Search results for: pre-natal health

Authors: Sevinj Asgarova

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Within the last few decades, major advances in the field of prenatal testing have transpired yet little research regarding the experiences of mothers who chose to continue their pregnancies after prenatally receiving a diagnosis of Down Syndrome (DS) has been undertaken. Using social constructionism and interpretive description, this retrospective research study explores this topic from the point of view of the mothers involved and provides insight as to how the experience could be improved. Using purposive sampling, 23 mothers were recruited from British Columbia (n=11) and Ontario (n=12) in Canada. Data retrieved through semi-structured in-depth interviews were analyzed using inductive, constant comparative analysis, the major analytical techniques of interpretive description. Four primary phases emerged from the data analysis 1) healthcare professional-mothers communications, 2) initial emotional response, 3) subsequent decision-making and 4) an adjustment and reorganization of lifestyle to the preparation for the birth of the child. This study validates the individualized and contextualized nature of mothers’ decisions as influenced by multiple factors, with moral values/spiritual beliefs being significant. The mothers’ ability to cope was affected by the information communicated to them about their unborn baby’s diagnosis and the manner in which that information was delivered to them. Mothers used emotional coping strategies, dependent upon support from partners, family, and friends, as well as from other families who have children with DS. Additionally, they employed practical coping strategies, such as engaging in healthcare planning, seeking relevant information, and reimagining and reorganizing their lifestyle. Over time many families gained a sense of control over their situation and readjusted to the preparation for the birth of the child. Many mothers expressed the importance of maintaining positivity and hopefulness with respect to positive outcomes and opportunities for their children. The comprehensive information generated through this study will also provide healthcare professionals with relevant information to assist them in understanding the informational and emotional needs of these mothers. This should lead to an improvement in their practice and enhance their ability to intervene appropriately and effectively, better offering improved support to parents dealing with a diagnosis of DS for their child.

Keywords: continuing affected pregnancy, decision making, disability, down syndrome, eugenic social attitudes, inequalities, life change events, prenatal care, prenatal testing, qualitative research, social change, social justice

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Authors: Adrita Banerjee, Ajeet Kumar Singh

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Antenatal care (ANC) from a skilled provider is important to monitor the pregnancy and reduce the risk of morbidity for mother and baby during pregnancy and delivery. The quality of antenatal care can be monitored through the content of services received and the kind of information mothers are given during their visit. Objective: The paper tries to examine the association between ANC check-ups and size/ birth weight. It also focuses on investigating the relationship between utilization of recommended prenatal care for mothers and its effect on infant survival in Nepal. Data and methods: This paper uses data from Nepal demographic Health Survey 2011. To understand the relationship bi-variate statistical analysis and logistic regressions has been done. Maternal health care utilization include ANC check-ups i.e. the type of ante-natal care providers, the number and timing of the visit. The various components of the check-ups include intake of iron tablets/syrups, intestinal parasitic drugs, etc. Results: The results show that women who had no antenatal care visits about 40% had small sized babies at the time of birth compared to women to had at least 3 ANC check up. Women who had at least 3 check-ups 17% of the babies have a small size. It has also been found that about 50 % of the women prefer ANC check-ups during pregnancies which have resulted in lowering the infant mortality by about 40% during 1996-2011. Conclusion: Ante natal care check is care and monitoring of the pregnant woman and her foetus throughout pregnancy. ANC checks have an effect on the infant health and child survival. A woman who had at least three check-ups the possibilities of adverse effect on infant health and infant survival was significantly lower. The findings argue for a more enhanced focus on ANC check-ups for improving the maternal and child health in Nepal.

Keywords: maternal, health, pregnancy, outcome

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Authors: Chinelo Igwenagu

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Teenage childbearing in developing countries has been a thing of great concern as it has often led to a number of socioeconomic problems both to the society and to the families affected. The outcome of teenage pregnancy has been generally associated with higher rates of maternal morbidity and mortality, greater risks for delivery complications, low-birth weight infants and child mortality. As a result of teenagers’ physiological and social immaturity and their lack of adequate prenatal care, health risks associated with their pregnancies and childbearing are more pronounced than those of older women. Therefore this study has examined the relationship between the age of teenagers and the outcome of teenage pregnancy. Based on this study, the result of the analysis shows that both teenagers and older mothers suffer similarly during child bearing. Hence improve medical care is paramount in all the situations.

Keywords: childbearing, mortality, Nigeria, pregnancy, prematurity, teenagers

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Authors: Amy Yee Kai Wan

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The arrival of a new baby to first-time parents is an exciting and joyous occasion, yet, the daunting task of raising the baby and the uncertainty of how it will affect the lives of the couple present a great challenge to them. This study examines the causes of conflicts and needs of the new parents through a qualitative research of five pairs of new parents in Hong Kong. Semi-structured in-depth qualitative interviews were conducted to explore the changes babies brought to their marriages, sources of support they received and found important and assistance they felt would help with their transition to parenthood. Thematic analysis was used to analyze the commonalities and differences between the five couples’ subjective experiences. Narrative analysis was used to compare the experiences of two parents who are the under-functioning parent of the couple, to study the different strategies they employed in response to the over-functioning parent and to analyze how the marital relationships were affected. Four main themes emerged from the study: 1) Change and adjustment in marital relationship, 2) parents’ level of involvement, 3) support in childcaring, and 4) challenges faced by the parents. Results from the study indicated that father involvement in childcaring is an important element in mother’s marital satisfaction Father’s marital satisfaction is dependent upon the mother – her satisfaction with father involvement, which affects the mother’s marital satisfaction. Marital convergence and co-parenting alliance acted as moderators for marital satisfaction. Implications from the study include: i) offering programmes that improve couple relationship and enhance parenting efficacy in tandem to improve overall marital satisfaction, and ii) offering prenatal counselling services or provide education to new parents from prenatal to postnatal period that can help couples reduce discrepancies between expectations and realities of their marital relationship and parenting responsibilities after their baby is born.

