Recognition of infants at high risk for vertical HIV transmission at delivery in rural Western Cape Province, South Africa

Despite South Africa's substantial reduction in vertical HIV transmission (VHT), national paediatric HIV elimination is not yet attained. National and Western Cape Province (WC) HIV guidelines recommend enhanced postnatal prophylaxis for infants at high risk for VHT, identified in the WC 2015/2016 guidelines by any single high-risk criterion (maternal antiretroviral therapy (ART) <12 weeks, absent/ unsuppressed maternal HIV viral load (HIV-VL) <12 weeks before/including delivery, spontaneous preterm labour, prolonged rupture of membranes, chorioamnionitis). Accuracy of high-risk infant identification is unknown. Objectives. Primarily, to determine the proportion of infants at high risk for VHT, the accuracy of labour-ward risk classification, the criteria determining high-risk statuses and the criteria missed among unrecognised high-risk infants; secondarily, to determine maternal factors associated with high-risk infants. Methods. Infants born to women living with HIV at a rural regional hospital (May 2016 - April 2017) were retrospectively evaluated using data from the labour ward VHT register, standardised maternity case records, National Health Laboratory Service database and WC Provincial Health Data Centre. The study-derived risk status for each infant was determined using documented presence/absence of risk criteria and compared with labour ward assigned risk to determine accuracy. Proportions of high-risk and unrecognised high-risk infants with each high-risk criterion were determined. Maternal characteristics associated with having a high-risk infant were evaluated using multivariable logistic regression. Results. For liveborn infants, labour ward assigned risk classifications were 40% (n=75/188) high risk, 50% (n=94/188) low risk and 10% (n=19/188) unclassified. Study-derived risk was high risk for 69% (n=129/188) and low risk for 31% (n=59/188), yielding a high-risk classification sensitivity of 51% (95% confidence interval (CI) 42 - 60) and specificity of 69% (95% CI 56 - 80). Absent/unsuppressed HIVVL <12 weeks before delivery accounted for 83% (n=119/143) of study-derived high-risk exposures and 81% (n=60/74) of missed high-risk exposures. Fewer mothers of high-risk infants had >4 antenatal visits (38% v. 81%, p<0.01) and first antenatal visit <20 weeks' gestation (57% v. 77%, p=0.01). Only the number of antenatal visits remained associated with having a high-risk infant after adjusting for gestation at first visit and timing of HIV diagnosis and ART initiation: each additional antenatal visit conferred a 39% (95% CI 25 - 50) reduction in the odds of having a high-risk infant. Conclusion. Labour ward risk classification failed to recognise half of high-risk infants. Infant high-risk status as well as non-detection thereof were driven by suboptimal maternal HIV-VL monitoring. Reinforcing visit frequency later in pregnancy may improve antenatal HIV-VL monitoring, and point-of-care HIV-VL monitoring at delivery could improve recognition of virally unsuppressed mothers and their high-risk infants

Postnatal Care Utilization and Associated Factors among Mothers who gave Birth in the Aysaeta District, Northeast Ethiopia: A Community Based Cross-sectional Study

BACKGROUND: Postnatal care is given to mothers and newborn babies within 42 days of delivery. It is a period of high maternal and newborn mortality and is also the most neglected in terms of maternal health services in many parts of the world. This study aimed to assess postnatal care and associated factors among mothers who gave birth in the year preceding the survey of the Ayssaeta district. METHODS: A community-based cross-sectional study was conducted among 406 mothers who gave birth in the year preceding the survey from August 02­30, 2020. Bivariable and multivariable logistic regression analyses were done to identify factors associated with postnatal care utilization. RESULTS: Slightly greater than four out of ten mothers have visited postnatal care units at least once. Living in urban areas, giving birth in a health facility, having complications during labor and after, and getting advice during antenatal care visits were associated with higher odds of postnatal care utilization. CONCLUSION: Less than half of the mothers received postnatal care following the delivery of their last child. Living in an urban, place of delivery, experiencing labor and postpartum complications, and receiving postnatal care advice during antenatal care have affected the utilization of postnatal care. Promoting skilled delivery and antenatal care with a focus on rural areas can help mothers learn about postnatal care and increase the number of mothers who use it

Implementation of postnatal care for HIV-positive mothers in the Free State: Nurses' perspectives

