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Non-communicable diseases (NCDs) claim 74% of global lives, disproportionately affecting lower and middle-income countries like Pakistan. NCDs may increase the risk of preterm birth (PTB), caesarean section (CS), and low birthweight. This study aims to determine whether the high prevalence of NCDs in Pakistan play a role in the high rates of preterm births, and CS. This retrospective cohort study from Aga Khan University Hospital, Pakistan, investigated effects of pre-existing NCDs on pregnancy outcomes of 817 pregnant women. Medical records were used to generate odds ratios for the risk of PTB, labour outcome and birthweight in women with type 1 and type 2 diabetes, hypertension, asthma and thyroid disorders. Multinomial logistic regression and general linear models were used to adjust for confounding variables using IBM SPSS Statistics (v27). Type 2 diabetes significantly increased the risk of PTB and elective CS (both P  < 0.05). Elective CS was significantly increased by hypertension and asthma (both, P  < 0.05). Surprisingly, asthma halved the risk of PTB ( P  < 0.05), while type 1 diabetes significantly increased birthweight from 2832 to 3253g ( P  < 0.001). In conclusion, pre-existing NCDs increase the risk of negative pregnancy outcomes, including PTB, elective CS and birthweight. Asthma, however reduced PTB and justifies further investigation.

Most pregnancy hypertension estimates in less-developed countries are from cross-sectional hospital surveys and are considered overestimates. We estimated population-based rates by standardised methods in 27 intervention clusters of the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. CLIP-eligible pregnant women identified in their homes or local primary health centres (2013-2017). Included here are women who had delivered by trial end and received a visit from a community health worker trained to provide supplementary hypertension-oriented care, including standardised blood pressure (BP) measurement. Hypertension (BP ≥ 140/90 mm Hg) was defined as chronic (first detected at <20 weeks gestation) or gestational (≥20 weeks); pre-eclampsia was gestational hypertension plus proteinuria or a pre-eclampsia-defining complication. A multi-level regression model compared hypertension rates and types between countries (p < 0.05 considered significant). In 28,420 pregnancies studied, women were usually young (median age 23-28 years), parous (53.7%-77.3%), with singletons (≥97.5%), and enrolled at a median gestational age of 10.4 (India) to 25.9 weeks (Mozambique). Basic education varied (22.8% in Pakistan to 57.9% in India). Pregnancy hypertension incidence was lower in Pakistan (9.3%) than India (10.3%), Mozambique (10.9%), or Nigeria (10.2%) (p = 0.001). Most hypertension was diastolic only (46.4% in India, 72.7% in Pakistan, 61.3% in Mozambique, and 63.3% in Nigeria). At first presentation with elevated BP, gestational hypertension was most common diagnosis (particularly in Mozambique [8.4%] versus India [6.9%], Pakistan [6.5%], and Nigeria [7.1%]; p < 0.001), followed by pre-eclampsia (India [3.8%], Nigeria [3.0%], Pakistan [2.4%], and Mozambique [2.3%]; p < 0.001) and chronic hypertension (especially in Mozambique [2.5%] and Nigeria [2.8%], compared with India [1.2%] and Pakistan [1.5%]; p < 0.001). Inclusion of additional diagnoses of hypertension and related complications, from household surveys or facility record review (unavailable in Nigeria), revealed higher hypertension incidence: 14.0% in India, 11.6% in Pakistan, and 16.8% in Mozambique; eclampsia was rare (<0.5%). Pregnancy hypertension is common in less-developed settings. Most women in this study presented with gestational hypertension amenable to surveillance and timed delivery to improve outcomes. This study is a secondary analysis of a clinical trial - ClinicalTrials.gov registration number NCT01911494.

