Medical Specialties Commons^™

Determinants Of Method Switching Among Social Franchise Clients Who Discontinued The Use Of Intrauterine Contraceptive Device, Waqas Hameed, Syed Khurram Azmat, Moazzam Ali, Wajahat Hussain, Ghulam Mustafa, Muhammad Ishaque, Safdar Ali, Aftab Ahmed, Marleen Temmerman

Community Health Sciences

Introduction: Women who do not switch to alternate methods after contraceptive discontinuation, for reasons other than the desire to get pregnant or not needing it, are at obvious risk for unplanned pregnancies or unwanted births. This paper examines the factors that influence women to switch from Intrauterine Contraceptive Device (IUCD) to other methods instead of terminating contraceptive usage altogether.
Methods: The data used for this study comes from a larger cross-sectional survey conducted in nine (9) randomly selected districts of Sindh and Punjab provinces of Pakistan, during January 2011. Using Stata 11.2, we analyzed data on 333 women, …

The Role Of Quality Health Services And Discussion About Birth Spacing In Postpartum Contraceptive Use In Sindh, Pakistan: A Multilevel Analysis, Hannah Tappis, Anis Kazi, Waqas Hameed, Zaib Dahar, Anayat Ali, Sohail Agha

Community Health Sciences

Introduction: Rapid population growth, stagnant contraceptive prevalence, and high unmet need for family planning present significant challenges for meeting Pakistan's national and international development goals. Although health behaviors are shaped by multiple social and environmental factors, research on contraceptive uptake in Pakistan has focused on individual and household determinants, and little attention has been given to community characteristics that may affect access to services and reproductive behavior.
Methods: Individual and community determinants of contraceptive use were identified using multivariable multilevel logistic regression to analyze data from a 2014 cross-sectional survey of 6,200 mothers in 503 communities in Sindh, Pakistan.
Results: …

The Perception Of Menstruation And Treatment Of Menstrual Ailments Among Tibetan Women In Mcleod Ganj, Himachal Pradesh, Kara Spafford

India: Public Health, Policy Advocacy, and Community

Despite recent incorporation of quality of life assessments into goal setting, menstrual ailments are still left out of public health initiatives in developing countries. Due to lack of studies on perceptions of menstruation and treatment options for menstrual ailments, the specific health needs of Tibetan women are not met. The present study seeks to determine how Tibetan women are influenced by societal views of menstruation and to explore access to treatment for menstrual problems in McLeod Ganj, Himachal Pradesh. A total of thirty-seven semi-structured interviews were conducted among Tibetan doctors at Men-Tsee-Khang (Tibetan Medical and Astronomy Institute) and Tibetan women …

El Parto Humanizado: Perspectivas De Profesionales En Las Maternidades Públicas De Buenos Aires, Lara Kaplan Westbrook

Independent Study Project (ISP) Collection

Con el reconocimiento de la tecnologización y medicalización del embarazo y parto en años recientes, el término violencia obstétrica y la ley del parto humanizado han surgido en Argentina. Aunque la ley define cómo los hospitales deben actuar para garantizar un parto donde la mujer sea la protagonista, su implementación depende de muchos factores, incluyendo la interpretación y opinión del profesional. Además, las mujeres que viven en situaciones de pobreza son quienes más frecuentemente usan los servicios de salud públicos y por ello suelen estar más expuestas a la naturalización de la violencia en la atención de la salud y …

Sexual And Reproductive Health Risks Amongst Female Adolescents Who Use Amphetamine-Type Stimulants And Sell Sex: A Qualitative Inquiry In Yunnan, China, Xu-Dong Zhang, Angela Kelly-Hanku, Jia-Jia Chai, Jian Luo, Marleen Temmerman, Stanley Luchters

Obstetrics and Gynaecology, East Africa

Background: China, as other Southeast Asian countries, has witnessed an increased use in amphetamine-type stimulants (ATS) amongst urban youth. Amongst female adolescents who both sell sex and use ATS, risk behaviours are compounded resulting in even poorer health outcomes. However, limited knowledge exists on ATS use patterns and ATS-related risk behaviours, particularly in this context. This research aimed to improve the understanding of these issues amongst female adolescents who use ATS and sell sex, and to inform future programming.