Keywords: co-parenting alliance, father involvement, marital convergence, maternal gatekeeping, new parents, transition to parenthood

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Authors: Galila Aisyah Latif Amini, Husnul Khatimah, Citra Amelia

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Smoking among women is of particular concern for the maternal and child health community due to the strong association between prenatal smoking and adverse birth outcomes. Pregnancy is perceived to be a unique reason for smoking cessation, as motivation to care for the unborn fetus. This study aimed to find out the determinants of smoking cessation among pregnant women. Method that we use in this study is systematic review. We identified relevant studies by searching on science database online through SAGE journals, Proquest, Scopus, Emerald, JSTOR, and Springerlink. Journals were screened by title and abstract according to the research topic then filtered using the criteria exclusion and inclusion. And then we did critical appraisal. The results of the four studies reviewed were found that the determinant of smoking cessation are parity, the level of education, socioeconomic status, household SHS exposure, smoking habits of both parents, partner smoking status, psychological factors, antenatal care, intervention for health care provider, age smoking duration. The factor most strongly associated with smoking cessation is parity (OR 2,55; Cl 2,34-2,77). The results of this study are expected to give advice for developing future smoking cessation and relapse prevention programs.

Keywords: pregnancy, smoking cessation, tobacco use cessation, smoking

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Authors: Memnun Seven, Aygül Akyüz

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Having a baby, giving birth and being a mother are generally considered happy events, especially for women who have had a history of infertility and may have suffered emotionally, physically and financially. Although the transition from the prenatal period to the postnatal period is usually desired and planned, it is a developmental and cognitive transition period full of complex emotional reactions. During this period, common mood disorders for women include maternity blues, postpartum depression and postpartum psychosis. Postpartum depression is a common and serious mood disorder which can jeopardize the health of the mother, baby and family within the first year of delivery. Knowing the risks factors is an important issue for the early detection and early intervention of postpartum depression. However, knowing that a history of infertility may contribute to the development of postpartum depression, there are few studies assessing the effects of infertility during the diagnosis and treatment of depression. In this review, the effects of infertility on the development of postpartum depression and nurse/midwives’ roles in this issue are discussed in light with the literature.

Keywords: infertility, postpartum depression, risk factors, mood disorder

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Authors: Abdulfatah Al-Jaradi, Marzoq Ali Odhah, Abdulnasser A. Haza’a

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Background: Antenatal care can be defined as the care provided by skilled healthcare professionals to pregnant women and adolescent girls to ensure the best health conditions for both mother and baby during pregnancy. The components of ANC include risk identification; prevention and management of pregnancy-related or concurrent diseases; and health education and health promotion. The aim of this study: to assess the knowledge, attitude, and practice of pregnant women regarding antenatal care. Methodology: A descriptive KAP study was conducting in public hospitals in Sana'a City-Yemen. The study population was included all pregnant women that intended to the prenatal department and clinical outpatient department, the final sample size was 371 pregnant women, a self-administered questionnaire was used to collect the data, statistical package for social sciences SPSS was used to data analysis. The results: Most (79%) of pregnant women were had correct answers in total knowledge regarding antenatal care, and about two-thirds (67%) of pregnant women were had performance practice regarding antenatal care and two-third (68%) of pregnant women were had a positive attitude. Conclusions & Recommendations: We concluded that a significant association between overall knowledge and practice level toward antenatal care and demographic characteristics of pregnant women, women (residence place, level of education, did your husband support you in attending antenatal care and place of delivery of the last baby), at (P-value ≤ 0.05). We recommended more education and training courses, lecturers and education sessions in clinical facilitators focused ANC, which relies on evidence-based interventions provided to women during pregnancy by skilled healthcare providers such as midwives, doctors, and nurses.

Keywords: antenatal care, knowledge, practice, attitude, pregnant women

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Authors: Ebenezer Kwesi Armah-Ansah, Kenneth Fosu Oteng, Esther Selasi Avinu, Eugene Budu, Edward Kwabena Ameyaw

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Background: Maternal mortality, particularly in Benin, is a major public health concern in Sub-Saharan Africa. To provide a positive pregnancy experience and reduce maternal morbidities, all pregnant women must get appropriate and timely prenatal support. However, many pregnant women in developing countries, including Benin, begin antenatal care late. There is a paucity of empirical literature on the prevalence and predictors of early antenatal care visits in Benin. As a result, the purpose of this study is to investigate the prevalence and predictors of early antenatal care visits among women of productive age in Benin. Methods: This is a secondary analysis of the 2017/2018 Benin Demographic and Health Survey (BDHS) data. The study involved 6,919 eligible women. Data analysis was conducted using Stata version 14.2 for Mac OS. We adopted a multilevel logistic regression to examine the predictors of early ANC visits in Benin. The results were presented as odds ratios (ORs) associated with 95% confidence intervals (CIs) and p-value <0.05 to determine the significant associations. Results: The prevalence of early ANC visits among pregnant women in Benin was 57.03% [95% CI: 55.41-58.64]. In the final multilevel logistic regression, early ANC visit was higher among women aged 30-34 [aOR=1.60, 95% CI=1.17-2.18] compared to those aged 15-19, women with primary education [aOR=1.22, 95% CI=1.06-142] compared to the non-educated women, women who were covered by health insurance [aOR=3.03, 95% CI=1.35-6.76], women without a big problem in getting the money needed for treatment [aOR=1.31, 95% CI=1.16-1.49], distance to the health facility, not a big problem [aOR=1.23, 95% CI=1.08-1.41], and women whose partners had secondary/higher education [aOR=1.35, 95% CI=1.15-1.57] compared with those who were not covered by health insurance, had big problem in getting money needed for treatment, distance to health facility is a big problem and whose partners had no education respectively. However, women who had four or more births [aOR=0.60, 95% CI=0.48-0.74] and those in Atacora Region [aOR=0.50, 95% CI=0.37-0.68] had lower odds of early ANC visit. Conclusion: This study revealed a relatively high prevalence of early ANC visits among women of reproductive age in Benin. Women's age, educational status of women and their partners, parity, health insurance coverage, distance to health facilities, and region were all associated with early ANC visits among women of reproductive in Benin. These factors ought to be taken into account when developing ANC policies and strategies in order to boost early ANC visits among women in Benin. This will significantly reduce maternal and newborn mortality and help achieve the World Health Organization’s recommendation that all pregnant women should initiate early ANC visits within the first three months of pregnancy.

