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Wealth quintiles tant to discount drospirenone 3.03 mg mastercard birth control for women doctors have supportive economic policies and labor analysis has shown that wealthier women have lower regulations in place to drospirenone 3.03 mg birth control for women of the moose reap the potential benefits of the fertility rates and better access to order 3.03 mg drospirenone with visa birth control questions family planning than demographic dividend; many countries in Sub Saharan poorer women generic 3.03mg drospirenone visa birth control for 18 year olds. Gillespie and others (2007), in a study Africa need to coordinate development of their eco of 41 countries, find that although variations were nomic and reproductive health policies to fully realize observed among countries, the number of unwanted this effect. Maternal and Child Health Rationale the improved health of mothers and children has Environment and Sustainable Development Rationale long been a rationale for the provision of family A resurgence of interest in global population dynam planning (Seltzer 2002). Reductions in fertility more than 16 billion by the end of the century under rates accounted for 53 percent of the decline in mater their high scenario. Unwanted pregnancies may lead have confirmed the usefulness of program initiatives to to unsafe abortions, which are associated with elevated promote healthy timing and spacing of births. All births carry some risk of maternal mortality, so women with a large number Human Rights and Equity Rationale of births have higher lifetime risk of dying from mater the right of couples and individuals to decide freely and nal causes. Among the key factors that allow potential users mortality by reducing the number of times a woman is to match contraceptive methods to their needs are exposed to the risk and by helping women avoid high effectiveness, duration of effectiveness, and reversibility. From 1990 to 2005, family planning may Other major considerations include side effects, ease of have averted more than 1. Some women are also concerned about due to fewer high parity births to older women (Stover whether the method regulates menstruation or causes and Ross 2009). Although the number of approved methods is quite Child mortality rates are generally higher for high risk large, in practice couples in most countries have limited births, typically defined as births of order four (a wom options. Family Planning Effort Index measures, among other Short birth intervals, young age of mother at birth, and things, the percentage of the population that has ready parity greater than three are associated with greater and easy access to contraceptive methods (Ross and chances of births that are preterm, low birth weight, and Smith 2011). If a method is considered to be available small for gestational age (Kozuki, Lee, Silveira, Sania, and when more than 50 percent of the population has access, others 2013; Kozuki, Lee, Silveira, Victora, and others then potential users had access to 3. Mortality rates are about 50 percent higher Globally, female sterilization is used by the largest for closely spaced births and births to mothers under age share of couples (figure 6. The largest effects occur when multiple risk fac mix in Asia, Latin America and the Caribbean, and tors are combined. Oral mothers and those with high parity and short birth inter contraceptives have a significant share of users in most vals. On average, the percentage of births with is in Latin America and the Caribbean and in Sub any one of these avoidable risk factors drops from about Saharan Africa. In Bangladesh, Contraceptive Methods Morocco, and Zimbabwe, oral contraceptives account for A wide variety of contraceptive methods are available 50 percent or more of all contraceptive use; in Brazil and to women and men (table 6. The method mix in Kenya has evolved, and injectables are the population, resulting in greater reliance on methods now the most popular form of contraception. In Turkey appropriate for those delivery channels, such as oral con and Ukraine, for example, withdrawal and condoms are traceptives, injectables, and condoms. Although many will never reach the market, some to programs that rely on community workers to reach have the potential to address current barriers to use large numbers of users. It is registered for use in about 1984 in Mexico City, and 1994 in Cairo, as well as 20 countries. The twentieth anniversary packaged in a Uniject system that allows subcutane of the 1994 International Conference on Population and ous injection. It is expected to appeal positioned family planning within a broad context of Interventions to Improve Reproductive Health 99 Figure 6. The 2012 Injectable London Summit on Family Planning resulted in pledges 6% of resources to reach an additional 120 million new users with voluntary family planning services by 2020 (Bill & Source: Biddlecom and Kantorova 2013. Currently, a focus on total various names, including community based distributor, market approaches includes all service modalities? community health worker, and health extension worker, this public, private, and nongovernmental organizations? cadre of staff has delivered information and selected ser to expand the reach of family planning services and vices to families? doorsteps, providing access for women meet the needs of the diverse clientele across countries with limited mobility and those