Background: Postnatal care (PNC) provides the opportunity for protecting the lives of women infected with human immune deficiency virus (HIV) and their babies. The prevention of mother-to-child transmission of HIV (PMTCT) guidelines provide a framework for implementation of PNC. There has been no empirical evidence on how the nurses at the clinic level implement these guidelines. In addition, there are reports that PNC has been neglected in South Africa. Aim: The study aimed to explore the implementation of PNC for HIV-positive women, by explicating nurses' views regarding their practices. Setting: The study was conducted in 2015 at three clinics at Mangaung Metro Municipality in the Free State. Methods: A qualitative, evaluative case study was conducted to provide a detailed account of the implementation of PNC, using 2015 PMTCT guidelines as a framework for evaluation. Eighteen key informants participated in three focus groups. Data were reviewed through direct thematic analysis. Results: Four themes emerged from data analysis, namely, guidelines as an empowering tool, implementation of HIV guidelines, perceived successes and challenges of postnatal HIV care, and measures to strengthen postnatal HIV care services. The study found that nurses interpreted and used guidelines to direct their practice. However, there were challenges and some successes. Conclusion: It was concluded that nurses had a good understanding of the guidelines provided for their practices and implemented them with various levels of success. Effective management of HIV-infected women during the postnatal period requires well-designed multidisciplinary collaborations, adequate resources, continuous professional development programmes, a high level of competence and confidence

Barriers to men's involvement in antenatal and postnatal care in Butula, western Kenya

Background: Men have a lot of influence on their partners' and children's health. However, studies have shown their involvement in antenatal care (ANC) and postnatal care (PNC) is relatively low owing to several factors. Aim: To explore the barriers to men's involvement in ANC and PNC in Butula sub-county, western Kenya. Setting: Butula sub-county, Busia county, western Kenya. Methods: A mixed methods study design, descriptive in nature, was used to collect both quantitative and qualitative data. A total of 96 men were selected to participate in the surveys. Also, four focus group discussions and four key informant interviews were conducted. Results: We found out that some men still participate in ANC and PNC despite the barriers. The perception that maternal health is a women's domain and existence of alternative traditional maternal services were key cultural barriers. The men's nature of work, low income and expenses incurred at ANC/PNC clinics were significant economic barriers. The lack of services targeting men, provider attitude, non-invitation to the clinic, time spent at the clinic and lack of privacy at the clinics were key facility-based barriers. Conclusion: A myriad of cultural, economic and health-facility barriers hinder men from active involvement in ANC and PNC. Awareness creation among men on ANC and PNC services and creating a client-friendly environment at the clinics is key in enhancing their involvement. This should be a concerted effort of all stake holders in maternal health services, as male involvement is a strong influencer to their partners' and children's health outcomes

Utilization and determinants of postnatal care services in Ethiopia: a systematic review and meta-analysis

BACKGROUND: Postnatal care use is vital in saving mother and newborn lives which is a continuum of care for maternal, neonatal and child health. This reviewaimed to determine the utilization and determinants of postnatal care use in Ethiopia. METHODS: PubMed, Scopus, Web of Science, and Embase databases were searched on June 25, 2017. The study screening, data extraction and quality assessment were done independently by two reviewers. Effect sizes were pooled using a random-effects model. RESULTS: Nine articles were included in the review. The pooled estimate for utilization of the service was 32% (95% CI: 21%, 43%). The pooled results of determinants of postnatal care use was statistically significant among those mothers who had ability to make decisions (1.89; 1.25, 2.54), had a history of antenatal care utilization (2.55; 1.42, 3.68), received more than two antenatal care visits (1.84; 1.28, 2.40), and received the service from skilled service provider (3.16; 1.62, 4.70). It was also found that mothers who gave birth in health faciliteis (2.13; 1.14, 3.12), had middle monthly income, richer, were from urban areas, and had knowledge of obstetric danger signs were significantly associated with increased odds of postnatal care use. CONCLUSION: Utilization of the services is low in Ethiopia. Antenatal care utilization, skilled service provider, being from urban area and delivery in health facility had a significant effect on postnatal care utilization. More rigorous studies are needed to identify determinant with the causal association to postnatal care utilization. The reviewwas registered on PROSPERO CRD42017060266

Magnitude and factors associated with optimal complementary feeding practices among children aged 6-23 months in Bensa District, Sidama Zone, South Ethiopia