Keywords: antenatal care, Benin, maternal health, pregnancy, DHS, public health

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Authors: Mohd. Ashik Shahrier, Hiromi Wada

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Prenatal ethanol exposure has potential to induce difficulties in the social behavior of rats and can alter pup-dam communication suggesting that deficits in pups could result in altered dam behavior, which in turn could result in more aberrant behavior in the pup. Ultrasonic vocalization (USV) is a sensitive tool for investigating social behavior between rat pups and their dam. Rat pups produce USVs on separation from their dam. This signals the dam to locate her pups and retrieve them back to the nest. In this study, it was predicted that prenatal ethanol exposure cause alterations on the acoustic characteristics of USVs in rat pups. Thirteen pregnant rats were purchased and randomly assigned into three groups: high-ethanol (n = 4), low-ethanol (n = 5), and control (n = 4) groups. Laboratory ethanol (purity = 99.5%) was dissolved in tap water and administered to the high- and low-ethanol groups as drinking water from gestational days (GD) 8-20. Ethanol-containing water was administered to the animals in three stages by gradually increasing the concentration between GDs 8–20. From GDs 8–10, 10% and 5%, from GDs 11–13, 20% and 10%, and from GDs 14–20, 30% and 15% ethanol-containing water (v/v) was administered to the high- and low-ethanol groups, respectively. Tap water without ethanol was given to the control group throughout the experiment. The day of birth of the pups was designated as postnatal day (PND) 0. On PND 4, each litter was culled to four male and four female pups. For the present study, two male and two female pups were randomly sampled from each litter as subjects. Thus, eight male and eight female pups from the high-ethanol and control groups and another 10 male and 10 female pups from the low-ethanol group, were sampled. An ultrasonic microphone and the Sonotrack system version 2.4.0 (Metris, Hoofddorp, The Netherlands) were used to record and analyze USVs of the pups. On postnatal days 4, 8, 12 and 16, the resultant pups were individually isolated from their dams and littermates, and USVs were recorded for 5 min in a sound-proof box. Pups in the high-ethanol group produced greater number of USVs compared with that in both low-ethanol and control groups on PND 12. Rat pups in the high-ethanol group also produced higher mean, minimum, and maximum fundamental frequencies of USVs compared with that in both low-ethanol and control groups. Male pups in the high-ethanol group had higher USV amplitudes than in those in low-ethanol and control groups on PND 12. These results suggest that pups in the high-ethanol group relatively experienced more negative emotionality due to the ethanol-induced neuronal activation in the core limbic system and tegmental structures and accordingly, produced altered USVs as distress calls.

Keywords: emotionality, ethanol, maternal separation, ultrasonic vocalization

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Authors: Stefan Kurbatfinski, Aliyah Dosani, Andrew F. Hayes, Deborah Dewey, Nicole Letourneau

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Background: Maternal adverse childhood experiences (ACEs) have been associated with internalizing and externalizing behavioral problems in preschool children. However, little is known about the influence of maternal adult attachment patterns on this association. Further, potential moderation by maternal mental health, maternal social support, or child sex is poorly understood. Therefore, this study examined associations between 1) maternal ACEs and preschool children’s behavioural problems, with mediation through maternal attachment patterns and moderation by maternal mental health, maternal social support, and child sex; and 2) maternal attachment patterns and children’s behavioural problems, with mediation through maternal mental health and social support and moderation by child sex. Methods: This secondary analysis used data (n=625) from a high socioeconomic, longitudinally prospective cohort (Alberta Pregnancy Outcomes and Nutrition). Child behaviour (BASC-2) and maternal adult attachment (ECR-Q) were measured at five years of child age, maternal ACEs (ACEs Questionnaire) at around 12 months, and maternal mental health (CESD and SCL-90-R) and social support (SSQ) across various prenatal and postnatal time points. All moderation and mediation analyses occurred through RStudio using PROCESS, interpreting significant interactions through Johnson-Neyman plots. Findings: Maternal ACEs interacted with maternal anxiety symptoms to predict both behavioural problems (pexternalizing=0.007; pinternalizing=0.0159). An indirect pathway via dismissive attachment was moderated by maternal social support ([0.0058, 0.0596]). Attachment patterns predicted all behavioural problems (p<0.05) and interacted with maternal anxiety symptoms to predict internalizing behaviours among male children ([0.0321, 0.1307]; [0.0321, 0.1291]). Interpretation: Maternal attachment patterns may predict children’s behavioural problems more than ACEs. Social support interventions may not always be beneficial for highly dismissively attached mothers. Implications for policy and child health include mandatory sex and gender education for teachers; assessing attachment patterns prior to recommending social support as an intervention; and anxiety-focused interventions for mothers in higher socioeconomic populations.

Keywords: maternal adverse childhood experiences, internalizing behaviours, externalizing behaviours, mediators and moderators, attachment patterns, child health

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Authors: Shannon Rappe, Elizabeth Morse, David Phillippi

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Postpartum women with an opioid use disorder (OUD) are at high risk for treatment disengagement, leaving them vulnerable to overdose and death between seven and twelve months postpartum. Intensive case management programs have been proposed as an effective strategy to reduce barriers and increase treatment engagement among postpartum women. The purpose of this project is to determine the effects of early engagement in an intensive case management program on postpartum engagement and infant health outcomes among postpartum women with opioid use. This retrospective review of secondary data was collected on 225 infants, and 221 postpartum women enrolled in an intensive case management program in Tennessee between May 1, 2019, and May 5, 2020. Chi-squares were computed to examine the timing of engagement during pregnancy, maternal treatment outcomes, and infant health outcomes, including neonatal abstinence syndrome (NAS), birth weight, gestational age, and length of stay. The mean prenatal program engagement was 109 days (SD = 67.6); 16.7% (n = 37) enrolled during the first trimester, 37.6% (n = 83) in the second trimester, and 45.7% (n = 101) in the third trimester. Of the 221 women engaged, 45.2% (n = 100) remained engaged in the case of management at the time of data collection, and 40% (n = 89) remained engaged in MAT at the time of data collection. Twenty- five percent (n = 25) of mothers who graduated sustained engagement in MAT. Of 225 infants 28.9% (n = 65) had a positive NAS status, mean birth weight was 6.5 lbs. (SD = 19.3); mean gestational age was 38.3 weeks (SD = 19.3) and mean length of stay was 8.19 days (SD = 9.8). This study's findings identified that engaging mothers during pregnancy in a program designed to meet their unique challenges positively impacts both the mother and infant outcomes, regardless of their timing.

