Wednesday 31 May 2023

Lupine Publishers | Paediatric Dentistry and Prevention from Teenage Pregnancy

 Lupine Publishers | Interventions in Pediatric Dentistry Open Access Journal


Abstract

Medical specialties have paid little attention to the teenage stage, including Dentistry. If to this we add the teen pregnancy trends due to economic, social or cultural circumstances, the results are young women with a high prevalence of caries, periodontal disease and early tooth loss.

Objective: To detect teenagers at risk through different educational institutions such as churches, health centers, sports clubs, etc.

Situation Analysis: The field study revealed a worrying number of adolescents who drop out of school or job due to pregnancy at a young age.

Intervention Strategies: Three different levels of prevention were stablished

a) Primary prevention: measures intended to prevent teenage pregnancy.

b) Secondary prevention: measures adopted when there was evidence of an ongoing pregnancy.

c) Tertiary prevention: measures taken to promote school reinsertion and reintegration into the labor market.

Results: Teachers, doctors, dentists, obstetricians, physical therapists, neonatologists and pediatricians worked in a multi and interdisciplinary way in order to educate and promote healthy living, and to avoid risk situations in this age group.

Keywords: Teenage pregnancy; Caries; Oral health; Education; Prevention

Abbreviations: UNFPA: United Nations Population Fund in Argentina; UNICEF: United Nations International Children’s Emergency Fund

Introduction

The topic to be developed is about an issue which has arisen in important sectors of young people from Chaco. Around sixteen million of young women between the ages of fifteen and nineteen give birth each year - roughly eleven percent of all births worldwide. Complications related to childbirth and pregnancy is the main cause of death among adolescent girls, especially in developing countries. In Latin America, ten percent of girls aged fifteen to nineteen are mothers. In Argentina, the number of teenage pregnancies has increased since 2001, representing a sixteen percent of pregnancies. The percentage recorded in some areas such as the Argentinian northeast and west was twenty five percent [1]. Teenage motherhood and fatherhood are more frequent among young, poor people who have a lower educational level. Eighty percent of teenagers who don’t have children attend school regularly, while twenty five percent of teenagers who have children don’t. The number of teenage mothers with incomplete primary education trebles the number of those with incomplete secondary education [2]. The national legislative framework contains rules as the Law 25.673 which ensures that young people have the right to access to sexual and reproductive health. The Law 26.150 states that individuals have the right to receive sexual integral education from elementary to superior level studies. The Laws 25.58 and 25.273 provide that the continued attendance at school of pregnant students is guaranteed. Carlos Dabalioni, Director of Children and Adolescents Department of La Plata City Hall, Buenos Aires, has stated that, although in some cases pregnancy is the result of misinformation, it goes beyond mere teaching teenagers how to take care of themselves; because the problem is, in many cases, the lack of social and family support. To many women, having a child is their only asset, the chance to have the family they didn’t have when they were younger, the only way to keep their partners or give the baby all they lacked. When that kind of support is missing, there is no point trying to teach young women how to take care of themselves. UNICEF’s Regional Office for Latin America and the Caribbean has claimed that “UNICEF is committed to focusing its efforts on the phases of adolescence as the opportunity to develop individual skills and abilities in favorable and safe surroundings, so as to enable the adolescent to contribute to and participate in the family, school, community and society” [3].

Adolescence Stages

Adolescence can be divided into three different stages, which entails different ways to deal with pregnancy:

Early adolescence (10 -13 years old):

a) Strong connection with the mother.

b) Denial of pregnancy.

c) Depression and social isolation caused by unplanned maternity.

d) The father is absent from the mother’s plans and decisions.

Middle adolescence (14-16 years old):

a) The mother sees the child as her possession and as an instrument to show independence from her parents.

b) Ambivalent attitude: blame and pride.

c) The father is given a more important role. He’s considered as a hope for the future.

Late adolescence (17-19 years old):

a) Adaptation to the reality impact.

b) Feelings of motherhood.

c) Search for affection, commitment, dedication from the baby’s father.

d) Mother’s desire to have a settled life with her partner.

It is important to highlight that a teenage pregnant won’t reach mental and emotional maturity earlier than expected. She will behave in accordance with the stage she is going through [4]. Consequences of an Unplanned Pregnancy

a) High risk of maternal mortality

b) Higher possibility of premature births

c) Risk of having a child with low birth weight

d) Difficulties in completing studies and having a life project.

At a global level, increased morbidity during teenage pregnancy is caused by:

a) Abortion

b) Anaemia

c) Urinary infection

d) Asymptomatic bacteriuria

e) Gestational hypertension

f) Preeclampsia – Eclampsia

g) Little weight gain

h) Maternal malnutrition

i) Haemorrhage associated with placental conditions

j) Preterm birth

k) Preterm rupture of the membranes

l) Cephalopelvic disproportion

m) Caesarean section

Levels of Prevention<./

Primary Prevention

The first level concerns the application of measures to prevent unplanned teenage pregnancy.

a) Information distribution about gradual and sequential reproductive physiology not only in school but also in all areas.

b) Appropriate use of mass media.

c) Fostering strong parents/school-children communication and collective reflection on adolescence issues.

d) Training of people who often deal with high-risk young people who quit school or job in order to help them reintegrate fully into society.

Secondary Prevention

The second level concerns the actions that should be taken if there is an existing pregnancy.

a) Activities to improve maternal health through the promotion of pre-natal and post- partum health care programmes for teenage mothers.

b) Assistance should be given to the teenage father, helping him to assume his social role.

c) Psychological support and information should be provided to young mothers who decide to place their children for adoption.

Tertiary Prevention

The third level concerns the monitoring of the mother/fatherchild bond and the support and fostering the parents’ reinsertion in the labor market. At an educational level, the emphasis is placed on the relevance of speaking about sexual and reproductive health with teenagers and their friends, parents, teachers and trustworthy adults, teaching teenagers how to resist social pressures and delay onset of sexual activity to prevent sexually transmitted diseases and unplanned pregnancies, teaching teenagers to support those who decide not to have sexual relations (they have to be prepared to say no and act firmly when faced with risk situations or threats), raising awareness about the importance of condom use during intercourse to ensure their protection, keeping reminding young people that they should avoid drinking alcohol or taking drugs when they are with their partners, so that they can make right and responsible decisions regarding sexuality and sexual behaviors, and promoting safe, healthy and responsible sexuality. Teenage pregnancy can be prevented, not cured. If an unplanned pregnancy happens, parents play a vital supportive role. They should teach their children to behave responsibly and confront life difficulties.

Caries Prevention during Pregnancy

It is well known that teeth and gums are affected during pregnancy since hormonal changes have a great impact on women’s gums. These may bleed spontaneously, be itemized and red, causing halitosis. There is a higher risk of tooth decay during pregnancy because of nausea, vomiting, reduced saliva pH and secretion, anxiety, and higher consumption of sweets. Caries can be prevented by adopting a good oral hygiene (for at least 2 minutes), brushing the teeth three times or more per day, consuming calcium-rich foods (such as milk, yogurt, cheese), proteins (meat, eggs), vitamins and minerals (fruits, vegetables, cereals, beans), avoiding sugary foods and drinks, and visiting the dentist once each trimester during pregnancy. Babies are born free from bacteria that cause tooth decay. Bacteria are spread through saliva when the mother kisses the baby in the mouth, or cleans the bottle or the pacifier, also when the baby’s first teeth appear. Babies shouldn’t sleep with the bottle in the mouth. The sugar contained in milk together with the bacteria produce an acid that can eat through the teeth, leading to dental enamel damage. To eliminate or reduce caries risk factors in the baby is necessary to use a mouthwash-soaked gauze to clean inside the baby’s mouth after breastfeeding or drinking from a baby bottle, brushing their teeth from the first moment they appear and visiting the dentist with the baby so they can monitor your child’s oral health from birth and every six months.

Materials and Methods

A Mother-Child Programmed was implemented in health centers, with the multidisciplinary professionals’ participation. Dental care and prevention were taught through games, as well as pre- birth gym. Efforts were made to empower individuals and government agencies, civil associations, academic institutions and the private sector.

