Perinatal deaths and low birthweight in an urban health centre in the Gambia: A prospective cohort study.

Perinatal deaths (stillbirths after 28 weeks gestation and early neonatal deaths) are rarely reported separately but are the deaths most closely associated with complications during pregnancy, birth and the first days of life. We conducted a prospective cohort study to report perinatal deaths, late neonatal deaths and low birthweight babies as they occur. This cohort of birth outcomes from The Gambia was conducted between 2012 and 2016 and followed 1611 women attending a government-supported health center from the first antenatal visit to 28 days post-delivery. The outcome of the pregnancy was known for 1372 women (85.2%) and included 20 stillbirths and 12 early neonatal deaths. Of 1252 singleton babies with known birthweight 85 weighed less than 2500g (6.8%). Using multivariate analysis it was shown that women who attended the antenatal clinic four times or more were less likely to have a low birthweight baby than women who attended less than four times, OR 0.47 (95% CI:0.273-0.799). We conclude that frequent visits to the antenatal clinic are associated with better outcomes.

Determinants of compliance with the World Health Organisation recommendations for pregnant women in an urban health centre in The Gambia.

In 2001 the World Health Organization drew up recommendations for pregnant women in order to reduce maternal mortality: the first visit to the antenatal clinic to be in the first trimester, at least four visits in total and delivery with a trained birth attendant. This study reports the extent to which pregnant women attending a health centre in The Gambia complied with the recommendations. A cohort of 1611 consecutive pregnant women was recruited. Only 384 (23.9%) women first attended in the first trimester and 568 (41.6%) attended at least four times. Only 15.8% of the women complied with all recommendations. Following multivariate analysis the educational level of the partner was the sole factor associated with both recommendations regarding attendance. This level of compliance reflects widespread ignorance of the value of early antenatal care and frequent visits. Public health programmes require a basic level of education to be effective.

Barriers to Antenatal Care in an Urban Community in the Gambia: An In-depth Qualitative Interview Study.

This qualitative study investigated the barriers to obtaining access to antenatal care in a small, urban government-supported health centre in the Gambia. It thus addresses an important issue related to maternal health and the prevention of maternal deaths. In-depth interviews were conducted with 25 pregnant women, 13 healthcare workers and 9 male partners. Three areas were identified for study: recognition and acknowledgment of pregnancy, recognition of the need for care and practical barriers to attendance. Intentional concealment of early pregnancy was common to avoid adverse social consequences or for fear that malign interventions would cause a miscarriage. In the absence of symptoms many women considered it unnecessary to attend the antenatal clinic until well into the second trimester. Practical barriers to attendance included conflicting domestic demands and the attitude of some healthcare workers. Access to antenatal care in the Gambia throughout pregnancy should be considered in a stepwise fashion and barriers to care were identified at each stage. Interviews with male partners and health workers highlighted their key role.

Psychosocial and socioeconomic risk factors for premature death in young people with type 1 diabetes.

OBJECTIVE: Mortality from acute diabetes-related events is greatly raised in young adults with type 1 diabetes. Psychosocial and socioeconomic risk factors are examined for deaths from acute events separately from deaths due to other causes. RESEARCH DESIGN AND METHODS: This study had a nested case-control design. The cases were patients from the Diabetes UK cohort who died before age 40 years. Deaths were categorized as acute events or chronic conditions related to diabetes. Where possible, two matched control subjects were selected for each case. Data relating to psychosocial and socioeconomic factors and variables related to diabetes complications were extracted from the case notes. Risks of death were estimated by calculation of odds ratios (ORs). RESULTS: Case notes were obtained for 98 case and 137 control subjects. Fifty-one deaths were attributed to acute causes, 34 to chronic conditions related to diabetes, and the remaining 13 were unrelated to diabetes. Living alone (OR 4.4), past drug abuse (5.7), and previous psychiatric referral (4.6) were all significantly associated with death from acute events but not death from chronic conditions. There was no association between deaths from acute events and nephropathy, hypertension, neuropathy, or retinopathy, although all of these were associated with deaths from chronic conditions. CONCLUSIONS: The results indicate that psychosocial factors are powerful risk factors for mortality from acute events in patients with type 1 diabetes, although not for mortality from chronic conditions. The data enable the identification of a high-risk group suitable for targeting with preventive measures to reduce acute event mortality.

Mortality from cerebrovascular disease in a cohort of 23 000 patients with insulin-treated diabetes.

BACKGROUND AND PURPOSE: Disease of the cardiovascular system is the main cause of long-term complications and mortality in patients with type I (insulin-dependent) and type II (non-insulin-dependent) diabetes. Cerebrovascular mortality rates have been shown to be raised in patients with type II diabetes but have not previously been reported by age and sex in patients with type I diabetes. METHODS: A cohort of 23 751 patients with insulin-treated diabetes, diagnosed under the age of 30 years from throughout the United Kingdom, was identified during 1972 to 1993 and followed up for mortality until the end of December 2000. Age- and sex-specific mortality rates and standardized mortality ratios (SMRs) were calculated. RESULTS: There were 1437 deaths during the follow-up, 80 due to cerebrovascular disease. Overall, the cerebrovascular mortality rates in the cohort were higher than the corresponding rates in the general population, and the SMRs were 3.1 (95% CI, 2.2 to 4.3) for men and 4.4 (95% CI, 3.1 to 6.0) for women. When stratified by age, the SMRs were highest in the 20- to 39-year age group. After subdivision of cause of death into hemorrhagic and nonhemorrhagic origins, there remained a significant increase in mortality from stroke of nonhemorrhagic origin. CONCLUSIONS: Analyses of mortality from this cohort, essentially one of patients with type I diabetes, has shown for the first time that cerebrovascular mortality is raised at all ages in these patients. Type I diabetes is at least as great a risk factor for cerebrovascular mortality as type II diabetes.