Keywords: intensive case management, neonatal abstinence syndrome, opioid addiction, opioid crisis, opioid use in pregnant women, postpartum addiction

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Authors: Linghua Kong, Xinxia Chen, Mika Gissler, Catharina Lavebratt

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Background: Prenatal exposure to preeclampsia has been associated with an increased risk of offspring attention-deficit/hyperactivity disorders (ADHD), autism spectrum disorder (ASD), and intellectual disability. However, little is known about the association between prenatal exposure to severe preeclampsia and neurodevelopmental and psychiatric disorders in offspring. Objective: This study aimed to assess the risk of maternal preeclampsia combined with perinatal problems, specifically low birth weight and prematurity, on offspring neuropsychiatric disorders. Methods: All singleton live births in Finland between 1996 and 2014 (n=1 012 723) were followed up in nation-wide registries until 2018. Main exposures included pre-eclampsia, small for gestational age, and delivery before 34 gestational weeks. Offspring neurodevelopmental and psychiatric disorders (ICD-10 codes) were examined as outcomes variables. Offspring birth year, sex, maternal age at delivery, parity, marital status at birth, mother's country of birth, maternal smoking, maternal gestational diabetes, maternal use of psychotropic medication during pregnancy, and maternal systemic inflammatory diseases were used as covariates. Risks for neurodevelopmental and psychiatric disorders were estimated using Cox proportional hazards modeling. Results: Of the 1 012 723 offspring, 25 901 (2.6%) were exposed to preeclampsia, and 93 281 (9.2%) were diagnosed with a neuropsychiatric disorder. Compared to births unexposed to preeclampsia, small for gestational age or delivery before 34 gestational weeks, those exposed to preeclampsia only had a 21% increase in the likelihood of any neuropsychiatric disorders after adjusting for potential confounding (adjusted HR=1.21, 95% CI: 1.15-1.26), while exposure to preeclampsia combined with small for gestational age or delivery before 34 gestational weeks had a more than twofold increased risk of having a child with neuropsychiatric disorders (adjusted HR=2.16, 95% CI: 2.02-2.32). The adjusted HR for neuropsychiatric disorders in offspring with small for gestational age or delivery before 34 gestational weeks only was 1.79 (95% CI: 1.73-1.83). In addition, the risk estimate in offspring exposed to both preeclampsia and perinatal problems was greater than those only exposed to preeclampsia for having personality disorders (adjusted HR=1.66; 95% CI: 1.07-2.57), intellectual disabilities (adjusted HR=3.47; 95% CI: 2.86-4.22), specific developmental disorders (adjusted HR=2.91; 95% CI: 2.69-3.15), ASD (adjusted HR=1.75; 95% CI: 1.42-2.17), ADHD and conduct disorders (adjusted HR=2.00; 95%CI: 1.76-2.27), and other behavioral and emotional disorders (adjusted HR=2.09; 95% CI: 1.84-2.37). Conclusion: In utero exposure to severe preeclampsia increased the risk of several neurodevelopmental and psychiatric disorders in offspring. Our findings are relevant to women with hypertensive disorders with regard to pregnancy consultation and management and may yield effective clues for the prevention of neurodevelopmental and psychiatric disorders in childhood.

Keywords: low birth weight, neurodevelopmental disorders, preeclampsia, prematurity, psychiatric disorders

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Authors: Esshili Awatef, Manitz Marie-Pierre, Eßlinger Manuela, Gerhardt Alexandra, Plümper Jennifer, Wachholz Simone, Friebe Astrid, Juckel Georg

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Maternal immune activation (MIA) resulting from maternal viral infection during pregnancy is a known risk factor for schizophrenia. The neural mechanisms by which maternal infections increase the risk for schizophrenia remain unknown, although the prevailing hypothesis argues that an activation of the maternal immune system induces changes in the maternal-fetal environment that might interact with fetal brain development. It may lead to an activation of fetal microglia inducing long-lasting functional changes of these cells. Based on post-mortem analysis showing an increased number of activated microglial cells in patients with schizophrenia, it can be hypothesized that these cells contribute to disease pathogenesis and may actively be involved in gray matter loss observed in such patients. In the present study, we hypothesize that prenatal treatment with the inflammatory agent Poly(I:C) during embryogenesis at contributes to microglial activation in the offspring, which may, therefore, represent a contributing factor to the pathogenesis of schizophrenia and underlines the need for new pharmacological treatment options. Pregnant rats were treated with intraperitoneal injections a single dose of Poly(I:C) or saline on gestation day 17. Brains of control and Poly(I:C) offspring, were removed and into 20-μm-thick coronal sections were cut by using a Cryostat. Brain slices were fixed and immunostained with ba1 antibody. Subsequently, Iba1-immunoreactivity was detected using a secondary antibody, goat anti-rabbit. The sections were viewed and photographed under microscope. The immunohistochemical analysis revealed increases in microglia cell number in the prefrontal cortex, in offspring of poly(I:C) treated-rats as compared to the controls injected with NaCl. However, no significant differences were observed in microglia activation in the cerebellum among the groups. Prenatal immune challenge with Poly(I:C) was able to induce long-lasting changes in the offspring brains. This lead to a higher activation of microglia cells in the prefrontal cortex, a brain region critical for many higher brain functions, including working memory and cognitive flexibility. which might be implicated in possible changes in cortical neuropil architecture in schizophrenia. Further studies will be needed to clarify the association between microglial cells activation and schizophrenia-related behavioral alterations.

Keywords: Microglia, neuroinflammation, PolyI:C, schizophrenia

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Authors: Kushal Patel, Manasa Dittakavi, Cyrus Falsafi, Gretchen Lovett

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Rural America has seen a surge in opioid addiction rates and overdose deaths in recent years, becoming a significant public health crisis. This may be due to a variety of factors, such as lack of access to healthcare or other economic and social factors that can contribute to addiction such as poverty, unemployment, and social isolation. As the opioid epidemic has disproportionately affected rural communities, pregnant women in these areas may be highly susceptible and face additional difficulties in facing the appropriate care they need. Opioid use disorder has many negative effects on prenatal infants. These include changes in their microbiome, mental health, neurodevelopment and cognition. These can affect how the child performs in various activities in life and how they interact with others. It has been demonstrated that using cognitive behavioral therapy improves not just pain-related results but also mobility, quality of life, disability, and mood outcomes. This indicates that cognitive behavioral therapy (CBT) may be a useful therapeutic strategy for enhancing general health and wellbeing in people with opioid use problems. In terms of treating psychiatric diseases, CBT carries fewer dangers than opioids. One study that illustrates the potential for CBT to promote a reduction in opioid use disorder used self-reported drug use patterns 6 months prior to and during their pregnancy. At the beginning of the study, participants reported an average of 3.78 drug or alcohol use days in the previous 28 days, which decreased to 1.63 days after treatment. The study also found a decrease in depression scores, as measured by IDS scores, from 23.9 to 17.1 at the end of treatment. These and other results show that CBT can have meaningful impacts on pregnant women in Rural America who struggle with an opioid use disorder. This project has been approved by the West Virginia School of Osteopathic Medicine- Office of Research and Sponsored Programs and deemed non-research scholarly work.