Results and Discussion

The present research is based on data field extracted from the UNFPA, an international cooperation organism for development formed in 1969. It has been running in Argentina since 2003, promoting women, men and children’s rights to enjoy a healthy life and equality of opportunities [5]. In 2018, the UNFPA struggled to achieve 3 transforming, ambitious goals which promise to change every man, woman and child’s life: to put an end to the family planning unsatisfied need, to the gender violence [6] and to the preventable maternal death [7].

Conclusion

Early pregnancy and motherhood are strictly linked to human right issues. A pregnant child is pushed to drop out school. In all regions of the world, poor children with lack of education and living in rural areas are at risk of getting pregnant. Pregnancy can have devastating effects on the young mother’s health. Many teenagers are not physically prepared to get pregnant or deliver; therefore, they are more vulnerable to complications. Besides, teenage pregnancy has tremendous costs in girls’ education and incomes potential. In Argentina, efforts are being made to prevent teenage pregnancy, trying to change factors such as inequality of gender, poverty, sexual violence and coercion. Such an approach must include provision of suitable, integral sexual education for every young man and woman, as well as investment in girls’ education and measures to guarantee the access to information about sexual and reproductive health and services to facilitate young people’s life choices.

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Tuesday 30 May 2023

Lupine Publishers | Anxiety and Language Development Correlation in Hearing Impaired Children

 Lupine Publishers | Journal of Otolaryngology


Abstract

Background: Hearing is critical for normal development and acquisition of language and speech and Hearing impairment exists when there is diminished sensitivity to the sounds normally heard. Several studies have suggested that one out of every two to three school-aged children with any degree of hearing impairment have academic, social, and behavioral difficulties. Purpose: To compare the degree of hearing loss regarding the Anxiety Related Emotional Disorders of hearing-impaired children and correlates this to language scale.

Methods: 75 children divided equally to three groups, mild, moderate and severe hearing impaired Arabic speaking children aged between 6 to 8 years were included in this study and were subjected to psychometric evaluation, audiological assessment, Arabic language scale, and The Screen for Child Anxiety Related Emotional Disorders (SCARED) questionnaire(Arabic version).

Results: Hearing-impaired children showed more language, emotional difficulties, and spent less time communicating than children with normal hearing. The lowest academic, social, and emotional scores were in severe hearing-impaired group than in the other two groups.

Conclusion: Even slight/mild hearing impairment can result in negative consequences in the psychological, social, and emotional and there is significant relationship between delayed language, anxiety, and child emotionalrelated problems.

Keywords: Hearing Impairment; Psychological; Anxiety; Emotions; Language; Speech

Introduction

Hearing, auditory perception, or audition is the ability to perceive sound by detecting vibrations changes in the pressure of the surrounding medium through time, through an organ such as the ear [1]. Hearing is critical for normal development and acquisition of language and Speech [2]. Hearing impairment exists when there is diminished sensitivity to the sounds normally heard [3]. According to Smith, the term hearing impairment is usually reserved for people who have relative insensitivity to sound in the speech frequencies [4]. The severity of a hearing impairment is categorized according to the increase in volume above the usual level necessary before the listener can detect it. Along the world approximately one child in 1,000 is hearing impaired from birth, and the number rises to about 1.6 per 1,000 in adolescents. The causes are hereditary in 30-39%, acquired in 19-30% and the cause remains unknown in 31-48% of children [5]. Language plays a central role in development. It is not only the medium for social exchange, but aids in internalizing social norms and the development of behavioral control [6]. Hearing impaired children do not acquire language and speech the same as normal hearing children because they cannot hear the language spoken around them. In normal language acquisition, auditory comprehension precedes the development of language [7]. So, children who have hearing impairment as they move into school are at risk of a raft of difficulties. Impacts of poor oral language skills go well beyond early literacy development and ‘school readiness’s to increasingly apparent associations with emotional, behavioral and social difficulties [8]. Hearing impaired children can be viewed as being different from the majority because of their observable hearing aids, use of sign language, and/or their distinct speech production. Moreover, hearing impaired children’s language problems and impaired socially skilled behaviors have been frequently reported. Refs [9,10] reports that school-aged children who are hearing impaired may be as much as five times more likely to suffer from emotional disturbance, defined as a pattern of behavior that deviates from the acceptable patterns of behavior in school that impact their ability to maintain normal social relationships. Questionnaires are frequently used in quantitative Marketing research and social research. They are a valuable method of collecting a wide range of information from a large number of Individuals often referred to as respondents. Adequate questionnaire Construction is critical to the success of a survey [11].

Objectives

The aim of this work is to compare between the different degrees of hearing loss regarding the Anxiety Related Emotional Disorders of hearing-impaired children and then correlate the data to their language scale.

Subjects & Methods

This research was conducted during the period between the months November 2018 and September 2019. The study protocol was approved by the Otolaryngology Department Council of King Abd Alaziz Specialized Hospital, Jouf, Saudi Arabia. Consent to participate in this research was obtained from the subjects’ parents before commencement of the study. This study was applied on 75 child, 53 males and 22 females. Their ages ranged from [72m (6 years) to 93m (7 years and 3m)] with a mean (81.15±5.53) diagnosed as hearing impairment. They were divided into three equal groups each one consists of 25 patients.

a) Group A? (mild hearing impairment) consisted of 16 males and 9 females with age range (72m-93m) with a mean (80.08±5.83).

b) Group B? (moderate hearing impairment) consisted of 19 males and 6 females with age range (72 m-90 m) with a mean (82.96±5.22).

c) Group C? (severe hearing impairment) consisted of 18 males and 7 females with age range (72m-90m) with a mean (80.40 ± 5.29). The subjects were randomly selected from a group of typically developing children in Nurseries and schools in Jouf area. All children were coming from Families of moderate socio-economic status. They were all reported to be free from profound hearing impairment (>90db) or those with cochlear implantation, hearing impairment with other psychological disorder (Autism, ADHD), neurological or physical handicap e.g. BDMH (brain damage motor handicap) and serious medical/chronic problems. The children were diagnosed as sensorineural or conductive hearing loss: (Mildmoderate- moderate to severe and severe), all the children were fitted with either unilateral or bilateral hearing aids (according to their audio logical needs) with regular use and follow up and with minimum two years ago. Arabic spoken as a primary language (monolingual Arabic-speaking family, where Arabic is the primary language) and regular use of satisfactory hearing aids and language rehabilitation sessions twice 20 minutes per week for minimum one year. All children were subjected to the following protocol of assessment: Audio logical assessment: Many formal audio logic testing to determine the type and etiology of hearing loss and the optimal treatment plan, such as, e.g. Auditory Brainstem Response (ABR) and Pure Tone Audiometry to measure the degree of hearing impairment then classify them accordingly to mild 20-40 dB, moderate 41-70 dB and sever 71-95dB. Psychometric and cognitive assessment by Stanford-Binet Intelligence Scales Fourth Edition (SB: FE): [12]. Language assessment by Language scales [13].

Screen for child anxiety related emotional disorders (SCARED)

The Questionnaire was translated to Arabic language and back translated by two of the psychiatric staff. Then pilot study was done for checking and is sure of its reliability although it is already applied on normal hearer attending to psychiatry department so, there was no mandatory need for control group. The SCARED has 41 sentences describing various feelings and behaviors possibly associated with anxiety symptoms [14]. The SCARED was chosen to measure the children for anxiety disorder SCARED could significantly discriminate between anxious and depressed children. Items that can be grouped into five subscales. Four of these subscales measure anxiety disorder symptoms as conceptualized in the Diagnostic and Statistical Manual of Mental Disorders DSM-IVTR: panic disorder, generalized anxiety disorder, separation anxiety disorder, and social anxiety. The Scared questionnaire in this study rated each symptom on a 3-point scale: 0 (no), 1 (sometimes), or 2 (yes).The subscales of the questionnaire are: panic disorder (13 items), generalized anxiety disorder (9 items), separation anxiety disorder (8 items), and social anxiety (4 items), and school anxiety (4 items). A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher that 30 are more specific.

a) A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms.

b) A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder.

c) A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate

d) Separation Anxiety Disorder.

e) A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder.

f) A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance.

The data was collected, coded and entered to computer. The data was analyzed with the program (SPSS) statistical package for social science version 16 under windows 7. Statistical tests used in this thesis were: description of qualitative variables by frequency and percentage, description of quantitative variables in the form of mean and standard deviation (mean ± SD) and Chi-square (x2) test was used for comparison of qualitative variables with each other. Comparison between quantitative variables was carried by using Student t-test of two independent samples while ANOVA test was used for more than two independent samples. The differences were considered significant if p<0.05. Spearman-rho method was used to test correlation between numerical variables (r > 0.3=no correlation, r=0.3-0.5=fair correlation, r=0.5-0.1=good correlation).