Background Adolescence is the second window of opportunity to catch-up growth, and children can attain their full physical growth potential. However, optimum dietary intake is essential for this. In this study, we aimed to estimate dietary diversity, stunting, thinness, and anemia among unmarried adolescent boys and girls in selected communities of rural Sindh, Pakistan. Methods A cross-sectional survey of 788 unmarried 10-19-year-old adolescents in rural Sindh was conducted. Adolescents were interviewed using a food frequency questionnaire. Daily intake of at least 5 out of 10 food groups was labelled as having minimum dietary diversity following the Minimum Dietary Diversity for Women (MDDS-W) guide. Less than 2 standard deviations for z-scores of height for age and BMI for age were labelled as stunting and thinness, respectively. Anemia was defined as Hb less than 12 gm/dl for girls and for boys between the ages of 10–15 years. Cut-off of < 13 gm/dl was used for anemia in boys more than 15 years of age. The Cox-proportional algorithm was used to analyze the associated factors of stunting, thinness, and anemia and prevalence ratios with 95% confidence interval were estimated. Results Our study found that < 1% of adolescents achieved minimum dietary diversity (MDD). There was a higher daily intake of sugar-sweetened beverages (SSB) and bread, and daily intake of meat, eggs, and nuts was among < 1% of the participants. The sub-optimum dietary intake was reflected as high rates of stunting 31.9%, thinness 18.0%, and anemia 68.2% in our sample. Stunting and anemia were significantly higher among girls compared to boys (35.8% vs. 28.0%; 82.1% vs. 54.7% respectively). In sex-stratified analysis, the age of the adolescent and wealth quintiles were associated with stunting among girls. No other variables were associated with stunting, thinness, or anemia among girls and boys. Conclusion The prevalence of low dietary diversity and anemia was alarmingly high in adolescents and calls for immediate attention. The high burden of stunting shows chronic undernutrition and missing the second window of opportunity during adolescence to gain potential adult height.

Background The Majority (99%) of maternal deaths occur in low and middle-income countries. The three most important causes of maternal deaths in these regions are postpartum hemorrhage, pre-eclampsia and puerperal sepsis. There are several diagnostic criteria used to identify sepsis and one of the commonly used criteria is systematic inflammatory response syndrome (SIRS). However, these criteria require laboratory investigations that may not be feasible in resource-constrained settings. Therefore, this study aimed to develop a model based on risk factors and clinical signs and symptoms that can identify sepsis early among postpartum women. Methods A case-control study was nested in an ongoing cohort of 4000 postpartum women who delivered or were admitted to the study hospital. According to standard criteria of SIRS, 100 women with sepsis (cases) and 498 women without sepsis (controls) were recruited from January to July 2017. Information related to the socio-demographic status, antenatal care and use of tobacco were obtained via interview while pregnancy and delivery related information, comorbid and clinical sign and symptoms were retrieved from the ongoing cohort. Multivariable logistic regression was performed and discriminative performance of the model was assessed using area under the curve (AUC) of the receiver operating characteristic (ROC). Results Multivariable analysis revealed that 1–4 antenatal visits (95% CI 0.01–0.62). , 3 or more vaginal examinations (95% CI 1.21–3.65), home delivery (95% CI 1.72–50.02), preterm delivery, diabetes in pregnancy (95% CI 1.93–20.23), lower abdominal pain (95% CI 1.15–3.42)) vaginal discharge (95% CI 2.97–20.21), SpO2 < 93% (95% CI 4.80–37.10) and blood glucose were significantly associated with sepsis. AUC was 0.84 (95% C.I 0.80–0.89) which indicated that risk factors and clinical sign and symptoms-based model has adequate ability to discriminate women with and without sepsis. Conclusion This study developed a non-invasive tool that can identify postpartum women with sepsis as accurately as SIRS criteria with good discriminative ability. Once validated, this tool has the potential to be scaled up for community use by frontline health care workers.