Keywords: appalachia, CBT, opiods, pregnancy

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Authors: H. Merhni, A. Sbiti, I. Ratbi, A. Sefiani

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The proximal spinal muscular atrophy (SMA) is a group of neuromuscular disorders characterized by progressive muscle weakness due to the degeneration and loss of anterior motor neurons of the spinal cord. Depending on the age of onset of symptoms and their evolution, four types of SMA, varying in severity, result in a mutations of the SMN gene (survival of Motor neuron). We have analyzed the DNA of 295 patients referred to our genetic counseling; since January 1996 until October 2014; for suspected SMA. The homozygous deletion of exon 7 of the SMN gene was found in 133 patients; of which, 40.6% were born to consanguineous parents. In countries like Morocco, where the frequency of heterozygotes for SMA is high, genetic testing should be offered as first-line and, after careful clinical assessment, especially in newborns and infants with congenital hypotonia unexplained and prognosis compromise. The molecular diagnosis of SMA allows a quick and certainly diagnosis, provide adequate genetic counseling for families at risk and suggest, for couples who want prenatal diagnosis. The analysis of the SMN gene is a perfect example of genetic testing with an excellent cost/benefit ratio that can be of great interest in public health, especially in low-income countries. We emphasize in this work for the benefit of the generalization of molecular diagnosis of SMA by the technique of PCR-enzymatic digestion in other centers in Morocco.

Keywords: Exon7, PCR-digestion, SMA, SMN gene

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Authors: Aizati N. A. Daud, Jorieke E. H. Bergman, Wilhelmina S. Kerstjens-Frederikse, Pieter Van Der Vlies, Eelko Hak, Rolf M. F. Berger, Henk Groen, Bob Wilffert

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Prenatal use of SRIs was previously associated with Congenital Heart Anomalies (CHA). The aim of the study is to explore whether pharmacogenetics plays a role in this teratogenicity using a gene-environment interaction study. A total of 33 case-mother dyads and 2 mother-only (children deceased) registered in EUROCAT Northern Netherlands were included in a case-only study. Five case-mother dyads and two mothers-only were exposed to SRIs (paroxetine=3, fluoxetine=2, venlafaxine=1, paroxetine and venlafaxine=1) in the first trimester of pregnancy. The remaining 28 case-mother dyads were not exposed to SRIs. Ten genes that encode the enzymes or proteins important in determining fetal exposure to SRIs or its mechanism of action were selected: CYPs (CYP1A2, CYP2C9, CYP2C19, CYP2D6), ABCB1 (placental P-glycoprotein), SLC6A4 (serotonin transporter) and serotonin receptor genes (HTR1A, HTR1B, HTR2A, and HTR3B). All included subjects were genotyped for 58 genetic variations in these ten genes. Logistic regression analyses were performed to determine the interaction odds ratio (OR) between genetic variations and SRIs exposure on the risk of CHA. Due to low phenotype frequencies of CYP450 poor metabolizers among exposed cases, the OR cannot be calculated. For ABCB1, there was no indication of changes in the risk of CHA with any of the ABCB1 SNPs in the children and their mothers. Several genetic variations of the serotonin transporter and receptors (SLC6A4 5-HTTLPR and 5-HTTVNTR, HTR1A rs1364043, HTR1B rs6296 & rs6298, HTR3B rs1176744) were associated with an increased risk of CHA, but with too limited sample size to reach statistical significance. For SLC6A4 genetic variations, the mean genetic scores of the exposed case-mothers tended to be higher than the unexposed mothers (2.5 ± 0.8 and 1.88 ± 0.7, respectively; p=0.061). For SNPs of the serotonin receptors, the mean genetic score for exposed cases (children) tended to be higher than the unexposed cases (3.4 ± 2.2, and 1.9 ± 1.6, respectively; p=0.065). This study might be among the first to explore the potential gene-environment interaction between pharmacogenetic determinants and SRIs use on the risk of CHA. With small sample sizes, it was not possible to find a significant interaction. However, there were indications for a role of serotonin receptor polymorphisms in fetuses exposed to SRIs on fetal risk of CHA which warrants further investigation.

Keywords: gene-environment interaction, heart defects, pharmacogenetics, serotonin reuptake inhibitors, teratogenicity

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Authors: Tracey Estriplet-Adams

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This paper focuses on the influence of maternal-fetal bonding by examining attachment theory, psycho-social-cultural influences/adaptations, and maternal well-being. A systematic review methodology was used to synthesize research results to summarize current evidence that can contribute to evidence-based practices. It explores the relationship between attachment styles, prenatal attachment, and perceptions of maternal-infant bonding/attachment six weeks postpartum. It also examines the protective factors of maternal-fetal attachment development. The research explores Bowlby's attachment theory and its relevance to maternal-fetal bonding with a Black Feminist Theory lens. Additionally, it discusses the impact of perceived stress, social support, and ecological models on maternal-fetal attachment. The relationship between maternal well-being, maternal-fetal attachment, and early postpartum bonding is reviewed. Moreover, the paper specifically addresses black mothers and maternal-fetal bonding, exploring the intersectionality of race, ethnicity, class, geographic location, cultural identities, and immigration status. It considers the role of familial and partner support, as well as the relationship between maternal attachment style and maternal-fetal bonding, within the framework of attachment theory and black feminist theory. Therefore, it is imperative to center Black women's voices in research, policy, and healthcare practices. Black women are experts in their own experiences and advocate for their autonomy in decision-making regarding maternal-fetal health. By amplifying their voices, we can ensure that interventions are grounded in their lived experiences.

Keywords: maternal-fetal bonding, infant well-being, maternal-infant attachment, black mothers

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Authors: Marek Kociuba, Jarosław Kurek

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Introduction: The digit length ratio (2D:4D) is generally higher in women compared to men. Lower 2D:4D is linked with greater physical ability, strength, and better sporting performance. Second-to-fourth digit lengths ratio (2D:4D) is an indicator of PT exposure. Lower 2D:4D indicates higher PT exposure and vice versa. Methods: The objectives of this paper were to investigate the relationship of 2D:4D with physical fitness in men and women. The study compared 137 female and 174 male students from Wrocław. Besides calculating 2D:4D for each hand, height and weight were also recorded. Assessment of physical fitness and endurance were performed through Eurofit tests. Handgrip strength was measured by a standardized isometric dynamometer. Results: Male participants had significantly lower 2D:4D than females on each hand. A weak relationship between 2D:4D and the results of strength tests was found.