BACKGROUND: Prevalence of optimal complementary feeding practices are lower than expected. Undernutrition contributes 35% of children mortality. Our study was aimed to assess magnitude and factors associated with optimal complementary feeding practices among children 6-23 months in Bensa Dstrict, Sidama Zone, South Ethiopia, 2016. METHOD: A community based cross sectional study was conducted from January to February 2016 in (8) randomly selected kebles found in Bensa District. Respondents were selected by using simple random sampling technique after sampling frame was prepared from rapid survey. Pre-tested questionnaire was used to collect information. Then, data were entered into SPSS version 20, Then, crude odds ratio (COR) and adjusted odds ratio (AOR) with 95% confidence interval were computed to examine statistical significance. RESULT: This study revealed that only 8.6% (95%CI: 6.4, 10.7%) of 6-23 months children had optimal complementary feeding practices. Mother's knowledge on optimal complementary feeding (AOR=5.4, 95%CI: 2.7, 11), postnatal care service utilization (AOR=3.4, 95%CI: 1.7, 7), and household food security (AOR=5, 95%CI: 2.5, 10.5) were positively associated with optimal complementary feeding practices. CONCLUSION: Mother's knowledge, postnatal care utilization and household food security positively affected optimal complementary feeding practices.Thus, Bensa District Health Office, Sidama Zone Health Departiment and other respective stakeholders should cooperatively work to enhance knowledge of mothers/care takers on optimal complementary feeding practices, household food security and on advantages of postnatal care service utilization

Bacterial profile, antibacterial susceptibility pattern and associated factors among women attending antenatal and post-natal health services at the University of Gondar Teaching Hospital, Northwest Ethiopia

Background: Bacterial infections are an important cause of maternal morbidity and mortality especially in re-source limited countries such as Ethiopia. The major bacterial infections include urinary tract infections, septice-mia and endometritis. Antibiotic resistant bacterial pathogens have become a growing problem worldwide and pose a serious threat to vulnerable populations, including mothers. However, studies which address the problem in the Ethiopian setting are scarce. Objective: To assess the bacterial profile, antibacterial susceptibility pattern and associated factors among mothers attending antenatal and postnatal care health services. Methods: A cross-sectional study was conducted on 222 study participants at the University of Gondar Teaching Hospital from January 1 to May 31, 2016. Clinical specimens such as urine, blood and cervical discharge specimens were collected from patients and antimicrobial susceptibility tests conducted following standard procedures. Data were entered and analyzed with SPSS version 20. Bivariate and multivariate logistic regression models were applied in data analysis. Results: Out of 222 specimens collected, 57(25.7%) bacterial species were isolated. The predominant bacterial isolates from urine culture were Escherichia coli (24/47; 51.1%) and Staphylococcus aureus (16/47;34%). From blood cultures, Staphylococcus aureus (2/8; 25%), Coagulase negative staphylococci (2/8;25%), Klebsiella pneumoniae (2/8;25%) and Streptococcus pyogenes 2/8(25%) were isolated. Neisseria gonorrheae (2/27;7.4%) was isolated from cervical discharge cultures. The majority of the isolates were resistant to amoxacillin and ampicillin but susceptible to ceftriaxone. Many multidrug resistant bacterial species were isolated. Being in the first trimester of pregnancy and having a history of diabetes mellitus were strongly associated with the presence of bacterial infections. Conclusion: The overall prevalence of bacterial infections was high with many being resistant to commonly pre-scribed antimicrobial agents. This calls for an urgent need to conduct screening of bacterial infectionsin both antenatal as well as postnatal women

Knowledge and practice of essential newborn care among postnatal mothers in Addis Ababa City Health Centers, Ethiopia