Results

Sex and age distribution for each group regarding mean and SD show no significant difference. Table 1 shows that there is significant difference between the three groups A, B and C (mild, moderate and sever hearing impairment) as regard the total language age. Also, there is significant difference between the three groups A, B and C (mild moderate and sever hearing impairment) as regard the IQ (Table 2). Figure 1 shows the subtypes of Child Anxiety Related Emotional Disorders (SCARED) test regard no. and % shows significant difference between the three groups A, B and C (mild, moderate and severe HI) in generalized and social disorders (p=0.0001). There was no significant difference between the three groups in panic (p=0.353), separation and school avoidance disorders (p=0.191). Figure 2 shows significant positive correlation between all children chronological ages (the three groups A, B and C) and their total language ages (R=0.0288). Figure 3 shows highly significant positive correlation between IQ scores of all children (the three groups A, B and C) and their total language ages (R=0.716). Figure 4 shows negative correlation between total language ages and Child Anxiety Related Emotional Disorders (SCARED) (R=- 0.197). Figure 5 shows significant negative correlation between anxiety scores and IQ total scores (R=0.422) of all children (the three groups A, B and C).

Figure 1: Subtypes of anxiety test regard no. and % shows significant difference between the three groups A, B and C (mild, moderate and sever hearing impairment) in generalized and social disorders (Value=0.0001) and there was no significant difference between the three groups in panic (Value=0.353), separation and school avoidance disorders (Value=0.191).

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Figure 2: Shows significant positive correlation between all children chronological ages (the three groups A, B and C) and their total language ages (R=0.0288).

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Figure 3: Highly significant positive correlation between IQ scores of all children (the three groups A, B and C) and their total language ages (R=0.716).

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Figure 4: Significant negative correlation between total language ages and Child Anxiety Related Emotional Disorders (SCARED) (R=-0.197).

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Figure 5: Significant negative correlation between anxiety scores and IQ total scores (R=0.422) of all children (the three groups A, B and C).

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Table 1: Significant difference between the three groups A, B and C (mild, moderate and severe hearing impairment) as regard the total language age.

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Table 2: Significant difference between the three groups A, B and C (mild, moderate and sever hearing impairment) as regard the IQ scores.

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Discussion

Hearing is critical for normal development and acquisition of language and speech. Hearing impairment in children may affect the development of behavior and language and can cause work related difficulties for adults [15]. Hearing loss brings with it some emotions and psychological problems before acceptance of the loss. These emotions can include denial and anger, as well as a sense of isolation [16]. All children with different degrees of hearing impairment had delayed language development and this can be explained by the interference of hearing impairment with the child detection and recognition of speech as well as the development of auditory skills that are prerequisites of the development of receptive and expressive language skills, as well as speech intelligibility [17]. Such auditory skills include detection, discrimination, recognition, comprehension, and attention and in turn, a delay in the early development of these auditory skills caused by hearing loss negatively impacts child’s ability. To learn and use an auditory-oral language system [18]. Strong positive associations between the degree of hearing impairment and language skills were proved and mild hearing-impaired children had better receptive and expressive language than the other two groups. So, their total language ages were highest than the other two groups. These results were also found by Halliday and Bishop [19] who discovered that even subtle deficits in sound processing can lead to marked impairments in language development and severe hearing impairment in childhood often leads to marked delays and deficits in the acquisition of spoken and written language.

However, children with mild hearing impairment usually attend regular schools and communicate with the others and when these children receive hearing aids, they usually find that school is easier, and their school performance improves. But the other two groups entail not only lowered hearing thresholds, but also distortion of sounds, and this means that language input is partial and degraded in spite of the significant positive correlation between the children chronological ages and their total language ages, the older the child age, the higher the speech perception abilities whatever the degree of hearing impairment and the higher its ability to learn [20]. These results were also found by Halliday and Bishop [19] who discovered that even subtle deficits in sound processing can lead to marked impairments in language development and severe hearing impairment in childhood often leads to marked delays and deficits in the acquisition of spoken and written language. However, children with mild hearing impairment usually attend regular schools and communicate with the others and when these children receive hearing aids, they usually find that school is easier, and their school performance improves. But the other two groups entail not only lowered hearing thresholds, but also distortion of sounds, and this means that language input is partial and degraded in spite of the significant positive correlation between the children chronological ages and their total language ages, the older the child age, the higher the speech perception abilities whatever the degree of hearing impairment and the higher its ability to learn [20]. Children intelligence quotient (IQ) scores and their determinants are generally considered predictors of eventual school performance, quality of life, and psychiatric morbidity. Focusing on the relationships between the cognitive assessment (IQ) and the three groups of the study, it will be found that IQ scores range between below average and dull average in hearing impaired children whatever the degree of hearing impairment with strong positive associations between the IQ score and the degree of hearing impairment as mild hearing impaired children have higher IQ than the other two group which is in agreement with Welch D, Dawes PJ (2007) who discovered that even slight to mild hearing loss (<30db) has been documented to have lifelong effects. Among children with losses <15db HL i.e., whose hearing is considered normal, some research has found that slight fluctuations in auditory perception affect neurocognitive outcomes [21]. Children with severe hearing impairment may have a higher frequency of poor cognitive and academic performance when compared with children with mild or even moderate hearing impairment. Also, the descriptive analysis shows highly significant positive correlation between cognitive assessment (IQ) and total language ages in the hearing-impaired children, the higher the language age the higher the IQ score.

As primary reasons why students with hearing deficits perform, on average, lower than their peers on cognitive assessments such as IQ tests, language and communication skills of these hearing impaired children are often delayed due to their disability and these students’ language skills and reading level are lower than average, which may also affect cognitive skills which was proved by Gallaudet Research Institute (2003) who proved that an estimated 40% of children with hearing loss have additional impairments that affect education and adaptive development and children with hearing impairment may have a higher frequency of language problem and had significantly lower intelligence coefficients when compared with children with normal hearing [22].

The descriptive analysis shows that hearing-impaired children -whatever the degree of hearing impairment fell lonely event if they are mild hearing impaired without significant different between the three groups because children feel that they are different from their peers and start to avoid them. Also limited access to services and exclusion from communication can have a significant impact on everyday life, causing feelings of loneliness, isolation. So, even slight/mild hearing impairment can result in negative consequences for the bio psychosocial development of children who often report feeling lonely, without friends and unhappy in school [23]. Anxiety is a normal human emotion that everyone experiences at times. Many people feel anxious, or nervous, when faced with a problem at work, before taking a test, or making an important decision. Anxiety disorders, however, are different; they can cause such distress that it interferes with a person’s ability to lead a normal life [24].

Hearing impaired children with anxiety disorders had an increased physical and psychological reaction to stress. Their reaction to danger, even if it is a small one, is quicker and stronger [25]. Research question investigated the feeling of anxiety in hearing impaired children and the analysis shows that the three groups has different degrees of anxiety feeling and each group shows number of children with anxiety. Mild hearing-impaired children have less anxiety feeling than the other two groups. Mild hearing-impaired children have less disability and better communication than the other two groups which lead to less stress and anxiety disorder, so the results are expected. Knutson et al. [26] found that the risk for clinically significant emotional distress and anxiety disorder (generalized anxiety disorder, social, separation, school avoidant disorder, and panic disorder; each has its own characteristics and symptoms) was two to four times higher among persons with hearing impairment than among persons with normal hearing. These results were also founded by Castrogiovanni [27] who found that school-aged children with any degree of hearing impairment have academic, social, emotional and behavioral difficulties because hearing impaired children, even with a minor degree, often miss information during play and are a target for bullying (person who is curl to other). Strong negative correlation between language and cognitive scale with anxiety disorder is expected that hearing impaired children, who experience significant disruptions in auditory input, are likely to show delays not only in the production of oral language but in other important aspects of development such as anxiety, emotion and behavioral control. With regard to socio-emotional aspects, Zandberg [28] studies have reported that hearing impaired children encounter difficulties acquiring spoken language, which often affects their communication abilities and social development. In turn, the children’s friendship relations and social feelings and mild hearing-impaired children have better language and cognitive scale than moderate or severe ones and the more the affected the child with hearing impairment the more the behavior problem and anxiety disorder or even other psychological interruptions. In addition to a small samples size, the limitations differed across a variety of factors such as duration of deafness, previous degree of benefit from hearing aids, mode of communication, device settings, and age.