Keywords: 2D:4D, physical fitness, prenatal testosterone, sexual dimorphism

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Authors: Chia-Ching Sun, Li-Yin Chien, Chun-Ting Hsiao

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Background: Appropriate gestation weight gain benefits pregnant women and their children; however, excessive weight gain could raise the risk of adverse health outcomes and chronicle diseases. Nevertheless, there is currently limited evidence on the effect of physical activities on pregnant women’s gestational weight gain. Purpose: This study aimed to explore the correlation between the level of physical activity and gestation weight gain during the second and third trimester of pregnancy. Methods: This longitudinal study enrolled 800 healthy pregnant women aged over 20 from six hospitals in northern Taiwan. Structured questionnaires were used to collect data twice for each participant during 14-27 and 28-40 weeks of gestation. Variables included demographic data, maternal health history, and lifestyle. The International Physical Activity Questionnaire-short form was used to measure the level of physical activity from walking and of moderate-intensity and vigorous-intensity before and during pregnancy. Weight recorded at prenatal checkups were used to calculate average weight gain in each trimester of pregnancy. T-tests, ANOVA, chi-squared tests, and multivariable logistic regression models were applied to determine the predicting factors for weight gain during the second and third trimester. Result: Participants who had achieved recommended physical activity level (150 minutes of moderate physical activity or 75 minutes of vigorous physical activity a week) before pregnancy (aOR=1.85, 95% CI=1.27-2.67) or who achieved recommended walking level (150 minutes a week) during the second trimester of pregnancy (aOR=1.43, 95% CI= 1.00-2.04) gained significantly more weight during the second trimester. Compared with those who did not reach recommended level of moderate-intensity physical activity (150 minutes a week), women who had reached that during the second trimester were more likely to be in the less than recommended weight gain group than in the recommended weight gain group (aOR=2.06, CI=1.06-4.00). However, there was no significant correlation between physical activity level and weight gain in the third trimester. Other predicting factors of excessive weight gain included education level which showed a negative correlation (aOR=0.38, CI=0.17-0.88), whereas overweight and obesity before pregnancy showed a positive correlation (OR=3.97, CI=1.23-12.78). Conclusions/implications for practice: Participants who had achieved recommended physical activity level before pregnancy significantly reduced exercise during pregnancy and gained excessive weight during the second trimester. However, women who engaged in the practice of physical activity as recommended could effectively control weight gain in the third trimester. Healthcare professionals could suggest that pregnant women who exercise maintain their pre-pregnancy level of physical activity, given activities requiring physical contact or causing falls are avoided. For those who do not exercise, health professionals should encourage them to gradually increase the level of physical activity. Health promotion strategies related to weight control and physical activity level achievement should be given to women before pregnancy.

Keywords: pregnant woman, physical activity, gestation weight gain, obesity, overweight

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Authors: Zeynep Karacor, Rahime Hulya Ozturk

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In recent years, the rise of population density and the problem of aging population took attention to the health expenditures. In Turkey, some regulations and infrastructure changes in health sector have occurred. These changes are called Health Transformation Program. The productivity of health services, patient satisfaction, quality of services are tried to be improved with this program. Some radical changes are applied in Turkish economy in this context. The aim of this paper is to present the effects of Health Transformation Program on health expenditures. In the first part of the paper, some information’s about health system and applications in Turkey are discussed. In the second part, the aims of Health Transformation Program are explained. And in the third part the effects of Health Transformation Program on health expenditures are examined.

Keywords: health transformation program, Turkey, health services, health expenditures

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Authors: Wafa Al Jabri

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Background: In Middle Eastern Islamic Countries (MEICs), there is a high prevalence of genetic blood disorders (GBDs), particularly sickle cell disease and thalassemia. The GBDs are considered a major public health concern, especially with the increase in affected populations along with the associated psychological, social, and financial cost of management. Despite the availability of premarital screening services (PSS) that aim to identify the asymptomatic carriers of GBDs and provide genetic counseling to couples in order toreduce the prevalence of these diseases; yet, the success rate of PSS is very low due to religious and socio-cultural concerns. Purpose: This paper aims to highlight the factors that affect the success of PSS in MEICs. Methods: A literature review of articles located in CINAHL, PubMed, SCOPUS, and MedLinewas carried out using the following terms: “premarital screening,” “success,” “effectiveness,” and “ genetic blood disorders.” Second, a hand search of the reference lists and Google searches were conducted to find studies that did not exist in the primary database searches. Only studies which are conducted in MEICs countries and published in the last five years were included. Studies that were not published in English were excluded. Results: Fourteen articles were included in the review. The results showed that PSS in most of the MEICs was successful in achieving its objective of identifying high-risk marriages; however, the service failed to meetitsultimate goal of reducing the prevalence of GBDs. Various factors seem to hinder the success of PSS, including poor public awareness, late timing of the screening, culture and social stigma, religious beliefs, availability of prenatal diagnosis and therapeutic abortion, emotional factors, and availability of genetic counseling services. However, poor public awareness, late timing of the screening, and unavailability of adequate counseling services were the most common barriers identified. Conclusion: Overcoming the identified barriers by providing effective health education programs, offering the screening test to young adults at an earlier stage, and tailoring the genetic counseling would be crucial steps to provide a framework for an effective PSS in MEICs.

Keywords: premarital screening, success, effectiveness, and genetic blood disorders

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Authors: Salma M. Wakil

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Advances in the field of genetics overwhelmed detecting large number of inherited disorders at the molecular level and directed to the development of innovative technologies. These innovations have led to gene sequencing, prenatal mutation detection, pre-implantation genetic diagnosis; population based carrier screening and genome wide analyses using microarrays. Microarrays are widely used in establishing clinical and diagnostic setup for genetic anomalies at a massive level, with the advent of cytoscan molecular karyotyping as a clinical utility card for detecting chromosomal aberrations with high coverage across the entire human genome. Unlike a regular karyotype that relies on the microscopic inspection of chromosomes, molecular karyotyping with cytoscan constructs virtual chromosomes based on the copy number analysis of DNA which improves its resolution by 100-fold. We have been investigating a large number of patients with Developmental Delay and Intellectual disability with this platform for establishing micro syndrome deletions and have detected number of novel CNV’s in the Arabian population with the clinical relevance.