Method: This study utilised monthly focus group discussions (four in total) with the same study participants in Yunnan, China. From within …

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy Tube Insertion In The Immediate Post-Partum Period For Head And Neck Cancer, Adil Aijaz Shah, Shabbir Akhtar, Nadeem Zuberi, Kamran Ali, Dania Aijaz Shah, Amir Hafeez Shariff

Department of Surgery Docs

Abstract

Percutaneous endoscopic gastrostomy (PEG) tube placement serves as a well-tolerated and efficacious technique for long-term enteral access in patients with medical conditions precluding oral food intake. The nutritional optimisation of patients with oral cancer is mostly achieved via PEG tube placement. However, certain special situations, such as pregnancy and the immediatepost-partum period, may render the placement of PEG tubes to be a challenge. A 28-year-old pregnant female patient presented to us with the diagnosis of squamous cell carcinoma of the tongue during her third trimester. Definitive surgical resection was planned post-delivery along with simultaneous PEG tube placement. Immediately following …

Fear, Blame And Transparency: Obstetric Caregivers' Rationales For High Caesarean Section Rates In A Low-Resource Setting, Helena Litorp, Andrew Mgaya, Columba Mbekenga, Hussein L. Kidanto, Sara Johnsdotter, Birgitta Essén

School of Nursing & Midwifery, East Africa

In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5–6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings …

Monitoring Human Growth And Development: A Continuum From The Womb To The Classroom, José Villar, Aris T. Papageorghiou, Ruyan Pang, Laurent J. Salomon, Ana Langer, Cesar Victora, Manorama Purwar, Cameron Chumlea, Wu Qingqing, Sicco A. Scherjon, Fernando C. Barros, Maria Carvalho, Douglas G. Altman, Francesca Giuliani, Enrico Bertino, Yasmin A. Jaffer, Leila Cheikh Ismail, Eric O. Ohuma, Ann Lambert, J. Alison Noble, Michael G. Gravett, Zulfiqar A. Bhutta, Stephen H. Kennedy

Obstetrics and Gynaecology, East Africa

A comprehensive set of fully integrated anthropometric measures is needed to evaluate human growth from conception to infancy so that consistent judgments can be made about the appropriateness of fetal and infant growth. At present, there are 2 barriers to this strategy. First, descriptive reference charts, which are derived from local, unselected samples with inadequate methods and poor characterization of their putatively healthy populations, commonly are used rather than prescriptive standards. The use of prescriptive standards is justified by the extensive biologic, genetic, and epidemiologic evidence that skeletal growth is similar from conception to childhood across geographic populations, when health, …

Impact Of An Educational Intervention On Breast Cancer Knowledge In Western Kenya, J. Kisuya, J. Wachira, N. Busakhala, V. Naanyu, A. F. Chite, Elkanah Omenge, G. Otieno, Alfred Keter, A. Mwangi, Thomas Inui

Obstetrics and Gynaecology, East Africa

Our objective was to assess the effectiveness of educational sessions that accompanied breast cancer screening events in three communities in western Kenya between October and November 2013. Five hundred and thirty-two women were recruited to complete a test of breast cancer-relevant knowledge and randomly allocated to ‘pre-test’ or ‘post-test’ groups that immediately preceded or followed participation in the educational sessions. The education was organized as a presentation by health professionals and focused mainly on causes of breast cancer, early and late cancer presentation signs, high-risk groups, screening methods to find early-stage breast cancer, self-breast exam procedures and treatment options for …

The Hippo/Yap Pathway Interacts With Egfr Signaling And Hpv Oncoproteins To Regulate Cervical Cancer Progression., Chunbo He, Dagan Mao, Guohua Hua, Xiangmin Lv, Xingcheng Chen, Peter C. Angeletti, Jixin Dong, Steven W. Remmenga, Kerry J. Rodabaugh, Jin Zhou, Paul F. Lambert, Peixin Yang, John S. Davis, Cheng Wang