Conclusion

Children with hearing impairment-whatever its degreeface multiple concurrent health, developmental, communicative and exhibit anxiety and emotional problems when they do not understand what is going on around them. Without appropriate interventions, these children are at risk of developing mental health disorders.

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Monday 29 May 2023

Lupine Publishers | Effects of Urban Farming Practices on Income Poverty Reduction in Dodoma Municipality, Tanzania

 Lupine Publishers | Journal of Agriculture and Current Research


Abstract

The main objective of this paper is to reveal the less known effects of urban farming practices on income poverty reduction in Dodoma Municipality, Tanzania. Collected primary and secondary data were analyzed both manually and by the use of SPSS software in which descriptive statistics and multiple responses presented by frequencies and cross tabulation employed. The findings show that the male raised higher income (61.7%) compared to women (38.3%) resulted from urban farming practices. It also shows that the majority of urban farmers use rain water compared to other sources of water. The capital availability found to be a problem (73.3%); has income below TZS 90,000 per month. The study also revealed that urban farmers use poor technology in farming activities. However, the study found that urban farmers practice agro-forestry which help to prevent land degradation and to enrich soil fertility as well as acting as wind breakers and shade provision. It was found that, though urban farming practices contribute to reduce income poverty in the study area but there are some factors which found to hinder the improvement of urban farming such as inadequate water supply, inefficiency laws and by laws and lack of improved seeds due to insufficient capital. These problems can be minimized through early seed provision from government and NGOs, use of irrigation technology rather than depending on rainfall, efficiency and effectiveness implementation of laws and by-laws and increase area for urban farming as population increase in Dodoma municipality due to concentration of colleges/universities and government activities.

Keywords: Urban farming; Urban famers; Income poverty; Land degradation

Introduction

Background information

farming is very extensive in urban areas in developing countries. Urban farming includes activities such as crop farming, vegetables, gardening, livestock keeping and poultry. It is estimated that; urban farming is practiced by about two thirds of urban workforce in developing countries [1]. Urban farming could contribute to mitigating the two most intractable problems facing third world cities which are poverty and waste management. Urban farming is one of several food security options for households. Similarly, it is one of several tools for making productive use of urban open spaces, treating urban waste, saving or generating income and employment and managing fresh water resources more effectively ibid, 2000.

The main motivation for urban farming is food production and/or higher income for personal consumption or sale ibid, 2000. Tanzania economy is still depending on agriculture as its main stay. In the year 2015, the contribution of the agriculture to the total GDP has been around 29%, and contributed 70% to the total employment and 55% of the country’s foreign currency [2]. Dodoma urban as one of the semi-arid areas in the country, through municipal councils’ authorities set strategies on encouraging farmers to put priority on production of drought resistant crops such as cassava, millet, sorghum and sunflowers in all areas with an annual rainfall between 400mm-600mm (Municipal Agricultural and Livestock Development Officer, 2016). In Miyuji ward there was more than 13.6 hectares which were used for growing grapes and other plants but now only 6.2 hectares are used for these activities (Dodoma Municipal Report, 2016). This shows that there is a decrease in urban farming practices in Miyuji ward more than half of the area which planned for agriculture.

Statement of the problem and significance of the study

Dodoma municipal council has 196,000 hectares suitable for cultivation but only 137,200(70%) hectares have been cultivated. Out of cultivated area, 11433(12%) hectares are used for urban farming and only 1509(1.1%) hectares are used by small farmers in Dodoma municipal council. Urban farming in Dodoma was mostly practiced by farmers in Miyuji, Msalato, Veyula, Mzakwe, Makutupora and other areas in Urban and Peri-Urban (Dodoma Municipal report, 2016). About 68% of the estimated 16,579 human population (2016) in Miyuji ward are relying on arable farming and livestock keeping.

The ward estimated to have 3832 hectares of arable land but only 1734.7 hectares are used for farming (Miyuji WEO office report, 2016).Despite of the hectares used for urban farming in Miyuji ward is being decreasing, yet the living standard of people, especially urban farmers, is very poor in the ward. Therefore, this study intended to examine the effects of urban farming practices on income poverty reduction in Dodoma municipality. The findings of the study will be useful in reducing income poverty to urban farmers by promoting urban farming through identified constraints and opportunities facing urban farming practices and formulating competent national policies which will be used in improving urban agriculture, and help to add literature related to urban farming.

Research objectives

General objective: The main objective of this research was to examine the effects of urban farming practices on income poverty reduction in Dodoma municipality.

Specific Objectives: Specifically, the study was intended to:

Examine factors affecting the performance of urban farming practices in the study area

Examine contribution of urban farming on income poverty reduction in the study area.

Examine the effects of urban farming on the environment in the study area.

Conceptual framework

The primary interested variable of this study is the dependent variables which is assessment of urban farming practices. The intermediate variables will be used in attempt to explain the dependent variables; these variables are amount of inputs, farmers’ income, Extension services and farming practice. Independent variables acting on and operating through intermediate variables which cause or determine or influence dependent variable to occur. The Figure 1 below shows the conceptual framework in a clear and simple way.

Figure 1: Conceptual Framework of the Study.

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Research Methodology

The study area

The researcher chooses Miyuji ward as the study area in Dodoma municipality due to the fact that, it is among the area which urban farming practices were given priority and there were planned land for such activities (Dodoma Municipal council report, 2016). Miyuji ward is located in urban area of Dodoma Municipality which lies between Latitude 60–6030/ South and longitude 3503/–36002/ East. Dodoma Municipality has an area of 421km2 of which 346km2 is arable land, 57.1km2 is residential and industrial area 17.9km2 occupied by natural resources and planted forests, mountains and non-arable land (Figure 2). According to projection basing on year 2012 population census, the current population of Dodoma municipality accounts to 446, 579 inhabitants, where by 240, 481 inhabitants live in urban areas and 206, 098 live in peripheral zone consisting of villages. The population size of Miyuji ward in 1988 was about 14,288; 2002 was about 15,779; and 2012 was about14, 965. This situation shows that the size of Miyuji was dramatically decline for about -0.47%/year from 2002 to 2012.

Figure 2: Map of the study area.

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Data types and sources

Both primary and secondary data were used. Primary data such as income levels and farm sizes were collected in Miyuji ward by using household questionnaire. Secondary data such as number of extension workers, number of market centers were collected from street and ward executive offices by reading different reports and documents existent.

Sampling design

Sampling frame: A list of all households was used to pick respondents where a sample of 70 respondents was taken to represent the total population. Judgmental sampling was categorizing samples into different groups such as household with large arable land, household with small arable land, local leaders, extension workers (EW) and District Agricultural Officer (DAO)

Sampling unit: The sampling unit for this study was a household.

Sample size: The sampling size for this study was 100 (Table 1), which involves 90 households and key informants. Yamane (1967), provides a simplified formula for calculating sample size as follows:

n=N/1+N(e)2

Where: n=Sample size

N=Population size (Number of households in my case)

e=Level of Precision

In Miyuji ward: N=3684

e= 10% as recommended to social sciences

n=3684/1+3684(0.1)2

n= 97~100 households

Sampling procedure: Both probability and no-probability sampling techniques was used.

Probability sampling: The method was used to obtain the sample required by employing stratification where the population was divided into a number of homogenous sub-population and a sample helped the researcher to obtain 90 respondents.

Table 1: Respondent Sample Composition.

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Non-probability sampling: The method was used to obtain the sample required by employing purposive sampling technique to select the 10 sample required to meet the objectives includes selection of AO (Agriculture Officers), MEOs (Mitaa Executive Officers), and WEO (Ward Executive Officer).

Data collection methods

Both primary and secondary data collection methods were used.

Primary data: Primary data was collected by using the following methods:

Interview: Structured questionnaire was used to enable face to face meeting in which the interviewer asked the interviewee questions and recorded responses. This method was used to obtain information from different respondents.

Observations: The method was used by visiting the selected areas to observe different things related to study such as how urban farming is practiced.