at a distance from clinical (Barnes, Vail, and Crosby 2012). These workers, for example, the Accredited Social the ingredients of successful family planning programs Health Activists in India, at times accompany clients to (Richey and Salem 2008) and high impact practices health facilities for clinical methods of contraception. Scaling up approaches include task shifting in contraceptive acceptance and use on the order of (Janowitz, Stanback, and Boyer 2012) and innovative 15 percent to 25 percent. Many middle income countries that individuals who had direct communication with fund contraceptive services, along with all other health community health workers were 10 times more likely services, out of tax revenues. Low income countries to use contraceptives than individuals who did not often rely on donor funding for commodities, training, (Stoebenau and Valente 2003). Community based health research, policy reform, evaluation, and service delivery workers have successfully reached underserved popula outside the health facility. Donors that have supported tions, including unmarried women, those with less sup family planning programs include bilateral donors portive husbands, and indigenous women (Malarcher such as the United States Agency for International and others 2011; Prata and others 2005). This support to a range of public health services, including family usually takes the form of commodities and funding planning, Ethiopia in 2003 began to deploy more than of nongovernmental organizations to provide specific 30,000 health extension workers at the community services. Community based marketing in family planning programs makes con programming has been part of family planning programs traceptive products accessible and affordable through since the 1970s. For keting has been used most widely to promote condoms mobile services to provide optimal care, it is important and oral contraceptives, with strong evidence of impact that adequate follow up care be available. Family planning programming has made use promote injectables, emergency contraception, and the of a range of media, including radio and television, Standard Days Method (CycleBeads?). In 1990, social to raise awareness and spread messages about services marketing contributed an estimated 7. Social franchising has been used to services, including providing training and support to increase the share of the private commercial sector in health workers, addressing commodity logistics, and family planning. These mHealth initiatives are ily planning that Sangini started in Nepal in 1994 and building on the rapidly growing use of wireless technol Greenstar in Pakistan in 1995, the use of this approach ogy. Fees that help to manage health data, drug supplies, patient can be paid with cash, vouchers, or other mechanisms. A 2010 ing, known by many names, including performance based assessment of evaluations of social franchising concludes financing and performance based incentives, is a rising that the studies demonstrate strong evidence that social trend in health programming. Given the history of mis franchising increases the uptake of family planning use of incentive payments in family planning (Norman services, and moderate evidence that it increases use by 2013), careful consideration of which aspects of perfor poor populations (Madhavan and Bishai 2010).

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Pre pump venous drainage line pressure (to avoid excessive negative suction pressure by the pump) can be used as a servo regulation system to generic drospirenone 3.03 mg without prescription birth control for skipping periods prevent excessive suction purchase drospirenone 3.03 mg visa birth control options for teens. The number of access sites should be minimized 3.03 mg drospirenone visa birth control for 3 months, but at least two are necessary (pre and post membrane lung) order drospirenone 3.03mg visa birth control 3 hour window. Blood access sites should be avoided between the patient and the inlet of the pump because of the risk of entraining air. Clotting in the oxygenator is represented by increasing membrane lung pressure gradient. Tubing is chosen to allow free venous drainage, and avoid high resistance pressure drop on the blood return side. The blood flow through 1 meter of tubing at 100 mmHg pressure gradient for common internal diameter in inches is: 3/16:1. Emergency circuits should be available within minutes of the call to a patient, and should be fully primed with crystalloid and ready to attach as soon as the patient is cannulated. They should also include safety factors to prevent high negative pressure on the inlet side and high positive pressure on the outlet side to avoid errors during emergent cannulation and attachment. The emergency circuit may include a microporous membrane lung (easy to prime), and a centrifugal pump (high pressure limited, does not require monitors or alarms during initial set up). Vascular Access (Chapters 4, 38) Vascular access is usually achieved by cannulation of large vessels in the neck or the groin. This approach is the quickest to establish, can be done without fluoroscopy or other imaging, has minimal recirculation, and provides full support. Placement requires imaging, usually fluoroscopy, so cannulation is more difficult than 2 cannula access. The advantage of single cannula access is that is easier to mobilize and ambulate the patient. Methods Cannulas can be placed via: 1) cut down, 