Journal Articles: Obstetrics & Gynecology

The Hippo signaling pathway controls organ size and tumorigenesis through a kinase cascade that inactivates Yes-associated protein (YAP). Here, we show that YAP plays a central role in controlling the progression of cervical cancer. Our results suggest that YAP expression is associated with a poor prognosis for cervical cancer. TGF-α and amphiregulin (AREG), via EGFR, inhibit the Hippo signaling pathway and activate YAP to induce cervical cancer cell proliferation and migration. Activated YAP allows for up-regulation of TGF-α, AREG, and EGFR, forming a positive signaling loop to drive cervical cancer cell proliferation. HPV E6 protein, a major etiological molecule of …

Towards A New Global Strategy For Women’S, Children’S And Adolescents’ Health, Marleen Temmerman, Rajat Khosla, Zulfiqar Ahmed Bhutta, Flavia Bustreo

Obstetrics and Gynaecology, East Africa

The year 2015 marks a defining moment for the health of women, children, and adolescents. It is the end point of the United Nations’ millennium development goals, and their transition to the sustainable development goals, and also the 20th anniversary of the International Conference on Population and Development’s plan of action and the Beijing Declaration and platform of action.

This is a moment of reflection as well as celebration. Although great strides have been made in reducing maternal and child mortality, showing that change is possible, many countries are lagging behind in reaching millennium development goal 4 (to reduce the …

Role Of The Hospitalist And Maternal Fetal Medicine Physician In Obstetrical Inpatient Care., Lisa D. Levine, Jay Schulkin, Brian M. Mercer, Daniel O'Keeffe, Vincenzo Berghella, Thomas J. Garite

Department of Obstetrics and Gynecology Faculty Papers

OBJECTIVE: The objective of this study was to evaluate the role of hospitalists and Maternal Fetal Medicine (MFM) subspecialists in obstetrical inpatient care.

STUDY DESIGN: This electronic survey study was offered to members of the American College of Obstetrics & Gynecology (ACOG; n = 1,039) and the Society for Maternal-Fetal Medicine (SMFM; n = 1,813).

RESULTS: Overall, 607 (21%) respondents completed the survey. Overall, 35% reported that hospitalists provided care in at least one of their hospitals. Compared with ACOG respondents, a higher frequency of SMFM respondents reported comfort with hospitalists providing care for all women on labor and delivery …

Evidence For Differential Viral Oncolytic Efficacy In An In Vitro Model Of Epithelial Ovarian Cancer Metastasis, Jessica G. Tong, Yudith Ramos Valdes, John W. Barrett, John C. Bell, David Stojdl, Grant Mcfadden, J. Andrea Mccart, Gabriel E. Dimattia, Trevor G. Shepherd

Obstetrics & Gynaecology Publications

Epithelial ovarian cancer is unique among most carcinomas in that metastasis occurs by direct dissemination of malignant cells traversing throughout the intraperitoneal fluid. Accordingly, we test new therapeutic strategies using an in vitro three-dimensional spheroid suspension culture model that mimics key steps of this metastatic process. In the present study, we sought to uncover the differential oncolytic efficacy among three different viruses—Myxoma virus, double-deleted vaccinia virus, and Maraba virus—using three ovarian cancer cell lines in our metastasis model system. Herein, we demonstrate that Maraba virus effectively infects, replicates, and kills epithelial ovarian cancer (EOC) cells in proliferating adherent cells and …

Family Planning Knowledge, Attitudes, And Practices Among Married Men And Women In Rural Areas Of Pakistan: Findings From A Qualitative Need Assessment Study, Ghulam Mustafa, Syed Khurram Azmat, Waqas Hameed, Safdar Ali, Muhammad Ishaque, Wajahat Hussain, Aftab Ahmed, Erik Munroe

Community Health Sciences

This paper presents the findings of a qualitative assessment aimed at exploring knowledge, attitudes, and practices regarding family planning and factors that influence the need for and use of modern contraceptives. A descriptive exploratory study was conducted with married women and men aged between 15 and 40. Overall, 24 focus group discussions were conducted with male and female participants in three provinces of Pakistan. The findings reveal that the majority knew about some modern contraceptive methods, but the overall contraceptive use was very low. Knowledge and use of any contraceptive method were particularly low. Reasons for not using family planning …

Pregnancy And Pertussis: Why The Change In Tdap Administration?, Marietta Sperry

Books, Presentations, Posters, Etc.