Background Food insecurity (FI) is alarmingly high in developing countries including Pakistan. A quarter of Pakistan’s population consists of adolescents yet there is no information on their experience of FI. FI at adolescent age have long term effect on mental and physical health hence we aimed to determine the prevalence of food insecurity (FI) among adolescents and compare it with household FI, and assess social determinants of adolescent FI. Methods A cross-sectional survey on 799 households with unmarried adolescents was conducted from September 2015 to June 2016 in three union councils of Hyderabad, Pakistan. Unmarried 10–19 years old girls and boys were interviewed regarding their FI status using Household Food Insecurity Assessment Scale (HFIAS). Household-level FI was also assessed by interviewing mothers of adolescents, and it was compared with adolescent’s FI. Association of adolescent’s FI with socio-demographic determinants was explored through Cox regression using STATA version 14.0. and prevalence ratios were estimated. Results FI was found among 52.4% of the adolescents compared to 39% of the households. Thirty percent of the adolescents were food insecure within the food secure households. Female adolescents were found to be less food insecure (Adjusted Prevalence Ratio (APR) 0.4 95% CI [0.3, 0.5]) compared to males. Social determinants like socioeconomic status (SES), crowding index or education of parents were not associated with adolescents’ FI. Conclusion Half of the adolescents were found to be food insecure which raises concerns regarding their health in the long run. Gender is an important social determinant of FI among adolescents which suggests an in-depth exploration of social dynamics of adolescent FI. We recommend the mixed-methods study to develop contextually relevant interventions to reduce FI among this group and improve their health status.

In this trial in women undergoing miscarriage surgery in low-resource countries, antibiotic prophylaxis did not result in a significantly lower risk of pelvic infection, as defined by broad criteria, than placebo. However, benefit was observed in a secondary analysis that defined pelvic infection by strict criteria (signs of infection).

Pakistani women suffer the highest rate of maternal mortality in South Asia. A lack of comprehensive knowledge about maternal and newborn health (MNH) services costs impedes policy decisions to maximize the benefit from existing, as well as emerging, MNH interventions in Pakistan. We compared MNH service costs at different levels of care. A cross-sectional survey was conducted during January to March 2016 as part of a large economic evaluation in Sindh, Pakistan. Health providers and facilities were selected from a sampling frame, inclusive of public and private sectors. This study utilized a broad perspective (i.e. costs to the health system and patients/families). The unit costs of MNH services were determined through a simultaneous allocation method in the public facilities; and patient billing department in the private facilities. Descriptive analysis was performed, and an analysis of variance (ANOVA) test was applied to compare overall mean costs both within and between health facilities. A total of 31 eligible health providers and facilities (n = 25 in private; n = 7 in public) were included in the final analysis. An ambulatory visit (AV) for routine antenatal care (ANC) costs $3.6 and $0.9 at secondary- and tertiary-level public facilities, respectively. In the private sector, the costs of an AV for ANC were slightly less ($2.8) at secondary-level and much higher ($6) at tertiary-level facilities compared to the public sector. Diagnostic test costs were much higher in private facilities. The average costs of inpatient admissions were $30.5 at general ward (GW), and $151 at the intensive care unit (ICU) in public facilities. In-patient admissions costs were lower such as $9.3 at GW and $36.5 at ICU in private facilities. Understanding cost is critical to guide decisions of resource allocation within the public sector; and risk mitigation for excessive OOP costs through third party payer for services in the private sector.

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on the mental health and wellbeing of Ontario's youth. Our study investigated the psychological impacts of COVID-19 on the pediatric population of Ontario, using a survey derived from the Revised Children's Anxiety and Depression Scale (RCADS) system to identify children who may benefit from seeking professional help. Our cross-sectional study examined the potential risk factors that contributed to worsening mental health and wellbeing in children, including changes in sleep patterns, appetite, and physical activity levels, as well as the diagnosis of a family member with COVID-19. Our study found that 24%, 9.4%, and 15.5% of participants exhibited symptoms of depression, anxiety, and obsessive-compulsive disorder (OCD), respectively, according to the RCADS system. Furthermore, there were significant associations between the presence of symptoms and the diagnosis of a family member with COVID-19 or a frontline worker in the family. This suggests a need to create interventions to support the families of frontline workers and those directly affected by a COVID-19 diagnosis.