2) percutaneously by a vessel puncture, guidewire placement, and serial dilation (Seldinger technique), 3) by a combination of cut down exposure and Seldinger cannulation, or 4) by direct cannulation of the right atrium and aorta via thoracotomy. Cut down exposure of the neck vessels is usually necessary in neonates and small children. The proximal vessel is occluded with a vascular clamp, the vessel opened, and the cannula placed. The vessel is ligated around the cannula, often over a plastic boot? to facilitate later cannula removal. The safest technique is to place small conventional intravascular catheters first. With current equipment, two people are necessary to do percutaneous access: one to load of the dilators on the wire and pass the dilators, and one to occlude the vessel between dilators to avoid bleeding. When using the Seldinger technique with a large dilator and cannulas, it important to check the wire after each dilator. Management of the distal vessels: If the neck cutdown access is used, the vein and artery are ligated distally, relying on collateral circulation to and from the head. If the access is via the femoral vessels the venous collateral is adequate but the femoral artery is often significantly occluded. If distal arterial flow to the leg is inadequate a separate perfusion line is placed in the distal superficial femoral artery by direct cutdown, or in the posterior tibial artery for retrograde perfusion. If a vascular access cannula is punctured, kinked, damaged, or clotted, the cannula must be changed. This will typically be 50 80 cc/kg/minute when total gas exchange support is needed. There is a rare condition called heparin induced thrombotic thrombocytopenia, characterized by multiple white arterial thrombi and platelet count less than 10,000. In such a case, if there are no other explanations for thrombocytopenia, it is reasonable to use a different anticoagulant than heparin. There is no reversal medication but the half life is a few hours so overdose is not long lasting. It may be a consequence of the primary disease, drugs, and other treatment, or caused by blood surface exposure. Circulating platelets adhere to the plastic surfaces, and undergo a release reaction? which attracts other platelets. These aggregates of effete? platelets circulate in the blood and are removed by the liver and spleen. If the pressure suddenly increases setting off the high pressure alarm, the cause is usually temporary occlusion of the infusion tubing or cannula. If air is detected in the circuit stop the pump, clamp the lines near the patient, and put the patient on support settings. The most common cause is aspiration of air into the venous drainage line at the site of cannulation or through a connector or open stopcock. When air is entrained on the drainage side it is usually as small bubbles, and usually is caught in the membrane lung or bubble trap before getting into the patient. These clots are in the range of 1 to 5 mm, do not require circuit changes, and are simply observed. Clots larger than 5 mm or enlarging clots on the infusion side of the circuit (post membrane lung) should be removed by removing that section of the circuit or by changing the entire circuit if there are many such clots. Platelet/fibrin thrombi appear as white areas on the circuit at connectors and stagnant sections. These are clots which have not accumulated red cells, usually because they are in areas of very high flow. As with dark clots, no intervention is necessary unless the white thrombi are greater than 5 mm or growing.

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The health and well being of women order 3.03mg drospirenone mastercard birth control for women age 40, new Substantial evidence suggests that community based interventions are an important platform for improv borns discount drospirenone 3.03mg with mastercard birth control kelnor, and children are inherently linked cheap drospirenone 3.03mg on-line birth control xanax interaction. When mothers ing health care delivery and outcomes (Bhutta and are malnourished order 3.03 mg drospirenone mastercard birth control mini pill, ill, or receive insufficient care, their others 2010; Kerber and others 2007; Lassi, Haider, newborns are at increased risk of disease and premature death. Better health requires that women and children have the ability to access quality services from conception and Home Visits pregnancy to delivery, the postnatal period, and childhood. Studies in Bangladesh, India, junction with administration of home based antibiotic and Pakistan suggest that home visits can reduce new therapy for suspected neonatal sepsis, resulted in born deaths in high mortality settings by 30 percent a 62 percent reduction in the neonatal mortality to 61 percent (Bang and others 1999; Baqui and others rate, when 93 percent of newborns in the intervention 2008; Bhutta and others 2008). Another study from an Indian urban slum reports a low case fatality Community Management of Delivery Complications, rate of 3. Home based interventions in India in resource limited settings with poorly accessible to reduce neonatal and infant deaths and stillbirths facility based care, when conducted in conjunction with included surveillance to identify pregnant women, community mobilization activities (Gogia and Sachdev followed by two home visits during pregnancy for 2010). The review also shows significant improvements birth preparedness and for routine neonatal care. In