Background and new guidelines vs. old guidelines. Systematic review of obstacles, recommendations, and conclusions.

Simulated Diabetic Ketoacidosis Therapy In Vitro Elicits Brain Cell Swelling Via Sodium-Hydrogen Exchange And Anion Transport., Keeley L Rose, Andrew J Watson, Thomas A Drysdale, Gediminas Cepinskas, Melissa Chan, C Anthony Rupar, Douglas D Fraser

Obstetrics & Gynaecology Publications

A common complication of type 1 diabetes mellitus is diabetic ketoacidosis (DKA), a state of severe insulin deficiency. A potentially harmful consequence of DKA therapy in children is cerebral edema (DKA-CE); however, the mechanisms of therapy-induced DKA-CE are unknown. Our aims were to identify the DKA treatment factors and membrane mechanisms that might contribute specifically to brain cell swelling. To this end, DKA was induced in juvenile mice with the administration of the pancreatic toxins streptozocin and alloxan. Brain slices were prepared and exposed to DKA-like conditions in vitro. Cell volume changes were imaged in response to simulated DKA therapy. …

Two Novel Genetic Variants In The Mineralocorticoid Receptor Gene Associated With Spontaneous Preterm Birth, Inge Christiaens, Q. Wei Ang, Lindsay N. Gordon, Xin Fang, Scott Williams

Dartmouth Scholarship

Background: Preterm birth is the leading cause of mortality and morbidity in newborn infants. Its etiology is multifactorial with genes and environmental factors, including chronic maternal stress, contributing to its risk. Our objective was to investigate whether single nucleotide polymorphisms (SNPs) in genes involved in the stress response are associated with spontaneous preterm birth using a candidate gene approach.

Methods: A total of 210 cases (singleton spontaneous preterm birth at <37 >weeks) and 412 controls (singleton term birth at 38–42 weeks without a history of preterm birth) were studied. High quality maternal DNA was available from saliva samples of 190 cases …

Confident Difference Criterion: A New Bayesian Differentially Expressed Gene Selection Algorithm With Applications., Fang Yu, Ming-Hui Chen, Lynn Kuo, Heather Talbott, John S. Davis

Journal Articles: Obstetrics & Gynecology

BACKGROUND: Recently, the Bayesian method becomes more popular for analyzing high dimensional gene expression data as it allows us to borrow information across different genes and provides powerful estimators for evaluating gene expression levels. It is crucial to develop a simple but efficient gene selection algorithm for detecting differentially expressed (DE) genes based on the Bayesian estimators.

RESULTS: In this paper, by extending the two-criterion idea of Chen et al. (Chen M-H, Ibrahim JG, Chi Y-Y. A new class of mixture models for differential gene expression in DNA microarray data. J Stat Plan Inference. 2008;138:387-404), we propose two new gene …

A Qualitative Exploration Of The Emotional Wellbeing And Support Needs Of New Mothers From Afghanistan Living In Melbourne, Australia, Alana Russo, Belinda Lewis, Andrew Joyce, Belinda Crockett, Stanley Luchters

Population Health, East Africa

Background: The Afghan community is a priority population for many health and social services within the southeast region of Melbourne, which is home to the largest population of Afghanistan-born people within the state of Victoria. The majority of Afghan women arriving in Australia are of childbearing age, and evidence suggests that they are at increased risk of emotional challenges following birth as a result of the refugee and migration experience. This research aimed to explored the experiences of Afghan women living in Melbourne throughout pregnancy, birth, and early motherhood, and gain insight into the aspects of their experiences that they …

Sexual And Reproductive Health Research And Research Capacity Strengthening In Africa: Perspectives From The Region., Richard Adanu, Michael T. Mbizvo, Adama Baguiya, Vincent Adam, Beyene W. Ademe, Augustine Ankomah, Godwin N. Aja, Ademola J. Ajuwon, Olapeju A. Esimai, Taofeek Ibrahim, Dintle K. Mogobe, Özge Tunçalp, Venkatraman Chandra-Mouli, Marleen Temmerman