Objective To estimate the prevalence and prognosis of proteinuria at enrolment in the 27 intervention clusters of the Community-Level Interventions for Pre-eclampsia cluster randomized trials. Methods We identified pregnant women eligible for inclusion in the trials in their communities in four countries (2013-2017). We included women who delivered by trial end and received an intervention antenatal care visit. The intervention was a community health worker providing supplementary hypertension-oriented care, including proteinuria assessment by visual assessment of urinary dipstick at the first visit and all subsequent visits when hypertension was detected. In a multilevel regression model, we compared baseline prevalence of proteinuria ([greater than or equal to] 1 + or [greater than or equal to] 2+) across countries. We compared the incidence of subsequent complications by baseline proteinuria. Findings Baseline proteinuria was detected in less than 5% of eligible pregnancies in each country (India: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004; Pakistan: 315/10 885), almost always with normotension (India: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). There was no consistent relationship between baseline proteinuria (either [greater than or equal to] 1+ or [greater than or equal to] 2+) and progression to hypertension, maternal mortality or morbidity, birth at < 37 weeks, caesarean section delivery or perinatal mortality or morbidity. If proteinuria testing were restricted to women with hypertension, we projected annual cost savings of 153 223 981 United States dollars (US$) in India, US$ 9 055 286 in Mozambique, US$ 53 181 933 in Nigeria and US$ 38 828 746 in Pakistan. Conclusion Our findings question the recommendations to routinely evaluate proteinuria at first assessment in pregnancy. Restricting proteinuria testing to pregnant women with hypertension has the potential to save resources. [phrase omitted] [phrase omitted] Metodos Se identificaron mujeres embarazadas que cumplian los requisitos para participar en los ensayos en sus comunidades en cuatro paises (2013-2017). Se incluyeron las mujeres que tuvieron un parto al final del ensayo y recibieron una visita de atencion prenatal de intervencion. Esta intervencion consistio en un profesional sanitario de la comunidad quien presto atencion suplementaria centrada en la hipertension, incluida la evaluacion de la proteinuria a traves del analisis visual de la tira reactiva de orina en la primera visita y en todas las visitas posteriores si se presentaba hipertension. En un modelo de regresion multinivel, se comparo la prevalencia del valor basal de la proteinuria ([greater than or equal to] 1 + o [greater than or equal to] 2+) en todos los paises. Luego, se comparo la incidencia de las complicaciones posteriores en funcion del valor basal de la proteinuria. Resultados El valor basal de la proteinuria se detecto en menos del 5 % de los embarazos que cumplian los requisitos en cada pais (India: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004, Pakistan: 315/10 885), la mayoria de las veces con una tension arterial normal (India: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). No se observo una relacion coherente entre el valor basal de la proteinuria (ya sea [greater than or equal to] 1 + o [greater than or equal to] 2+) y la progresion a la hipertension, la mortalidad o morbilidad materna, el nacimiento a las < 37 semanas, el parto por cesarea o la mortalidad o morbilidad perinatal. Si la prueba de proteinuria se limitara a las mujeres con hipertension, se calcularian ahorros anuales de 153 223 981 dolares estadounidenses (USD) en la India, 9 055 286 USD en Mozambique, 53 181 933 USD en Nigeria y 38 828 746 USD en Pakistan. Conclusion Los resultados cuestionan las recomendaciones de evaluar la proteinuria de forma rutinaria en la primera evaluacion durante el embarazo. Limitar la prueba de proteinuria a las mujeres embarazadas con hipertension podria suponer un ahorro de recursos. [phrase omitted] Objectif Estimer la prevalence et le pronostlc de la proteinurie au moment de l'inscription dans l'un des 27 groupes repris dans les essais randomises en grappes sur les interventions communautaires liees a la preeclampsie. Methodes Nous avons selectionne des femmes enceintes remplissant les conditions requises pour les essais menes au sein de leur communaute dans quatre pays (2013-2017). Nous avons inclus des femmes ayant accouche au terme de l'essai et ayant fait l'objet d'une consultation prenatale avec intervention. Lintervention etait menee par un professionnel de sante communautaire prodiguant des soins complementaires en lien avec l'hypertension, dont un controle de la proteinurie par examen visuel d'une bandelette reactive trempee dans les urines lors de la premiere visite, ainsi que lors des visites qui suivent tout diagnostic d'hypertension. Nous avons employe un modele de regression multiniveaux pour analyser la prevalence initiale de la proteinurie ([greater than or equal to] 1+ ou [greater than or equal to] 2+) dans les differents pays. Enfin, nous avons compare l'incidence des complications ulterieures en fonction de la proteinurie initiale. Resultats La proteinurie initiale a ete detectee chez moins de 5% des grossesses etudiees dans chaque pays (Inde: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004, Pakistan: 315/10 885), et allait presque toujours de pair avec une tension arterielle normale (Inde: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). Nous n'avons identifie aucun lien concluant entre la proteinurie initiale (qu'elle soit [greater than or equal to] 1+ ou [greater than or equal to] 2+) et une progression vers de l'hypertension, une mortalite ou morbidite maternelle, une naissance avant 37 semaines, un accouchement par cesarienne, ou encore une mortalite ou morbidite perinatale. Si les tests de depistage de proteinurie etaient reserves aux femmes souffrant d'hypertension, les economies realisees chaque annee representeraient 153 223 981 dollars americains en Inde, 9 055 286 dollars americains au Mozambique, 53 181 933 dollars americains au Nigeria et 38 828 746 dollars americains au Pakistan. Conclusion Nos resultats remettent en question les recommandations selon lesquelles il convient de controler regulierement la proteinurie des le premier bilan de grossesse. Limiter les tests aux femmes enceintes souffrant d'hypertension pourrait potentiellement permettre de menager les ressources. Objetivo Estimar la prevalencia y el pronostico de la proteinuria al momento de la inscripcion en los 27 grupos de intervencion de los ensayos aleatorizados del grupo de intervenciones a nivel comunitario para la preeclampsia.