Focused group discussion: Focused group discussion enabled respondents to express and exchange their views on how they practice urban farming. This group involved Mtaa C/p, Extension officer, and few urban farmers. Group of not more than 25 people is recommended since they will be difficult to manage [3]. Fourteen respondents were invited to participate in focus group discussion for Miyuji ward as follow; Ward executive officer (1), Mtaa government chairpersons (3), Mtaa executive officer (3), Ward agriculture extension officer (1), and prominent urban farmers (6). Group discussions were conducted in a ward executive office where flip charts and marker pens were available after seeking permission from ward authorities. Questions were written on the flip chart, and the chairman who was elected by the participants guided the discussions by first reading the questions loudly for every member to hear and allowed for contributions through raising a hand. The group leader’s role also was to make sure that one person does not dominate and influence the discussion. The researcher took notes as well as probing questions when judged that the respondent’s statement was ambiguous. The information collected was used to supplement the household questionnaire.

Secondary data: Secondary data was gathered through.

Documentary review: The method was involving reading various published and unpublished materials related with the study. These materials include internet, books, Magazine, newspaper and Journals.

Data Processing, analysis and presentation

Data processing: Data was processed both manually and by computer using SPSS (Statistical package for social sciences) and MS-Excel where the exercise involved editing questionnaires, coding, clearing and verifying the entered data for easy interpretation.

Data Analysis: The data was analyzed manually and by the use of SPSS Version 11.5 software. Bivariate analysis technique was used in which the researcher examined the relationship between two variables for example farm size and Household income by the use of Cross- tabulation method.

Data presentation: The results from the research are presented by using charts, tables and graphs.

Limitations of the study

Time was not enough to cover the whole ward instead only 3 streets (mitaa) were represented.

Some respondent especially key informants were reluctant to give out the needed information as they thought that, they will be responsible when the wrong things/issues concerned with urban farming been recognized by the institution, however observation and literature review overcome this difficult.

Disturbances/bureaucracy of getting permission to conduct research in a study area.

Results and Discussion

General characteristics of the respondents

The study population comprised of males and females with different ages, family size and education background (Table 2). Of the household heads interviewed, 53.3% of the respondents were between 35-44 years old and 46.7% were between 25-34 years old. This was important because these age groups are the one who practice urban farming; understand the historical trend of their areas as well various indigenous technical knowledge. The study mitaa were found to have large household sizes. Results show that 55.6%have 6-10 persons per household and 44.4% have 1-5 persons. This is due to the behavior and culture of excluding family plan, of which results into a lot of dependents to feed and take care of Education background of the surveyed population is mainly primary education (90.0%), very few had college education (6.7%), and 3.3% had secondary education. Despite of having primary and secondary schools but the number joining secondary schools is small due to financial base of study population.

Table 2: General information on residents of study villages.

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According to URT [4]; World Bank (2014); and Deloitte [5], one of the signs of both income and non-income poverty in the country is the low level of literacy and numeracy. The literacy level in Tanzania is now estimated to be 68%, down from 90% achieved in the 1980s. The gross enrolment rate for primary school pupils was 77.8% in 1996, down from 90% in 1980s. the literacy rate for youths and adults in the year 2014 was 76% and 73% for male and female youths respectively; and 75% and 61% for male and female adults respectively World Bank (2014).The Tanzanian government has managed to pay teachers’ salaries and allowances but number of teachers employed is not enough despite the efforts made to recruit more teachers due to agenda of having at least one secondary school in each ward and primary school in each village. With free tuition fees in public schools, the number of girls will be increased in schools as parents had have tendencies to choose between boys and girls to educate before the year 2016 because of cost sharing [6-8].

Factors affecting the performance of urban farming practices

Water availability: Availability of water is an important factor for urban farming practices. Miyuji ward is within semiarid region of Dodoma where enough rainfall for urban farming practices is a problem. The study mitaa in miyuji ward based on multiple responses (Table 3) found to have water mostly from rainfall (46.2%), 23.5% shallow wells, 19.3% underground water, 7.6% pipe water and 3.4% borehole. The results show that many urban farmers in Miyuji ward prefer rain harvesting as source of water, and due to low water table in Dodoma region, underground water also seems to be preferred although it require some fund for investment in it like pump machine, fuel etc.

Table 3: Main source of Water in Miyuji Ward.

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Laws and by laws: The study mitaa found to have by laws that deal with urban farming. The results Table 4 shows that 77.7% of respondents in study mitaa understand and respect by laws present while only 22.3% claims that they do not know if there is by laws for making urban farming sustainable. By laws is very important for guiding urban farming practices. The following by laws which enforced in the study area based on multiple responses Table 5 shows that 45.3% of urban farmers responded to bylaw dealing with protection of soil erosion by restrict quarry activities, 36% protection of forests (cutting down of trees), 10.7% protection of water and 8% protection of illegal farm burning. The study made revealed that 80.4% of the urban farmers in the study area are aware with existing by-laws and its effectiveness. However, 19.6% of urban farmers complained that the existing by-laws are not enforced hence are not effective. It was established that 90.2% of urban farmers want any person acting against the existing by-laws to be penalized the rest 9.8% want any criminal to be jailed (Table 6).

Table 4: Presence of by Laws Dealing with Urban Farming.

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Table 5: By laws guiding urban farming.

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Table 6: Efficiency and Effectiveness of By-laws Guiding Urban Farming.

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Table 7: Income level of Respondent per Month.

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Capital Availability: Urban farming needs starting and operating capital so as to harvest considerable crops per acre and end products results from livestock and poultry. Capital helps to buy chemicals, fertilizers and other inputs helps in farming practices (Personal Observation). The study mitaa found to have different income groups in which 61.1% of study population has income per month above TZS 60,000 (Table 7). The results show that 38.9% of the urban farmers are living in absolute income poverty for both employed and unemployed and cannot even have power to buy any input for farming or self-sustenance. That majority with high income above TZS 60,000 can use the money earned to buy different equipment. During focus group discussion it was found that, urban farmers are not recognized in financial institutions for providing them loans unless they form a group of five persons or above and follow long procedures until given that loan. Also these urban farming practices are also done by employed people so as to raise household income, reduce income poverty and provide food to households’ members who are large in number. Also the study found that, urban farmers in Miyuji ward are practiced by both men and women from all income groups where by the majority of them were from below TZS 60,000 income earners as shown in Table 8. It was established that those urban farmers grow food crops for security and income generation as stipulated by Nugent [9,10] and URT [7]. In Miyuji ward women who engaged in urban agriculture are actively participate in urban garden for home production but also in food processing and marketing though in Miyuji ward women are involved in small scale production as explained much by Mouget [10] and URT [7].

Table 8: Income level of Respondent per Month interms of Sex.

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Market availability: The study area found to have markets for their products from urban farming practices. The results show that 87.7% of study households said they have market for their farming products. This shows that in Miyuji ward market for urban farming products is not a serious problem what is required is to increase crops production. Crops produced includes millet, cassava, sorghum, sunflower, grapes, groundnuts, njugu, maize, vegetables, tomatoes and others; while livestock keeping includes cows, goats and pigs; and poultry which mostly includes hens (Table 9). Due to increase of higher learning institutions in Dodoma urban, it is likely the market to be extended and scarcity of this products resulted from urban farming practices increase and leads to poverty reduction to those people involved in these practices.

Table 9: Market availability of Crops, Livestock and Poultry.

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Plot size and type of tools used for agriculture: The study area found to have scarcity of land for urban farming. The results show that 84.4% of study households own land and only 15.6% rent those lands for urban farming plots (Table 10). Also 100% of the study area own 1-4 acres of land and within this study population 95.6% claims that land is not enough and 85.6% propose average farmland required to be 5-9 acres and 14.4% propose to remain 1-4 hectares with maximum land size of 4 acres. Due to the use of hand hoe (low technology) in study area for agricultural activities, farmland shortage will continue to be a problem until the situation is reversed. Most urban farmers claim that, though urban agriculture is potentially viable and productive but not a panacea to solve the most severe problems of food security in Miyuji ward as explained also much by Nugent [9] and Mboganie [11].

Table 10: Market availability of Crops, Livestock and Poultry.