the trial, 93 percent of key newborn care practices such as early initiation of of neonates in the intervention areas received home breastfeeding and exclusive breastfeeding; skin to skin based care (Bang and others 1999). These interventions are also associated and treat those with nonsevere pneumonia with amox with an up to 160 percent increase in the use of oral icillin. In the intervention group, only of community based case management of pneumonia 27. Lady health supervisors are responsible for supervising the Source: Bhutta and others 2010. Community Based Intervention Packages through community based approaches, is associated Data suggest that the introduction of community based with a higher mean birth weight compared with case intervention packages has the potential to reduce maternal management (weighted mean difference 108. Salam, Maredia, and others (2014) also find increased by 45 percent, leading to decreases in neonatal that interventions such as preventive chemotherapy, and maternal morbidity (tables 14. Evidence suggests that school based delivery of antihelminths can signifi Malaria. Community based interventions may also cantly reduce soil transmitted helminths prevalence by contribute to prevention of malaria. Community Based Care to Improve Maternal, Newborn, and Child Health 269 Tuberculosis. Tuberculosis can be managed and pre months, complementary feeding between ages 6 and 23 vented through community based intervention pack months, and dietary diversity for older children, thereby ages, including through variants of the directly observed reducing morbidity and mortality related to malnutri treatment short course, community outreach, training tion (Getachew 2011; World Bank 2012). Findings from 41 studies tions to improve child nutrition status suggests that on the effectiveness of community based interventions nutrition education in both food secure and food for tuberculosis show that these interventions were asso insecure populations is associated with an increase in ciated with a significant increase in cure and the success height for age Z scores of 0. Nepal, and Pakistan?in which community support Monthly tracking of all children in the community groups and group advocacy sessions that targeted women enables the timely identification of severely underweight were implemented as part of community interventions? children and their referral for further examination and suggests that these interventions led to a 30 percent treatment. A decrease this initiative in 2008 in drought prone and food in neonatal morbidity through bene? The study ing pregnancy, delivery, and postpartum period?are also finds that the program positively influenced infant associated with a nonsignificant 23 percent reduction in and young child feeding, including greater adherence to maternal mortality and a 20 percent reduction in neona exclusive breastfeeding for babies younger than age six tal mortality (Prost and others 2013) (table 14. In the intervention area where community received voluntary training (Bhutta and others 2008). Usage is particularly seen more in the South Asia region, with uterotonic usage rates of up to 69 percent Expanding the Community Health Worker Mandate (Flandermeyer, Stanton, and Armbruster 2010). Although and are considered to be a core pillar for successful deliv promising evidence is emerging for their possible new ery of the program. Investigators should focus on this area of research as a promising approach in low resource settings. The Tanzania CommCare project used an automated in cultural and religious beliefs and particular practices text message system to remotely monitor the real of communities. A program tailored to communities? time performance of midwives and provide workers specific needs and health concerns is preferable. Regular received these messages improved the number of follow up and evaluation of training courses will rein timely visits to expectant mothers. Allowing communities to take an active part in the decision making and implementation processes permits differences in cul Figure 14. Outreach A bottom up approach from educated communities with activities adequate support from reliable government and national Linkages institutions will be key for sustainable interventions. We have developed an evidence driven framework based on a continuum of care model for reproductive, Household and community maternal, neonatal, and child health (figure 14. Once the links are firmly estab ing communities with the primary health care system. The introduction of community based interventions requires personnel, resources, training, management, and infrastructure. Scaling up the intervention finding is noted in a review of the cost effectiveness from 2011 to 2020 was considered cost effective at Figure 14. The main cost drivers relate to the intensity of the intervention and the numbers covered. Even in As countries grow as a result of increased global eco cases in which intensive resources are required, the cost nomic development, existing health care systems are ill per capita can be quite low. Improving reproductive, maternal, newborn, and McCord, Liu, and Singh (2013) estimate that it would child health requires successful community engagement. Yet numerous wide ranging effects on the sustainability, effectiveness, research gaps exist that, if studied, could have a signifi and longevity of community health systems, bringing all cant impact on the delivery of health care.

