Public provision of emergency obstetric care: a case study in two districts of Pakistan.

OBJECTIVES: Pakistan is one out of five countries where together half of the global neonatal deaths occur. As the provision of services and facilities is one of the key elements vital to reducing this rate as well as the maternal mortality rate, this study investigates the status of the delivery of essential obstetric care provided by the public health sector in two districts in Khyber Pakhtunkhwa in 2015 aiming to highlight areas where critical improvements are needed. SETTING: We analysed data from a survey of 22 primary and secondary healthcare facilities as well as 85 community midwives (CMWs) in Haripur and Nowshera districts. PARTICIPANTS: Using a structured questionnaire we evaluated the performance of emergency obstetric care (EmOC) signal functions and patient statistics in public health facilities. Also, 102 CMWs were interviewed about working hours, basic and specialised delivery service provision, referral system and patient statistics. PRIMARY OUTCOME MEASURES: We investigate the public provision of emergency obstetric care using seven key medical services identified by the United Nations (UN). RESULTS: Deliveries by public health cadres account for about 30% of the total number of births in these districts. According to the UN benchmark, only a small fraction of basic EmOC (2/18) and half of the comprehensive EmOC (2/4) facilities of the recommended minimum number were available to the population in both districts. Only a minority of health facilities and CMWs carry out several signal functions. Only 8% of the total births in one of the study districts are performed in public EmOC health facilities. CONCLUSIONS: Both districts show a significant shortage of available public EmOC service provisions. Development priorities need to be realigned to improve the availability, accessibility and quality of EmOC service provisions by the public health sector alongside with existing activities to increase institutional births.

Polychlorinated biphenyls, polychlorinated dibenzo-p-dioxins and dibenzofurans in street dust of North Rhine-Westphalia, Germany.

In this study the occurrence of polychlorinated biphenyls (PCBs), polychlorinated dibenzodioxins and polychlorinated dibenzofurans (PCDDs/PCDFs) in street dust samples was investigated using pressurized liquid extraction and gas chromatography coupled to mass spectrometry. Street dust samples were taken from rural, urban, industrial and industrially influenced urban areas. PCB6 concentrations ranged from 5090±2200 µg/kg (average±standard error of mean) in dusts from industrial premises to 29±8.7 µg/kg in rural areas. Concentration ranges were for dioxin-like PCB toxicity equivalents (dl-PCB TEQ) from 362±164 ng/kg (industrial premises) to 6.5±1.8 ng/kg (rural areas), and for PCDD/PCDF TEQ from 503±448 ng/kg to 2.4±0.13 ng/kg, respectively. Area concentrations of PCB6 (0.040 µg/m2-22 µg/m2), dl-PCB TEQ (0.0038 ng/m2-2.6 ng/m2) and PCDD/PCDF TEQs (14 pg/m2-1980 pg/m2) were estimated. Furthermore, particle size related concentrations of PCBs and PCDD/PCDFs in street dusts were analysed showing throughout almost all samples a distinctive trend of increasing concentrations with decreasing particle sizes. Characterization of homologue patterns of PCBs and PCDDs/PCDFs in street dusts was performed showing a dependence of homologue patterns on different area types, especially for PCBs. It could be demonstrated that the analysis of concentrations in combination with specific homologue patterns of PCBs and PCDDs/PCDFs in street dust samples enables allocation of potential emission sources.

Trends of PCDD/F and PCB concentrations and depositions in ambient air in Northwestern Germany.