Essential newborn care is a wide-ranging approach planned to improve the health of newborn through interventions after pregnancy. In Ethiopia, about 120,000 newborns die every year in the first weeks of life which accounts for 42% of all deaths of under-five mortality. Therefore this study is aimed to assess the knowledge and practice of essential newborn care practices among mothers in Addis Ababa, Ethiopia. A facility-based cross-sectional study was conducted amog the enroll 576 women in the first six weeks of post-partum who attending ANC in Addis Abeba Health facility. Written consent was obtained from each participated individuals before the actual data taken. Data were gathered by using pre tested standard questionnaire. The collected data were uploaded to computer using EpiData version 3.1. and the analysis was made through SPSS package version 21. Logistic regression was carried out to assess possible associations. The strength of association was measured at P<0.05 with 95% confidence interval. The study revealed that the level of essential newborn care practices was 38.8%. Education and advise about essential newborn care practices during and after birth by skilled birth attendants (OR=2.17, 95%, CI=1.42,3.31), home visit by health extension worker (OR=1.55, 95% CI=1.03,2.32) and place of delivery at health center (OR=7.69, 95% CI =1.32, 36.42), at private health facility (OR=9.18, 95% CI=1.32, 63.75) and government hospital (OR=6.68, 95% CI =1.32, 33.87) were found to have statistically significant association with essential newborn care practices. The result of this study has indicated that the level of essential newborn care practices was low. A home visit by health extension workers, the timing of postnatal care visit by skilled birth attendants, advice about essential newborn care practices during and after pregnancy and place of delivery were found to be independent predictors of essential newborn care practices in the study area. Government should take remedial action to improve newborn care practice

Impact of health education intervention on knowledge and utilization of postnatal care services among women in Edu local Government of Kwara State, Nigeria

Background: This study examined the impact of health education intervention (HEI) on the knowledge and utilization of postnatal care services among women in Edu, Nigeria.Methods: A quasi-experimental research design using pre-test and post-test control group to examine impact of HEI among women. Researchers-developed questionnaire was used for data collection.Intervention: One hundred and twenty women were exposed to ten weeks health education intervention; sixty (n=60) experimental group exposed to postnatal care services lectures and sixty (n=60) control group were exposed to HIV/AIDS prevention lectures. The results were analyzed using descriptive and inferential statistics to answer research question and test null hypothesis at 0.05 significant levels.Results: The findings showed an improvement from pre intervention mean scores of 64.26 to post intervention scores of 98.15 for the experimental group against 68.88 post intervention mean score of control group. While, the pre intervention mean score of utilization was 56.67 compared with post intervention mean scores of 92.91 for the experimental group and 61.04 for the control group utilization This showed positive impact of health education intervention on knowledge and willingness of women of childbearing age to utilize postnatal care services in Edu LGA.Conclusion: Study concluded that, health education intervention had positive impact on knowledge and willingness of WCA to utilize postnatal care, and the knowledge gained need to be sustained to improve WCA health seeking behaviour in the communities of Edu LGA

Delay and Poor Diagnosis of Down Syndrome in KwaZulu-Natal; South Africa: A Retrospective Review of Postnatal Cytogenetic Testing

BACKGROUND:Down syndrome (DS) is the most common chromosomal disorder in newborns. Until 20 years ago DS was considered rare in black African children in South Africa (SA). Lack of awareness of DS on the part of medical staff in SA; and difficulty in diagnosing it; appear to persist. OBJECTIVES:To establish an epidemiological profile of DS and investigate the ability of clinicians in KwaZulu-Natal Province (KZN); SA; to make accurate clinical diagnoses of DS.METHODS:Records at the South African National Blood Service cytogenetic laboratory in Pinetown; KZN; were examined for all tests for clinically suspected DS undertaken during January 2009 - December 2013 and all cytogenetically proven DS test results. Age at diagnosis; the hospital from where the test was sent and type of chromosomal pattern for each confirmed DS test result were recorded. RESULTS:Of a total of 1 578 tests requested; 875 confirmed DS; indicating that clinicians correctly clinically diagnosed DS 55.4% of the time. The average age of cytogenetic diagnosis of DS was 1 year and 20 days. The minimum population prevalence of DS was 0.8/1 000.CONCLUSIONS: The diagnosis of DS is a challenge in KZN; potentiating missed opportunities for early intervention. The relatively low population prevalence of DS may be attributable to a lack of confirmatory cytogenetic tests or missed clinical diagnoses. It may also be attributable to a high mortality rate for children with DS in the province

Factors Responsible for Under-Utilization of Postnatal Care Services in Maiduguri; North-Eastern Nigeria