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Use of fertilizers: The made in the study area found to have high fertilizers users. The results show that 63.3% use fertilizers and 36.7% are not using fertilizers (Table 11). This shows that disparities of income groups are the determinant for using fertilizers as those urban farmers with high income group are the one with ability to buy fertilizers. Also those practice either livestock keeping and agricultural or poultry keeping and agriculture can use manure type of fertilizer which is not costly [12]. Kinds of fertilizers used are shown in Table 12. The increase in fertilizer prices and reduction in credit have hit urban farmers harder because they are on poorer land which needs more of fertilizer which they are less able to afford. This has resulted in increasing cultivation of marginal areas with associated deforestation and erosion problems.

Table 11: Fertilizers Usage in Farming.

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Table 12: Kind of Fertilizers Used.

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Contribution of urban farming on income poverty reduction

Activities of urban farming: The study made found to have high number of household using rain fed farming as their main source of water for urban farming [13]. Results shows that, 56.7% use rain harvesting only 9.3% and 4.1% use pipe water and borehole respectively (Figure 3). This shows that those use pipe water from DUWASA are the one who cultivate leafy vegetables includes chinese, beans, sweet potatoes leaves, cassava leaves and non-leafy vegetable includes tomato, cucumber and carrot; and cultivate both vegetable and fruits includes orange, grapes and pawpaw. The common crops grown by both groups of different main water sources includes millet (23.6%), sunflower (23.2%), sorghum (21.4%), maize (14.5%), groundnuts (7.7%), cassava (5%), and njugu (4.5%)(Table 13). Also livestock kept includes cows (28.1%), goats (6.3%) and poultry (hens) (65.6%) (Table 14). These crops grown and livestock kept are both for subsistence use in families and business to increase income of household whereby keeping hens found to be done by large number of households in study area. The study found that, men in Miyuji ward dominate commercial urban food production such as sunflower and groundnuts and selling of livestock kept. Most of women earn/control the money from milk and eggs selling. The study also revealed that children were involved in urban farming activities through weeding and watering. Involving children is contrary to child labour rights [14].

Figure 3: Source of Water in Miyuji Ward.

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Table 13: Crops grown kept in Miyuji Ward.

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Table 14: Livestock kept in Miyuji Ward.

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Table 15: Crops production per acre.

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Amount produced and sold and price of products: The study population found to have medium production of urban farming products [15]. Crops production per acre as shown in Table 15 below shows that, 35.1% produce 2-4 bags per acre of sunflower, 21.6% below 2bags of sorghum, 25.8% produce 4-6 bags of millet per acre, 13.4% produce 6-8 bags per acre of Maize, Njugu 15.5% produce below 2bags per acre, 11.3% produce 2-4bags of cassava per acre, and 12.4% produce Groundnuts below 2bags per acre. Animal production based on end products shows (Figure 4) that, 43.3% produce hens’ eggs and 18.6% produce milk During focus group discussion, it was shown that, urban farmers of Miyuji ward use products obtained for home use and business whereby most of them sell all products in order to get income for covering some expenses for example paying fees for their children, health issues, water bills and all other household necessities needed rather than priotised using crops produced to solve the problem of food insecurity. Market availability for products produced is not a problem in a study area [16]. Results in Figure 4 shows that 88% of the respondents in study area have market for their products and only 12% have no market. This shows that as population increase in Dodoma urban then demands for urban farming products increases, therefore production should be increased in order sustain the available population.

Figure 4: Animal end product produced.

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When the researcher interviewed households, it was found that, price of crops products varies depending on demand especially during parliamentary meetings and higher learning students’ institutions studying semester’s periods. Animal products includes milk and eggs found to have constant price of TZS 1000 per liter and TZS 500 per egg while the price of cow and chicken are subject to change ranging from TZS 300.000 to 600,000 depending on size and specie of cow, while chicken range from TZS7000 to 15,000. In order this farming practices to be improved so as to increase production, the study households suggested as shown in Table 16. 30.1% said if they can be supplied by early seeds provision, adopt irrigation technology (28%), establishment of market nearby, increase number of extension officers (8.3%), separating agriculture and livestock area (6.2%), education and training provision to urban farmers on good method of agriculture (3.2%) and Subsides provided on fertilizers and pesticides to reach urban farmers (3.2%) tgether with financial support from Banks and Credit agencies [17], altogether can improve urban farming practices and more urban dwellers can engage themselves as explained much by Nelson, 1996.

Table 16: Suggestion given by urban farmers on the improvement of their farming practices.

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Effects of urban farming on the environment

Chemicals used and cow dung disposal: The study found that urban farmers have low usage of chemicals in farming practices. Results shows that, 71.7% do not use any insecticides or pesticides in crops production and only 28.3% use insecticides and pesticides for the crops production (Figure 5). This shows that farming products produced in Miyuji ward have little concentration of chemicals which can have negative effect to human being. However, during interview with ward agricultural officer, it was shown that sometimes aerial sprays to kill “koleakolea” have been done in the area few years ago. Also during focus group discussion, it was revealed that cow dung disposal in farm plots make them to increase nutrients as a results production per acre increase compared to plots without any fertilizer. Additionally, it was found that cow dung can be used for production of bio-gas which is alternative source of energy rather than concentrating using fuel wood and charcoal as the main source of energy in study area.

Figure 5: Market availability for crops and animals products.

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Figure 6: Insecticides/Pesticides usage in farms.

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Figure 7: Land Degradation Resulted From Urban Farming Practices.

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The study area found to have land degradation resulted from urban farming practices. Results shows that 93.3% of study households experienced land degradation resulted from urban farming practices and only 6.7% do not experience it. This shows that poor farming practices present in the area, so the duty of extension officers to reverse the situation will be appreciated (Figure 6). Land degradation is among of the effects on urban farming which experienced in the study area [18]. Types of land degradation experienced are shown in Table 17. Also it shows that this land degradation decreasing. Results from observation and household questionnaire shows that, 92.9% of study households have seen this degradation as decreasing and only 7.1% responding to increasing land degradation (Figure 7). This shows that presence of extension officers helps to conservation of environment by teaching community proper way of practicing urban faming. Major reasons for increasing and decreasing land degradation are shown in Table 18.

Table 17: Types of Land Degradation experienced in study area.

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Table 18: Major Reasons for Increasing and Decreasing Land degradation.

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Figure 8: Status of Land Degradation.

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Figure 9: Tree planting.

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Table 19: Purpose of growing trees in study area.

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Planting trees: Planting trees is a positive strategy towards environmental in many areas of the world, and collaborative measures whereby, all community together practice this tree planting for the benefit of extracting carbon dioxide gas concentration resulted from daily productive activities Smit and Nasr, 1997. The study found that 93% of respondents in study area planted trees and only 7% did not plant trees (Figures 8 & 9). This shows that indigenous technical knowledge and NGOs play a good role in providing conservation education and importance of growing trees for the benefit of urban farming practices. The study population found to have behavior of planting trees for shades rather than combating fuel wood shortage. Results shows that 27.4% of planted trees are meant for shades, 26.7% for soil fertility maintenance, 15.6% for fuel wood and building materials respectively, and 14.8% for wind breakers (Table 19). Also the study revealed that in Miyuji ward have high populations who plant few trees per year. Results in Table 20 shows that 40% of respondents planted two trees per year and 60% plant more than two trees per year. This implies that, as times goes on and those trees planted being protected then in few years to come Miyuji ward can have large amount of tree.

Table 20: Number of Trees Planted Per Year.

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Conclusion and Recommendations

Conclusion

Generally, urban farming practices contribute much to reduce income poverty in Dodoma Municipal especially in Miyuji ward. Based on analyzed data most of respondents are in a position of improving their living standard and getting their basic human needs due to involvement in urban farming practices though there are some factors which observed to hinder urban farming practices in the study area such as inadequate water, inefficiency laws and by laws which govern urban farming practices, lack of enough capital, small plot size, low technology and lack of nearby market to sell their crops and livestock products.

Recommendations

Urban farming practices is a new employment opportunity to urban dwellers as the study shows it increase income to households, fight food insecurity, provide room for environmental conservation through planting trees and adopting proper way of farming and other benefits associated with urban farming. In order this sector to be improved and increase production, the following issues found in the study area must be taken into account:

Early seed provision from the government and non-government organization can help to improve urban farming practices in Miyuji ward. This can be facilitated by ward agricultural extension officer.

Improvements of irrigation method can help to improve urban farming practices rather than depends much on tap and rain harvest water. Urban farmers, extension officers and government are in position to incorporate in order to reach consensus.

