective strategy in promoting exclusive breastfeeding in low socio-economic rural settings and should therefore be strengthened in Kenya and similar circumstances.

Abstract WP429: A Nurse Driven Acute Stroke Alert Process Improves Treatment Times and Treatment Rates

Introduction: Treatment time has gained sufficient popularity because it is now well-known that “Time is Brain”. Treatment rates, however, lag behind in importance even though more lives can be saved by treating more often. Our TJC Comprehensive Stroke Center has a nurse-led stroke alert process that focuses on multiple, rapid, parallel steps to reduce DTN for IV alteplase. The Baptist Emergency Stroke Team (BEST) responders are highly-trained and skilled nurses that assess, coordinate, and initiate processes to ensure the best times. We identified that our treatment rate was lower than the national rate for certified CSCs, so the BEST responders used a stepwise process to develop their own interventions to improve rates. Methods: First, the BEST responders started tracking our monthly rate. Next, they set a rate goal, and then brainstormed how to influence treatment decision-making. The BEST team initiated a monthly PI meeting that focused on the importance of treating disability rather than an NIHSS score. Then the team scripted and rehearsed critical conversations to have providers that advocated specifically for treating disability. The team adopted the motto, “Treat Disability, Not Numbers”. Results Conclusions: Our CSC observed a small decrease in median DTN but double the treatment rate after the BEST responder intervention. In comparison, these statistics did not change at the national CSC level. The sICH rate was reduced from Period A to C, meaning that increased treatment rate did not lead to increased hemorrhagic rate. Nursing initiatives can have a substantial positive effect on increasing the number of patients treated with IV alteplase for acute ischemic stroke.

Analysis on Human Resources, Facility and Infrastructure, and Planning to Decrease the Incidence Rate of Malaria in Batu Bara Regency

Malaria is one of public health problems throughout the world, including Indonesia. Nationally, Annual Parasite Incidence (API) decreased to 0.99 per mil in 2017, but there are some malaria villages with API above the national rate. Batu Bara Regency is categorized as an endemic area and not malaria elimination with API of 0.47 per mil in 2018. The objective of the research was to analyze human resources, facility and infrastructure, and planning to decrease the incidence rate of malaria in Batu Bara Regency. The research used qualitative research method by conducting in-depth interviews with eight informants. The study found that there were no entomology assistant, malaria cadres for villages, and microscopist in the Health Agency, and of the 15 puskesmas (Primary Health Care), only five of them had microscopists. There was no transportation facility for personnel; there were only three spraycans although it should have been eight of them needed. Handling planning was not based on the mapping for detecting mosquito breeding places. The conclusion was that human resources were still unstandardized, there was no facility and infrastructure for malaria personnel. It’s suggested to mapping mosquito breeding and spraycans should be added.

N11 Pregnancy Outcomes in Patients with inflammatory bowel disease: A single-centre experience

Background This study aimed to examine the current management and outcomes in pregnancy in our cohort of inflammatory bowel disease (IBD) patients. Methods Following ethical approval patients with at least one pregnancy with known Crohn’s Disease (CD) or Ulcerative Colitis (UC) were identified. Using a self-assessment questionnaire basic demographic, clinical data and pregnancy outcomes were recorded. Results Eighty-five patients were recruited between January and October 2019; 38 CD, 26 UC and 1 Indeterminate (ID). The mean age was 28.6 years (range 14–46 years) at diagnosis. In total there were 199 pregnancies: 168 live births, 2 stillbirths (1%); lower than the national rate of 3.0 per 1000 and 29 miscarriages (14.5%) compared with national rates of 1 in 5. The majority attended routine combined GP and maternity services, only 17 (20%) attended a specific high-risk maternity clinic. Biologic usage was similar pre and during pregnancy; 16 (22%), 11 (16%) with a slight increase post pregnancy 19 (30%). Overall 26% continued to smoke and 7% drank alcohol during their pregnancy. The total of reported flares were less frequent during pregnancy 45% (n = 35) vs. pre-partum 61% (n = 47) and post-partum 79% (n = 61), p = 0.021. In all there were 138 vaginal deliveries and 32 (19%) caesarean sections (CS). CS rates did not differ by disease type, UC 9/26 & CD 26/58, p = 0.4 There were 12 (7%) preterm deliveries 3 of which had low birth weights. 2 congenital abnormalities 1 % (cleft palate and spina bifida) lower that the national rate of 2–3% of live births and 14–24% of stillbirths, were recorded. Breast feeding rates were reported at 34% (n = 28), significantly lower than the national average rate of 46.3%. 81% of patients reported having had a recent smear test and 18% reported an abnormal smear. Seventy per cent of patients who reported having an abnormal smear were on immunosuppressant therapy. Conclusion The results from our ongoing study have found less disease activity during pregnancy possibly associated with continued use of biological therapy. However, there were higher rate of flares reported post-partum possibly related loss to immune tolerance developed during pregnancy, or lifestyle and environmental factors. Despite not attending a specific IBD pregnancy service outcomes in our cohort were good with lower than National average rates of miscarriage, stillbirths and congenital abnormalities. Worryingly rates of over a quarter of patients continued to smoke during pregnancy and only a third of patients breastfed; factors which could be targets for future education. High rate of abnormal smear tests, low rate of HPV vaccination warrants further research.