Background: In Maiduguri; the utilization of available postnatal care services is still very low. This may be influenced by demographic; socioeconomic; cultural; and obstetric factors among others. Objective: The aim of this study is to understand the current status of utilization of maternal postnatal health care services and identify factors responsible for under.utilization of available postnatal care services in Maiduguri. Materials and Methods: A. cross.sectional; questionnaire.based study was conducted involving 350 women in their reproductive age group. (15.49. years); who had delivered previously; residing in Maiduguri and who came to access any of the available maternal health care services at the State Specialist Hospital; Maiduguri over a 3.month period. The Chi.squared statistics and multivariate logistic regression analysis were used. Results: Out of the grand total of 350 questionnaires that were distributed during the study period; 18 questionnaires were excluded from analysis due to incomplete responses; 332 with complete responses were therefore analyzed; giving a response rate of 94.9. The results showed that only 16.9 of the respondents attended postnatal care services within 42. days after delivery. Most of the mothers. (60.9) were not knowledgeable about postnatal care services. A. very high proportion of participants. (69.4) did not attend antenatal clinics; and over. 70of the study population had delivered at home. The study has identified some factors that have an important influence on utilization of postnatal care services in Maiduguri. These included awareness of postnatal care services. (odds ratio. [OR] 12.04; 95 confidence interval. [CI]: 10.26; P =. 0.000); higher educational status of the woman. (OR 7.15; 95 CI: 5.19; P =0.000); lower parity. (OR 5.22; 95 CI: 3.21; P = 0.001) and marital status. (married woman.OR 3.44; 95 CI: 2.17; P =0.002). Educational attainment of the husband also significantly affected the respondents' seeking behavior of postnatal care. (OR 2.01; 95 CI: 1.13; P =0.042). Conclusion: Utilization of postnatal care services is quite low in Maiduguri. Socioeconomic and sociodemographic factors influenced the use of postnatal care services. Government should provide culturally acceptable health educational programs and expands maternal health care services into the communities for the better; effective and efficient health care delivery

The experiences of postnatal patients regarding postnatal care in Mopani District, Limpopo Province, South Africa

This paper describes the experiences of postnatal patients regarding postnatal care; with the intention of making recommendations to improve the quality of care during the postnatal period. The participants receive care from midwives for the first six hours after delivery and are discharged home. On discharge; the participants receive health advice from midwives on how to take care of themselves and newborn infants at home during the postnatal period. At home they receive care and advice from traditional birth attendants. Different pieces of advice confuse the participants because they interfere with decision-making skills. A qualitative; exploratory; descriptive and contextual research method was used in this study. A semi-structured interview guide was also used to conduct focus group interviews. Data were collected until saturation was reached during the second focus group interview. Participants revealed the following challenges: lack of openness and transparency between the midwives and the traditional birth attendants; exclusion of participants' relatives when giving health advice on discharge; conflicting postnatal care advice; lack of postnatal care supervision and follow up; postnatal patients under direct care of traditional birth attendants only; and feeling of insecurity by the participants. The participants suggested that there should be incorporation of indigenous postnatal care practices into the midwifery healthcare system in order to enhance teamwork between the midwives and the traditional birth attendants. Follow up should be conducted by the midwives to ensure safety; support; supervision and continuity of care to the participants during the postnatal period

Determinants of postnatal care use in Kenya

Pregnancy related complications may result in maternal deaths post delivery especially in developing countries. Skilled deliveries and postnatal care (PNC) use in Kenya is low. The objective of this study was to identify the determinants of PNC use. Kenya Demographic and Health Survey (2008-09 KDHS) women's data were analyzed. Overall data from 3;970 women were analyzed. Results indicate that 47 percent of the women received PNC services. Factors associated with PNC use are mothers' age at delivery of the last child; 4+ ANC visits; urban residence; and skilled delivery. However; lack of education and unskilled delivery were associated with low use of PNC services (p 0.05). In conclusion; the use of PNC services is low at 47 percent although the main determinants for PNC use are amenable to intervention. Strengthening of maternal health services throughout the continuum of care and promoting the use of high quality services by pregnant women is recommended