Regular education to the urban farmers from urban farmers’ expertise can help to increase the crop and livestock yield hence poverty reduction to the urban farmers.

The village government must ensure implementation of existing laws and by laws governing urban farming practices which help to conserve the environment so as to be conducive for practicing urban farming.

Town planners should plan an alternative area for urban farming practices to suit the urban farmers as their areas are too small as compared to the size of their family.

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Saturday 27 May 2023

Lupine Publishers | Laparoscopic Surgery in Pregnancy and Consequences According to Gestational Age

 Lupine Publishers | Journal of Gynaecology and Women's Healthcare


Abstract

Introduction: Laparoscopic surgery has been revealed and displayed by various research teams to reduce operative time, postoperative pain, hospital length of stay, recovery time, and wound complications in comparison to laparotomy during pregnancy. However, research efforts and analytical methods should explore the feasibility and safety to perform laparoscopic surgery at different gestational ages. Surgical and anesthetic challenges arise due to anatomical and physiological changes that normally appear as a normal adaptation to pregnancy status.

Aim of the Work: The main aim of this research study was to evaluate the clinical and obstetric consequences of interventional laparoscopic procedures conducted during late gestation in comparison to cases conducted in early gestation.

Methodology: The research was conducted in a retrospective manner on 18 cases of laparoscopic surgeries performed during pregnancy from January 2011 till March 2017 comparing cases performed early in pregnancy to those in late pregnancy.

Result: The research data was collected and analyzed from 18 pregnant study subjects that had undergone laparoscopic procedures during the research study period. The mean operative time was significantly lower among women of early pregnancy research group [45.0±7.7 min vs. 57.9±3.9min, p value=0.001]. None of women of early pregnancy group had postoperative complications, in contrast to 3 cases in the late pregnancy group [1 (14.3%) had port-site infection after laparoscopic appendectomy and 2 (28.6%) had threatened preterm labor that was managed by rectal indomethacin for 48 hours; this difference was close to be statistically significant (p value =0.059) there were no conversions to laparotomy.

Conclusion: According to the current research findings, laparoscopic interventional procedures in late and early gestation have a high safety profile and with appropriate preparation are considered feasible without any hazardous impact on pregnancy as regards maternal and fetal wellbeing.

Introduction

The requirement of abdominal surgery during pregnancy is a common concern and issue that integrates the efforts of various subspecialties to perform a multidisciplinary management for those cases scenarios in favor of the maternal and fetal wellbeing. The rates and incidences of abdominal surgery requirement varies widely according to various prior research studies however the cornerstone issue of concern is safety and capability to perform laparoscopic procedures with the great challenge of anatomical and physiological changes that normally exist during pregnancy, that requires laparoscopic surgeon that have the experience and skill to conduct the surgery taking into account the anatomical changes that vary greatly according to the gestational trimester. Research efforts in this aspect are still inadequate and scarce and requires various investigations as regards the type and safety profile of laparoscopic surgery during pregnancy [1,2]. The most frequent etiology in non-gynecological surgical interventions is appendicitis and cholecystitis and the most common gynecological interventional challenges is ovarian torsion and symptomatic adnexal masses requiring both surgical and clinical skills and expertise to have a proper and safe management handling of those clinical scenarios to avoid unnecessary surgical intervention or misdiagnosis [3,4]. Laparoscopy in pregnancy is a growing area of interest in research in the last two decades due to the advantages of minimally invasive surgeries although it carries concerns around possible injuries or complications that could affect the maternal and fetal health [5,2]. The presence of a viable intrauterine gestation with requirement of surgical intervention is a challenge that needs proper counselling and preparation of patients due to the potential risks [6].

Methodology

This study was carried out in Saudi Arabia, in Jeddah at a private hospital (Bugshan Hospital) for a period starting from January 2011 to March 2017. The study protocol was approved by the institutional ethics review board. The patients were provided with an informed consent after receiving a full explanation of the nature and protocol of the study. This study was conducted in a retrospective way the medical records of 18 pregnant cases that performed laparoscopic procedures were reviewed as regards demographic and clinical features and indication of laparoscopic procedure performance and clinical outcomes of conducted cases in from January 2011 till March 2017. Usage of tocolytic Therapy preoperatively or postoperatively was conducted on a case-by-case basis, and not in a routine manner. Cases scheduled for laparoscopic surgical intervention have been positioned in the dorsal supine position with slight a left sided tilt to avoid aorto-caval compression by the gravid uterus. Positional changes have been adjusted in harmony and conjugated efforts with the anesthesia team and according to the cases hemodynamic monitoring parameters. General anesthesia has been implemented in all cases. The laparoscopic and operative trocars placement was adjusted according to uterine size and corresponding gestational age. The following was generally performed as a rule in all cases performed and recruited in the research study in which first gestational trimester cases, Initial placement of the trocar for the laparoscopic procedure was in the umbilicus by positioning a Veress-Palmer needle followed by a 10mm trocar. The other regions for trocar placement were decided according to the surgical intervention performed.

Surgical laparoscopic interventions during the second and third gestational trimesters, the preliminary trocar was positioned within the umbilicus or supra umbilical zone, within midline by implementing Hasson open technique, being cephalic a few centimeters to the uterine fundus to avoid entry injuries to the uterus. Laparoscopic procedure insufflation has been conducted using Co2 pressure sustained under 12mmHg for sufficient venous return, to reduce aorto-caval pressure and avoid subsequent fetal acidosis.

Abdominal structures were intraoperatively manipulated according to the site, symptoms, and features of the pelvic or abdominal pathology using laparoscopic graspers and manipulators to permit adequate and optimal performance of the required interventional surgery, facial layer was closed when above 10mm trocars were implemented in the laparoscopic surgical intervention to avoid incisional abdominal hernia. While performing the procedures minimized manipulations of the gravid uterus as much as possible. Routine preprocedural performance of sonographic assessment of fetal wellbeing was performed for all cases and Cardio tocography for gestations above 24 gestational weeks. Post-operative follows up for premature contractions was conducted and tocolytic therapy was administered when required. Sonographic and CTG assessment for fetal wellbeing was repeated after one day from performing the surgical procedure according to the gestational age.

Statistical analysis

Inferential analyses were done for quantitative variables using independent t-test in cases of two independent groups, ANOVA test for more than two independent groups with post hoc Tuky’s test. In qualitative data, inferential analyses for independent variables were done using Chi square test for differences between proportions and Fisher’s Exact test for variables with small expected numbers. Logistic regression was done for factors affecting clinical and completed first trimester pregnancy among the studied cases. The level of significance was taken at P value < 0.050 is significant, otherwise is non-significant. Table 1 reveal and display that 11 study subjects (61.1%) were in early pregnancy (before 14 weeks of gestation) while 7 cases (38.9%) were in late pregnancy. The mean (± SD) gestational age of women in the early pregnancy group was 9.39±1.92 weeks (range: 7-12.57 weeks), while that in the late pregnancy group was 32.63±1.05 weeks (range: 30.43 - 33.86 weeks). There were no statistically significant differences between women of both research groups regarding the initial characteristics (age, parity and BMI) (p values=0.531,0.833,0.970, consecutively) (Table 1).

Table 1: Initial Characteristics in Included Women.

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Data presented as mean ± standard deviation

BMI body mass index (calculated as weight in kilograms divided by squared height in meters)

Analysis using independent student’s t-test

Table 2 reveals and displays that 11 women of early pregnancy research group, 5 (45.5%) underwent laparoscopy for suspected adnexal torsion, while 2 (18.2%) for bowel obstruction, 2 (18.2%) for appendicitis, and 2 (18.2%) for persistent adnexal mass. On the contrary, of the 7 women of late pregnancy group, 4 (57.1%) were for appendicitis, 1 (14.3%) for persistent adnexal mass, while 1 (14.3%) for persistent pain and vomiting due to Calcular Cholecystitis. These differences were not statistically significant (Table-2). The median admission-to-intervention interval was significantly lower among women of early pregnancy group (p=0.028), owing to the close-to-be-significant higher rate of emergent (within 6 hours after admission) laparoscopy among women of early pregnancy group (p=0.064) (Table 2).

Table 2: Laparoscopy Procedure Characteristics in Included Women.