Keywords: microarrays, molecular karyotyping, developmental delay, genetics

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Authors: Wafa Al Jabri

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Background: In Middle Eastern Countries (MECs), there is a high prevalence of genetic blood disorders (GBDs), particularly sickle cell disease and thalassemia. The GBDs are considered a major public health concern that place a huge burden to individuals, families, communities, and health care systems. The high rates of consanguineous marriages, along with the unacceptable termination of at-risk pregnancy in MECs, reduce the possible solutions to control the high prevalence of GBDs. Since the early 1970s, most of MECs have started introducing premarital screening services (PSS) as a preventive measure to identify the asymptomatic carriers of GBDs and to provide genetic counseling to help couples plan for healthy families; yet, the success rate of PSS is very low. Purpose: This paper aims to highlight the factors that affect the success of PSS in MECs. Methods: An integrative review of articles located in CINAHL, PubMed, SCOPUS, and MedLine was carried out using the following terms: “premarital screening,” “success,” “effectiveness,” and “ genetic blood disorders”. Second, a hand search of the reference lists and Google searches were conducted to find studies that did not exist in the primary database searches. Only studies which are conducted in MECs and published after 2010 were included. Studies that were not published in English were excluded. Results: Eighteen articles were included in the review. The results showed that PSS in most of the MECs was successful in achieving its objective of identifying high-risk marriages; however, the service failed to meet its ultimate goal of reducing the prevalence of GBDs. Various factors seem to hinder the success of PSS, including poor public awareness, late timing of the screening, culture and social stigma, lack of prenatal diagnosis services and therapeutic abortion, emotional factors, religious beliefs, and lack of genetic counseling services. However, poor public awareness, late timing of the screening, religious misbeliefs, and the lack of adequate counseling services were the most common barriers identified. Conclusion and Implications: The review help in providing a framework for an effective preventive measure to reduce the prevalence of GBDs in MECS. This framework focuses primarily in overcoming the identified barriers by providing effective health education programs in collaboration with religious leaders, offering the screening test to young adults at an earlier stage, and tailoring the genetic counseling to consider people’s values, beliefs, and preferences.

Keywords: premarital screening, middle east, genetic blood disorders, factors

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Authors: Laila Vivas

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Fossil Health is proposed as a value-concept to describe the hegemonic health paradigms that underpin health enactment. Such representation is justified by Foucaldian and related ideas on biopower and biosocialities, calling for the politicization of health and signalling the importance of narratives. This approach, hence, enables contemplating health paradigms as reflexive or co-constitutive of health itself or, in other words, conceiving health as a verb. Fossil health is a symbolic representation, influenced by Andreas Malm’s concept of fossil capitalism, that integrates environment and health as non-dichotomic areas. Fossil Health sustains that current notions of human and non-human health revolve around fossil fuel dependencies. Moreover, addressing disequilibria from established health ideals involves fossil-fixes. Fossil Health, therefore, represents causes and consequences of a health conception that has the agency to contribute to the functioning of a particular structural eco-social model. Moreover, within current capitalist relations, Fossil Health expands its meaning to cover not only fossil implications but also other dominant paradigms of the capitalist system that are (re)produced through health paradigms, such as the burgeoning of technoscience and biomedicalization, privatization of health, expertization of health, or the imposing of standards of uniformity. Overall, Fossil Health is a comprehensive approach to environment and health, where understanding hegemonic health paradigms means understanding our (human-non-human) nature paradigms and the structuring effect these narratives convey.

Keywords: fossil health, environment, paradigm, capitalism

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Authors: S. Yesmin, N. F.Rahman, R. Akther, T. Begum, T. Tahmid, T. Chowdury, S. Afrin, J. D. Hamadani

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Abstract: Maternal depression is one of the risk factors of developmental delay in young children in low-income countries. Maternal depressions during pregnancy are rarely reported in Bangladesh. Objectives: The purpose of the present study was to examine the efficacy of a community based psychosocial intervention on women with mild to moderate depressive illness during the perinatal period and on their children from birth to 12 months on mothers’ mental status and their infants’ growth and development. Methodology: The study followed a prospective longitudinal approach with a randomized controlled design. Total 250 pregnant women aged between 15 and 40 years were enrolled in their third trimester of pregnancy of which 125 women were in the intervention group and 125 in the control group. Women in the intervention group received the “Thinking Healthy (CBT based) program” at their home setting, from their last month of pregnancy till 10 months after delivery. Their children received psychosocial stimulation from birth till 12 months. The following instruments were applied to get the outcome information- Bangla version of Edinburgh Postnatal Depression Scale (BEPDS), Prenatal Attachment Inventory (PAI), Maternal Attachment Inventory (MAI), Bayley Scale of Infant Development-Third version (Bayley–III) and Family Care Indicator (FCI). In addition, sever morbidity; breastfeeding, immunization, socio-economic and demographic information were collected. Data were collected at three time points viz. baseline, midline (6 months after delivery) and endline (12 months after delivery). Results: There was no significant difference between any of the socioeconomic and demographic variables at baseline. A very preliminary analysis of the data shows an intervention effect on Socioemotional behaviour of children at endline (p<0.001), motor development at midline (p=0.016) and at endline (p=0.065), language development at midline (p=0.004) and at endline (p=0.023), cognitive development at midline (p=0.008) and at endline (p=0.002), and quality of psychosocial stimulation at midline (p=0.023) and at endline (p=0.010). EPDS at baseline was not different between the groups (p=0.419), but there was a significant improvement at midline (p=0.027) and at endline (p=0.024) between the groups following the intervention. Conclusion: Psychosocial intervention is found effective in reducing women’s low and moderate depressive illness to cope with mental health problem and improving development of young children in Bangladesh.

Keywords: mental health, maternal depression, infant development, CBT, EPDS

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Authors: Elaheh Ezami, Behzad Mohammadian, Elham Aznab

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Health service design will need to change due to bringing in new digital health tools. This highlights the importance of innovation in adopting Health Information Technology (HIT). It can be argued that innovation in the health sector correlates with entrepreneurship. Various reasons exist for health entrepreneurs to advocate increased investment in HIT to compensate for shortcomings in the health sector and improve the quality of healthcare. Furthermore, every innovative program presents challenges and motivations for entrepreneurs that may distract or encourage the adoption of technology. Our study used a systematic literature review to identify relevant articles that defined the frustrations and promotions of using health information technology in organizations or enterprises. A meta-analysis of the articles was conducted to identify the factors driving or pulling entrepreneurs to use HIT.