Time series of polychlorinated dioxins and furans (PCDD/F) and polychlorinated biphenyls (PCB) in ambient air of a large conurbation in North-Western Germany are presented and analyzed. The trend of PCDD/F concentrations, starting from as early as 1988, shows a pronounced decrease by at least one order of magnitude, demonstrating that the emission reductions were effective. The PCDD/F depositions also have decreased by a factor of 5 since 1992. However, both trends have leveled out since 2005. Time series of PCB concentrations and depositions starting in 1994 show only slight decreases for the concentrations and almost no decrease for the depositions. From the decay rates following first order kinetics, half-lives in the order of 5-15 years for the PCDD/F and 15-31 years for the sum of the six indicator PCB could be calculated, which are much longer than the half-lives estimated from their reactivity towards the OH radical. Apparently, small fresh emissions (PCDD/F), considerable secondary emissions and evaporation from contaminated soils slow down their decay in the atmosphere of big conurbations. Analyzing the decay rates of individual PCB congeners shows that the lower chlorinated and more volatile ones are removed faster than the higher chlorinated congeners, probably via gas phase reactions with the OH radical. It can be concluded from the present study that the input of PCDD/F and PCB into the food chain via the air path will continue for another one or two decades in big conurbations.

Determination of polychlorinated biphenyls and polychlorinated dibenzo-p-dioxins and dibenzofurans by pressurized liquid extraction and gas chromatography coupled to mass spectrometry in street dust samples.

Owing to massive pollution with polychlorinated biphenyls in the harbour area of Dortmund (Germany), several dust samples were taken from surfaces at industrial sites and analyzed by the North-Rhine Westphalian State Agency for Nature, Environment, and Consumer Protection (LANUV NRW). This report describes and validates a rapid approach to screening for the presence of polychlorinated biphenyls (PCBs) in street dust. Samples were collected by using a natural bristle brush and stainless steel scoops. Mass recovery of fine-particle sea sand (a dust surrogate) on asphalt and concrete surfaces was used as a criterion for the effectiveness of sampling. Better recoveries of sea sand were achieved on concrete than on asphalt surfaces. Furthermore, temperature optimization for a pressurized liquid extraction (PLE) method used to extract PCBs and polychlorinated dibenzodioxins and polychlorinated furans (PCDD/Fs) from street dust samples was developed and compared with Soxhlet extraction for the analysis of PCBs in real street dust samples. Toluene was used as the extraction solvent in both cases. During this study, a combination of toluene and PLE achieved better extraction efficiencies than Soxhlet extraction. Finally, the performance of the PLE method was evaluated by analysing NIST Standard Reference Material 1649a for PCB and PCDD/F concentrations. This demonstrated that the accuracy of the PLE method for the determination of both substance classes was satisfactory. In addition, concentrations of PCBs and PCDD/Fs in street dust samples from industrial sites are reported.

Health effects of particles in ambient air.

A summary of a critical review by a working group of the German commission on Air Pollution Prevention of VDI and DIN of the actual data on exposure and health effects (excluding cancer) of fine particulate air pollution is presented. EXPOSURE: Typical ambient particle concentrations for PM10 (PM2.5) in Germany are in the range of 10-45 (10-30) microg/m3 as annual mean and 50-200 (40-150) microg/m3 as maximum daily mean. The ratio of PM2.5/PM10 generally amounts between 0.7 and 0.9. HEALTH EFFECTS: During the past 10 years many new epidemiological and toxicological studies on health effects of particulate matter (PM) have been published. In summary, long-term exposure against PM for years or decades is associated with elevated total, cardiovascular, and infant mortality. With respect to morbidity, respiratory symptoms, lung growth, and function of the immune system are affected. Short-term studies show consistant associations of exposure to daily concentrations of PM with mortality and morbidity on the same day or the subsequent days. Patients with asthma, COPD, pneumonia, and other respiratory diseases as well as patients with cardio-vascular diseases and diabetes are especially affected. The strongest associations are found for PM2.5 followed by PM10, with no indication of a threshold value for the health effects. The data base for ultra fine particles is too small for final conclusions. The available toxicological data support the epidemiological findings and give hints as to the mechanisms of the effects. CONCLUSION: The working group concludes that a further reduction of the limit values proposed for 2005 will substantially reduce health risks due to particulate air pollution. Because of the strong correlation of PM10 with PM2.5 at most German sites there is no specific need for limit values of PM2.5 for Germany in addition to those of PM10.