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Data presented as number (percentage); median (interquartile range); or mean ± standard deviation

1 Analysis using chi-squared test

2 Analysis using Mann-Whitney’s U-test

3 Analysis using independent student’s t-test

Among women of early pregnancy group, only 2 (18.2%) women had the insufflation needle inserted through the Palmar’s point (left midclavicular line, subcostal), in contrast to all women [7 (100%)] of the late pregnancy group; this difference was statistically significant (p=0.004) (Table 2). The mean operative time was significantly lower among women of early pregnancy group [45.0±7.7 min vs. 57.9±3.9 min, p=0.001] (table-2). Only 1 (11.1%) case had significant intraoperative bleeding that required blood transfusion (a case of adnexal torsion who underwent detorsion and ovarian cystectomy). None of women of early pregnancy group had postoperative complications, in contrast to 3 cases in the late pregnancy group [1 (14.3%) had port-site infection after laparoscopic appendectomy and 2 (28.6%) had threatened preterm labor that was managed by rectal indomethacin for 48 hours; this difference was close to be statistically significant (p=0.059) (table-2). Table 3 reveals and displays that the mean gestational age at delivery and mean birth weight were both significantly lower in women of the late pregnancy group [p=0.006 and p=0.046, respectively]. Only 1 (9.1%) woman of the early pregnancy group versus 4 (57.1%) women of the late pregnancy group had preterm labor (< 37 weeks of gestation); this latter difference was statistically insignificant (p=0.093) (Table 3).

Table 3: Obstetric Outcome in Included Women.

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Data presented as mean ± standard deviation; or number (percentage)

1 Analysis using independent student’s t-test

2 Analysis using chi-squared test

Discussion

Recently laparoscopy have shown great advances in practice and became increasingly popular and more frequently conducted during Pregnancy. Laparoscopy as minimally invasive procedure permits early patient ambulation that avoids serious clinical issues such as deep venous thrombosis. As pregnancy is a hypercoagulable state and thromboembolic events are more frequent in pregnant women consequently early ambulation is considered a desired privilege obtained by laparoscopic approach in surgical management of cases requiring intervention in pregnancy. Even though laparoscopic procedures are feasible in all gestational trimester’s injuries are greater issues of concerns as gestation advances since the gravid uterus is at increased risk of injury in late gestational ages raising the risks of prematurity [4,7]. Besides the gravid uterus could affect the adequate and proper visualization. The growing uterus may make the traditional umbilical site less desirable. To decrease the risk of laparoscopic entry injuries, it is crucial to consider alternative sites for peritoneal injury, in advanced pregnancy gestation other than umbilical zone [8,9].

In the current research study, a cohort of 18 gravid women undergone laparoscopy during the interval between January 2011 and March 2017; 11 cases (61.1%) were in early gestation (before 14 weeks of gestation) whereas 7 study subjects (38.9%) were in late gestation. The mean (±SD) gestational age of women in the early pregnancy research group was 9.39±1.92 weeks (range: 7-12.57 weeks), whereas that in the late pregnancy research group was 32.63±1.05 weeks (range: 30.43-33.86 weeks). There were no statistically significant differences between women of both research groups regarding the initial characteristics (age, parity and BMI) Of the included 11 women of early pregnancy research group, 5 (45.5%) undergone laparoscopy for suspected adnexal torsion, whereas 2 (18.2%) for intestinal obstruction, 2 (18.2%) for appendicitis, and 2 (18.2%) for persistent adnexal mass. On the contrary, of the 7 women of late pregnancy research group, 4 (57.1%) were for appendicitis, 1 (14.3%) for persistent adnexal mass, whereas 1 (14.3%) for persistent pain and vomiting due to Calcular Cholecystitis. Those differences were not statistically significant. The median admission-to-intervention interval was statistically significantly lower among women of early pregnancy research group (p value =0.028), owing to the close-to-besignificant higher rate of emergent (within 6 hours after admission) laparoscopy among women of early pregnancy group (p value =0.064). Among women of early pregnancy research group, only 2 (18.2%) women had the insufflation needle inserted through the Palmar’s point (left mid clavicular line, subcostal), in contrast to all women [7 (100%)] of the late pregnancy group; this difference was statistically significant (p value =0.004).

The mean operative time was significantly lower among women of early pregnancy research group [45.0±7.7 min vs. 57.9±3.9 min, p value =0.001]. Only 1 (11.1%) case had considerable intraoperative bleeding that required blood transfusion (a case of adnexal torsion who underwent de-torsion and ovarian cystectomy). None of cases recruited from early pregnancy research group had postoperative complications, in contrast to 3 cases in the late pregnancy research group [1 (14.3%) had port-site infection after laparoscopic appendectomy and 2 (28.6%) had threatened preterm labor that was managed by rectal indomethacin for 48 hours; this difference was close to be statistically significant (p value =0.059). The mean gestational age at delivery and mean birth weight were both statistically significantly lower in women of the late pregnancy group [p value =0.006 and p value =0.046, consecutively]. Only 1 (9.1%) woman of the early pregnancy group versus 4 (57.1%) women of the late pregnancy group had preterm labor (< 37 weeks of gestation); this latter difference was statistically insignificant (p=0.093). A prior similar research study similar to the current research study revealed and displayed that laparoscopic surgeries, could be performed with adequate safety profile despite the indication for surgical intervention in advanced gestations up to 34 weeks [10,11].

As in the non-pregnant cases, laparoscopic surgical approaches have been revealed by various research teams and cases series to reduce operative time, postoperative pain, hospital admission time, period of recovery, and wound complications in comparison to laparotomy during gestation. Various research issues and concerns of grate debate and controversies such as risk of uterine injury and pneumoperitoneum during pregnancy that had make draw backs for performing laparoscopic surgeries in the past [12,13]. Prior research groups have revealed and displayed that CO2 insufflation triggered maternal hypercapnia, which caused fetal hypercapnia, tachycardia, and hypertension. On the other hand, that contradicts with recent research based, evidence that have emerged to show that laparoscopy, even in late gestational ages, could be undertaken safely and is the preferred management modality for many various clinical and surgical scenarios faced in every day practice in pregnant cases [1,3,14]. Laparoscopy could permit better abdominal exploration with less uterine manipulation in comparison to laparotomy that favors laparoscopic approach. the open, closed or optical trocar initial entry techniques are implemented, depending on the fundal height and experience of the surgeon. Left subcostal entry or entry under sonographic guidance have been described to prevent uterine injury. Interestingly CO2 insufflation pressure levels of 10-15mm Hg are recommended by the Society of American Gastrointestinal and Endoscopic Surgeons for the pregnant cases [2,4].

When first trimester ends the organogenesis phase of development is completed, subsequently gestational loss rate falls. Laparoscopic procedures require great skill and experience by the operator to avoid any complications possible due to physiological and anatomical changes in pregnancy which is considered a surgical and anesthetic challenge. in various clinical and surgical scenarios, the surgeon is faced by a restricted by the reduced peritoneal space available to conduct the surgery. Interestingly pregnant cases must be positioned in the left lateral decubitus position to reduce aorto- caval compression, therefore improving venous return and cardiac output. Carbon dioxide insufflation of 10-15mmHg could be implemented with adequate and acceptable safety levels for laparoscopic surgical procedures in pregnancy [5,4]. Some research studies have revealed and displayed the issue of concern that the intra-abdominal insufflation pressure should be kept under 12mmHg to prevent deterioration of pulmonary physiological status in gravid cases on the other hand other research teams have claimed that less than 12mmHg insufflation does not provide enough visualization of the intra-abdominal cavity. Additionally, 15mmHg pressure have been implemented during laparoscopic surgeries in pregnant cases without any adverse clinical outcome, whether at maternal or fetal levels [6,11]. Research groups didn’t resolve the concern and continuous debate about prophylactic tocolysis therefore all clinicians consider this issue pre or post operatively according to clinical experience and clinical scenarios tailored according to the cases scenario and requirements [3,6,13].

Conclusions and Recommendations for Future Research

Laparoscopic procedures in pregnancy appears to have a high safety profile levels however future research is recommended to be conducted in multicentric fashion with larger sample sizes and to put in consideration various indications for surgical intervention and different gestational ages .Future research should also consider ethnic and racial differences in anatomical detailed changes that could influence surgical laparoscopic practice approach to aid in future guideline implementation in practice.

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