Home Births and Postnatal Practices in Madagali; North-Eastern Nigeria

Background: Home births are common in resource poor countries and postnatal practices vary from one community to the other. Objective: To determine the proportion of home births; reasons for home delivery; and evaluate postnatal practices in Madagali; north-eastern Nigeria. Materials and Methods: This was a cross-sectional descriptive study of 400 women of reproductive age; who had put to birth in the past 1 year. The study was carried out over a period of 8 weeks from April to June 2010. The multistage method of sampling was used to select respondents. In the first stage; four of the five health districts were chosen randomly; namely; Gulak; Madagali; Sukur; and Duhu. The questionnaires were evenly distributed among the four health districts. In the second stage; from each district; two villages were chosen by simple random sample. In the third stage; two wards were selected in each village by simple random sampling. Result: Of the 400 respondents interviewed; 289 (72.2) were aged between 20 and 39 years; and most; 374 (93.5) were married. Only 14 (3.5) had tertiary education. Most respondents; 224 (56.0) were farmers and grandmultiparae; 187 (46.7). A total of 196 (49.0) women delivered at home; whereas 204 (51.0) delivered at the hospital. Of the 196 respondents who delivered at home; the bedroom 142 (72.4); was the preferred place of birth. The most common reason for home birth was short duration of labor in 71 (36.3) cases. Delivery was conducted by untrained persons in 50; (25.4); whereas 99 (50.8) and 31 (15.5) deliveries were supervised by Traditional Birth Attendants (TBAs) and Midwives/Nurses; respectively. Postpartum; the majority; 235 (58.7) respondents used sanitary pads to stanch lochia; whereas 140 (35) used rags. Conclusion: A significant number of births take place in the home and supervised by unskilled persons. Against the backdrop of poor education and low socio-economic status of respondents; perineal hygiene can be adjudged satisfactory. There is the need to increase on the number of hospital birth and also trained TBA who conduct most of home deliveries

Barriers to Postnatal Care and Exclusive Breastfeeding among Urban Women in Southeastern Nigeria

Available evidence shows that only a small proportion of Nigerian women access postnatal care and practice exclusive breastfeeding. Given that both interventions are critical to the survival of both the mother and the new born; it is important to identify factors that militate against an effective postnatal care and exclusive breastfeeding in the country; in order to scale up services. The aim was to determine the major barriers to postnatal care and exclusive breastfeeding among urban women in southeastern Nigeria. Materials and Methods: A cross-sectional survey of 400 urban market women using semistructured questionnaires and focus group discussions. Results: Out of 400 women interviewed; 365 (91.7) attended postnatal clinic. Lack of knowledge about postnatal care services (42.2; n = 14); distant location of the hospitals (36.4; n = 12) and feeling that postnatal visits was not necessary (21.1; n = 7) were the main reasons for non-attendance to postnatal clinic. With respect to exclusive breastfeeding; 143 (35.9) of the women practiced EBF. The main reasons for nonpractice of EBF were that EBF was very stressful (26.2; n = 67); mother's refusal (23.5; n = 60); and the feeling that EBF was not necessary (18.1; n = 46). Thirty five (13.7) of the women were constrained by time while the husband's refusal accounted for 1.5 (n = 3) of the reasons for nonpractice of exclusive breastfeeding. Conclusion: Poor knowledge and inaccessibility to health facilities were the main obstacles to postnatal care while the practice of exclusive breastfeeding was limited by the stress and mothers refusal

Perception and Knowledge on Exclusive Breastfeeding among Women Attending Antenatal and Postnatal Clinics. a Study from Mbarara Hospital Uganda; August

Objective : Assessment of the perception and knowledge on EBF practice among women attending antenatal and infant follow up clinics in Mbarara hospital; Uganda in August 2008. Methodology This was a Descriptive Cross-sectional study. Results From a total of 203 respondents; 49.8had exclusively breastfed their infants for six months; 12.3for more than six months. The majority of the respondents; 73.8; knew that a child is supposed to be exclusively breastfed for six months. The main advantage of EBF perceived by 55.2of the women who were interviewed was nutrition. The main disadvantage of exclusive breastfeeding perceived by the women was depletion of the mother's health; in only 20. However majority; 66perceived that EBF had no disadvantage. Milk not being enough was the main reason why women did not exclusively breastfeed. The preferred duration of breastfeeding was 18 months in 58of the women and the main source of information was the health facilities for 48of the women. Conclusion:The results from this study showed that women have increased knowledge about exclusive breastfeeding. But the perception that EBF is not disadvantageous to the child was substantial. The health facilities provided a good source of information for mothers in Mbarara. Therefore it can be concluded that strengthening this mode of providing information can help to raise the prevalence of EBF significantly