Keywords: health information technology, health entrepreneurship, health enterprise, health entrepreneurs' innovation

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Authors: Leila Maleki, Ahmad Esmali Kooraneh, Hossein Taghi Derakhshi

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Neural activity in the human brain starts from the early stages of prenatal development. This activity or signals generated by the brain are electrical in nature and represent not only the brain function but also the status of the whole body. At the present moment, three methods can record functional and physiological changes within the brain with high temporal resolution of neuronal interactions at the network level: the electroencephalogram (EEG), the magnet oencephalogram (MEG), and functional magnetic resonance imaging (fMRI); each of these has advantages and shortcomings. EEG recording with a large number of electrodes is now feasible in clinical practice. Multichannel EEG recorded from the scalp surface provides a very valuable but indirect information about the source distribution. However, deep electrode measurements yield more reliable information about the source locations، Intracranial recordings and scalp EEG are used with the source imaging techniques to determine the locations and strengths of the epileptic activity. As a source localization method, Low Resolution Electro-Magnetic Tomography (LORETA) is solved for the realistic geometry based on both forward methods, the Boundary Element Method (BEM) and the Finite Difference Method (FDM). In this paper, we review The findings EEG- LORETA about epilepsy.

Keywords: epilepsy, EEG, EEG-LORETA

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Authors: Kinga Zebrowska, Maria Falis, Katarzyna Kosinska-Kaczynska, Bartosz Godek, Olga Plaza, Katarzyna Kwiatkowska

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Introduction: According to the ministerial decree of 16 August 2018, each woman in Poland during childbirth has the right to the pharmacological and non-pharmacological labour pain management (LPM). Aim: The aim of the study was to assess the knowledge of Polish mothers about pharmacological and non-pharmacological LPM, to investigate which methods they chose and their satisfaction with chosen ones. Material And Methods: A prospective cross-sectional study was performed among women who gave birth between 2015 and 2018. The self-composed questionnaire was distributed via the Internet in October 2018. Results: 13.727 women participated in the study. 75% have learned about LPM from the Internet. 68% of them did not gain any information on LPM from doctors during their prenatal appointments Safety of the newborn (46%), midwife’s advice (40%) and the chance of the immediate pain relief (39%) were the most important issues while choosing LPM. Respondents used a wide range of non-pharmacological methods, such as the assistance of partner during labour (81%), physical activity (58%), immersion in water (37%), relaxation techniques (15%) and others. 11% of mothers did not use any of the LPM methods. 52% of women declared that they wanted to use the pharmacological anaesthesia, while 49% had it performed (28% epidural, 16% inhaled anaesthesia, 5% parenteral opioids). Pharmacological methods were unavailable due to lack of anaesthesiologist in the maternity ward (41%) or inaccessibility of the chosen methods in the hospital (31%) and too advanced labour (43%). 48% of respondents did not decide to use pharmacological methods, because the pain was bearable (29%), anxiety of child’s health (17%), or belief that the pain is natural and it should not be avoided (16%). 83% of respondents believed that epidural analgesia has no influence on the time needed to gain a full cervix dilatation and 81% of them claimed that serious spinal cord injury is a common side effect of epidural. 51% believed that epidural increases the risk of caesarean section. Conclusions: The knowledge about the methods of LPM is not satisfactory. We should focus on well- maintained education guided by doctors, midwives, and media.

Keywords: childbirth, labour pain management, maternity experiences, obstetrics

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Authors: Taddese Alemu Zerfu, Melaku Umeta Deressa, Kaleab Baye

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Background: Maternal and child under-nutrition is the underlying cause of 3•5 million annual deaths, globally. Anemia during pregnancy is among the leading nutritional disorders with serious short and long term consequences to both the mother and fetus. Objective: Examine the effect of dietary diversity on maternal anemia, nutritional status and key pregnancy outcomes of pregnancy. Methods: A prospective cohort study design, involving a total of 432 eligible pregnant women, in their second antenatal care visit was conducted between August 2014 to March, 2015. The individual dietary diversity status of mothers was used as the exposure variable to select, enroll and follow the mothers. All mothers were enrolled during second antenatal care visit and followed until delivery. Epi-data, SPSS and STATA software are used to enter and analyze the data. Chi-square test, independent 't'-test, and GLM are used to calculate risk, association and differences between key variables at P < 0.05. Results: Study participants did not differ in many of the basic characteristics (p < 0.05). The incidence of maternal anemia increased significantly from 28.6% to 32.1% between baseline and term. Pregnant mothers with inadequate dietary diversity groups had more (56% at baseline and 68% at term) risk of anemia than the comparison (adequate) groups, (RR, 1.56 and 1.68; 95% CI, 1.24 - 1.83 and 1.39 - 2.04). The overall incidence of still birth, low birth weight and pre-term birth was 4.5%, 9.1% and 13.6%, respectively. The variation of these outcomes was significant across study groups (P < 0.05). Conclusion and recommendations: Dietary diversity status of pregnant mothers has significant effect on the incidence of anemia and key pregnancy outcomes in resource limited settings, like rural Ethiopia. Therefore, apart from the ongoing routine IFA supplementation, special emphasis should be given to dietary diversity of mothers to improve related outcomes of pregnancy and maternal health.

Keywords: anemia, birth weight, dietary diversity, pregnancy, pregnancy outcome

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Authors: Ayşe Coban, Orhan Coban, Haldun Soydal, Sükrü Sürücü

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While health is a source of prosperity for individuals, it is also one of the most important determinants of economic growth for a country. Health, by increasing the productivity of labor, contributes to economic growth. Therefore, countries should give the necessary emphasis to health services. The primary aim of this study is to analyze the changes occurring in health services in Turkey by examining the developments in the sector. In this scope, the second aim of the study is to reveal the place of health expenditures in the Turkish economy. As a result of the analysis in the dataset, in which the 1999-2013 periods is considered, it was determined that some increase in health expenditures took place and that the increase in the share of health expenditures in GDP was too small. Furthermore, analysis of the results points out that in financing health expenditures, the public sector is prominent compared to the private sector.

Keywords: health, health service, health expenditures, Turkey

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