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However the studies reviewed in the Cochrane database provided insufficient information to order drospirenone 3.03 mg online birth control pills when to start draw conclusions about the impact on maternal and fetal outcomes and randomised controlled studies have found conflicting evidence that maternal or neonatal health will benefit from correcting these deficits (Palma et al generic drospirenone 3.03mg otc birth control for women 90s style, 2008; Cogswell et al cheap 3.03 mg drospirenone with visa birth control for 13 year old, 2003) order drospirenone 3.03 mg otc birth control 8 hours late. There are also other potential downsides to routine supplementation, to consider: 7. Non compliance Whilst studies of routine iron supplementation have shown improvements in Hb and ferritin, at present there is no good evidence of benefit when implemented as a large scale program through the primary health care system. Significant discrepancy exists between the impact of iron supplementation reported in the clinical trials? setting and that observed in large scale public health programs. This is likely to be a combination of patients? and carers? behaviour; with, respectively, poor compliance due to lack of patient knowledge and concern about maternal anaemia and inadequate counselling about the need for iron supplementation and its potential benefits and side effects. Research has shown that drug compliance is inconsistent and often poor, despite relatively simple regimes and even where there is obvious life threatening disease. In contrast, during clinical trials, patients are closely supervised, counselled and non compliance kept to a minimum. Clinical hazards of routine supplementation 18 | Page There are potential clinical hazards of iron supplemention in already iron replete women, including raised Hb with risk of placental insufficiency and secondary haemochromatosis in women with iron loading states. However these are mainly theoretical rather than practical considerations for short term iron administration. Raised Hb the rheological status (haemoconcentration and elevated red cell aggregation) appears to have an important influence on the outcome of pregnancy (Heilmann, 1987, Sagen et al, 1982). There is a risk of elevated Hb, with the use of iron supplements in non anaemic women and particularly those given daily regimes from an early gestational age <20 weeks (Pena Rosas et al, 2009). This could represent excessive erythropoiesis but may have more to do with changes in plasma volume than with iron therapy. A U shaped association has been observed between maternal Hb concentrations and birth weight. A large observational study of 54,382 pregnancies showed higher rates of perinatal death, low birth weights and preterm delivery in women with high (Hb >13. Oxidant stress When products of oxygen are brought into contact with transition metals capable of 2+ 3+ changing valence, such as iron (Fe Fe), reactive free radicals, the hydroxyl radicals are formed, which have the potential to damage cells and tissues (Halliwell et al, 1999). Thus tissue iron excess contributes to producing and amplifying the injury caused by free radicals as well as to modulating various steps involved in the inflammatory lesion. The placenta is particularly susceptible to oxidative stress, being rich in mitochondria and highly vascular. Markers of oxidant stress (such as malondialdehyde) have been found to be significantly elevated in the placenta of women with regular iron supplementation in pregnancy (Devrim et al, 2006). The intestinal mucosa is also vulnerable to oxidative damage, caused by the continuous presence of a relatively small amount of excess iron intake (Lund et al, 2001) and iron accumulation leading to intestinal abnormalities and injury has been observed in patients receiving therapeutic iron (Abraham et al, 1999). Previously iron deficient pregnant women are potentially more susceptible, due to excessive iron absorption, particularly when given daily pharmacological doses of iron (Viteri, 1997). Practical difficulties There are clear logistical problems associated with widespread use. These include cost and supply of iron tablets, cost and ability to deliver adequate supportive care and the 19 | Page potential risk of accidental overdose by children in the home. Iron ingestion has been the most common cause of paediatric poisoning deaths and doses as low as 60 mg/kg have proved fatal (Baker, 1989). These appear to be as efficacious as daily regimes (Institute of Medicine, 1993; Anderson, 1991). However the extent to which these findings can be generalized needs to be determined and it may be that the response is not the same for all locations, depending upon variability in other background factors. Success has also been obtained with low dose daily regimes, such as 20mg elemental iron (Makrides et al, 2003) given under controlled trial conditions. An individual approach is preferable, based on results of blood count screening tests as well as identification of women at increased risk (1A). Acknowledgements and declarations of interest All authors have contributed to the guideline and none have declared a conflict of interest. Department of Health and Human Services, Food and Drug Administration, Center for Food Safety and Applied Nutrition 1 36. Iron therapy in iron deficiency anaemia in pregnancy:Intravenous route versus oral route. European Journal of Obstetrics and Gynecology and Reproductive Biology 2005; 123:S15 S19. European Journal of Obstetrics and Gynecology and Reproductive Biology 123, S21 S27. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. U seinpregnancy N oadequatedatafor N otinfirsttrim ester Avoiduseinfirst N oadequatedataforusein useinpregnant trim ester pregnantwom en,contra wom en,contra indicatedinfirsttrim ester indicatedinfirst thereafterriskbenefit trim esterthereafterrisk basedonclinicalneed benefitbasedon clinicalneed L actation R isknotknown U nlikelytopassto <1% ironpassedinto R isknotknown m aternalm ilkno m ilkunlikelytobe clinicaltrials significant Adversedrug related 5% patientsm ay 0. If no agreement had been reached on the appropriate grading of a recommendation, a vote would have been held and the majority opinion carried. Conflicts of Interest Statement All authors made declarations of interest in line with the policy in the Renal Association Clinical Practice Guidelines Development Manual. Databases were searched for all published papers between January 2009 and November 2016, using relevant medical subject headings, free text terms and study type filters where appropriate. Articles available in abstract forms; letters; case reports; editorials or review articles were also excluded. Where evidence was available from the above sources, recommendations were based on these publications. Kidney Disease: Improving Global Outcomes guidelines on anaemia management in chronic kidney disease: a European Renal Best Practice position statement.

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