Obstetrics and Gynaecology, East Africa

Developing the capacity to effectively carry out public health research is an integral part of health systems at both the national and global levels and strengthening research capacity is recognized as an approach to better health and development in low- and middle-income countries (LMICs). Especially fields such as sexual and reproductive health (SRH) would require inter-disciplinary teams of researchers equipped with a range of methodologies to achieve this. In November 2013, as part of the International Family Planning Conference in Addis Ababa, Ethiopia, a group of African researchers came together to discuss the gaps and strategies to improve sexual and …

‘What About The Mother?’ Women׳S And Caregivers׳ Perspectives On Caesarean Birth In A Low-Resource Setting With Rising Caesarean Section Rates, Helena Litorp, Andrew Mgaya, Hussein Kidanto, Sara Johnsdotter, Birgitta Essén

Faculty of Health Sciences, East Africa

Objective in light of the rising caesarean section rates in many developing countries, we sought to explore women׳s and caregivers׳ experiences, perceptions, attitudes, and beliefs in relation to caesarean section.

Design qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis.

Setting a public university hospital in Dar es Salaam, Tanzania.

Participants we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone …

Pregnancy Apps: A Closer Look At The Implications For Childbirth Educators, Christine Frazer, Leslie Hussey, Emily Bosch, Michelle Squire

Walden Faculty and Staff Publications

Most pregnant women download an average of three pregnancy apps during their gestational period. There are no set standards in place for what needs to be included in an app’s description leaving consumers to decide for themselves when it comes to selecting the right app to download. The childbirth educator must be knowledgeable about pregnancy apps, in-tune as to what apps their clientele download, and how to analyze them for credibility. This article presents characteristics associated with women of childbearing age (i.e. Millennial/Net generation); the reasons why pregnant women are turning to apps; the limitations of apps, and the childbirth …

Effect Of Pelvic Floor Muscle Training Among Pregnant Black African Population On The Risk Of Postpartum Urinary Incontinence, A Single Blind Randomized Control Trial, Samuel Ngugi

Master of Medicine in Obstetrics and Gynecology

Trial registration: The study was registered at the Pan African Clinical Trial Registry and a unique identification number issued PACTR201407000850309. Background: Pelvic Floor Muscle Training (PFMT) in the antenatal period has been found to be an effective primary prevention intervention in the Caucasian population in reducing the risk of postpartum Urinary incontinence. Objective: This study was primarily designed to determine the effect of PFMT introduced in the second trimester amongst pregnant black African population on the risk of six weeks postpartum Urinary Incontinence. Secondary objectives included investigating the risk of postpartum Urinary Incontinence, the effect of mode of delivery on …

Child Marriage Legislation In The Asia-Pacific Region, Elisa Scolaro, Aleksandra Blagojevic, Brigitte Fillion, Venkatraman Chandra-Mouli, Lale Say, Joar Svanemyr, Marleen Temmerman

Obstetrics and Gynaecology, East Africa

Child marriage is a human rights violation that robs a girl of her childhood, puts her health, growth, and development at risk, disrupts her education, limits her opportunities for empowerment and social development, and increases her risk of exposure to violence and abuse (for a review of the evidence on the negative effects of child marriage on girls and their children, see Parsons et al. 2015, in this issue). While child marriage is not mentioned specifically in the 1989 Convention on the Rights of the Child (CRC), the Convention does contain a provision requiring governments to abolish “traditional practices prejudicial …

‘What About The Mother?’ Women׳S And Caregivers׳ Perspectives On Caesarean Birth In A Low-Resource Setting With Rising Caesarean Section Rates, Helena Litorp, Andrew Mgaya, Hussein Kidanto, Sara Johnsdotter, Birgitta Essén

Obstetrics and Gynaecology, East Africa

Objective: in light of the rising caesarean section rates in many developing countries, we sought to explore women׳s and caregivers׳ experiences, perceptions, attitudes, and beliefs in relation to caesarean section.

Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis.

Setting: a public university hospital in Dar es Salaam, Tanzania.

Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone …

Quality Of Care For Pregnant Women And Newborns—The Who Vision, Ӧ. Tuncalp, W. M. Were, C. Maclennan, O. T. Oladapo, A. M. Gulmezoglu, R. Bahl, B. Daelmans, M. Mathai, L. Say, F. Kristensen, Marleen Temmerman, F. Bustreo

Obstetrics and Gynaecology, East Africa

In 2015, as we review progress towards Millennium Development Goals (MDGs), despite significant progress in reduction of mortality, we still have unacceptably high numbers of maternal and newborn deaths globally. Efforts over the past decade to reduce adverse outcomes for pregnant women and newborns have been directed at increasing skilled birth attendance.1,2 This has resulted in higher rates of births in health facilities in all regions.3 The proportion of deliveries reportedly attended by skilled health personnel in developing countries rose from 56% in 1990 to 68% in 2012.4 With increasing utilisation of health services, a higher proportion of avoidable maternal …

Obstetrician-Gynecologists’ Knowledge Of Health Disparities And Barriers Among American Indian/Alaska Native Women In Washington State, Katherine M. Jones, Greta B. Raglan, Sophia M. Lannon, Jay Schulkin

Journal of Health Disparities Research and Practice

Background: Health disparities between American Indian/Alaska Native (AI/AN) women and other races/ethnicities have long been noted. Obstetricians-Gynecologists (Ob-Gyn) play a significant role in well-woman care and are often the first and most frequent point of medical contact for women, particularly among minority and low-income women.

Objective: This study aimed to assess Ob-Gyns’ knowledge, beliefs, and practices related to health disparities among AI/AN women.

Method: A self-administered questionnaire, consisting of questions about knowledge, beliefs, and practices of health disparities among AI/AN women, was mailed to 722 members of The American College of Obstetricians and Gynecologists (ACOG) practicing in the state of …

Do I Buy It? How Aidettm Training Changes Residents’ Values About Communication Skills In Doctor-Patient Interactions, Andrea Braverman, Phd, Austin Katona, B.Sc., Elisabeth Kunkel, Md, Leo Katz, Md, Matthew Keller, Md, Constantine Daskalakis, Sc.D, Jennifer Jasmine Arfaa, Phd, Mhsa

Department of Obstetrics and Gynecology Presentations and Grand Rounds

OBJECTIVES

Acquiring communication and interpersonal skills is an important part of providing patient-centered care and improving patient satisfaction. This study explores whether residents’ own values about patient communication change over time.

Comparing Neonatal Respiratory Morbidity In Neonates Delivered At Term By Elective Caesarean Section With And Without Dexamethasone: Retrospective Cohort Study, Anita Dileep, Neelofur Babar Khan, Sana Sadiq Sheikh

Department of Obstetrics & Gynaecology

Objective: To assess the effect of dexamethasone on neonatal respiratory morbidity in babies delivered by early term elective lower segment Caesarean section. Method: The retrospective cohort study was conducted at a secondary level hospital in Karachi. It reviewed the medical record of pregnant women and their babies who were delivered by elective lower segment Caesarean section between January 1 and June 30, 2013, at 37-38+6 weeks of pregnancy. The women were divided into exposed group (Group A) who received prophylactic dexamethasone, and non-exposed group (Group B) who did not receive dexamethasone Neonatal respiratory morbidity was compared between the two groups. …

Impact Of Self Regulation Skills On Students Academic Grades, Abeer Kathawala, Shelina Bhamani

Department of Obstetrics & Gynaecology

This research aimed to explore if self-regulation skills had any effect on the academic outcomes of young children in private schools of Karachi, Pakistan. Quantitative research method was used to determine the impact of self-regulation upon the academic outcome of young children by utilizing Early School Self-Regulation Scale-Care Giver Version (Bhamani, 2012).The sample size consisted of randomly chosen 210 children, studying in grades 1 and 2 from seven different private schools in Karachi. The results of the research show that selfregulation skills had a significant impact on the academic outcome of young children in private schools of Karachi, b = …