IntroductionThe prevalence of gestational diabetes mellitus (GDM) is on the rise in low-income and middle-income countries, such as Pakistan. Therefore, the development of a risk score that is simple, affordable and easy to administer is needed. Our study aimed to develop a Non-INvaSive Pregnancy RIsk ScoRE (INSPIRE) for GDM screening in Pakistani pregnant women based on risk factors reported in the literature.MethodsUsing a cross-sectional study design, we enrolled 500 pregnant women who attended antenatal clinics at one tertiary and two secondary care hospitals in Karachi between the 28th and 32nd weeks of gestation. We randomly divided data into derivation (n=404; 80%) and validation datasets (n=96; 20%). We conducted interviews to collect information on sociodemographic factors and family history of diabetes, measured mid-upper arm circumference (MUAC) and reviewed the medical records of women for obstetric history and oral glucose tolerance test (OGTT) results. We performed a multivariable logistic regression analysis to obtain coefficients of selected predictors for GDM in the derivation dataset. Calibration was estimated using Pearson’s χ2 goodness of fit test while discrimination was checked using the area under the curve (AUC) in the validation dataset.ResultsOverall, the GDM prevalence was 26% (n=130). INSPIRE was based on six predictors: maternal age, MUAC, family history of diabetes, a history of GDM, previous bad obstetrical outcome and a history of macrosomia. INSPIRE achieved a good calibration (Pearson’s χ2=29.55, p=0.08) and acceptable discrimination with an AUC of 0.721 (95% CI 0.61 to 0.83) with a sensitivity of 74.1% and specificity of 59.4% in the validation dataset.ConclusionWe developed and validated an INSPIRE that efficiently differentiates Pakistani pregnant women at high risk of GDM from those at low risk, thus reducing the unnecessary burden of the OGTT test.