Can mean platelet volume values predict maternal and fetal outcomes in the third trimester of pregnancy in gestational diabetic patients? A retrospective cohort study

Abstract

This study aims to determine if mean platelet volume (MPV) can predict maternal and fetal outcomes in pregnant women during their third trimester. A retrospective case-control study was conducted at Medipol Hospital's Obstetrics and Gynecology Clinic, involving 200 women with gestational diabetes mellitus (GDM) and 200 healthy pregnant women. Data collected included age, gestational age, body mass index (BMI), and complete blood count parameters such as hemoglobin, hematocrit, thrombocyte count, and MPV values. The results indicated that the GDM group had significantly higher age, BMI, cesarean rates, and MPV values compared to the healthy group. Maternal complications like preeclampsia, preterm labor, shoulder dystocia, and fetal growth restriction were more frequent in the GDM group. Neonatal complications, including hyperbilirubinemia, hypoglycemia, transient tachypnea of the newborn (TTN), and increased admissions to the neonatal intensive care unit, were also significantly higher. A notable finding was the significant association between elevated maternal MPV values and the occurrence of TTN in newborns (p=0.043). Mothers of infants with TTN had higher third-trimester MPV values. Receiver operating characteristic (ROC) curve analysis established a cut-off MPV value of >11.35 ft for predicting TTN. The study concludes that elevated MPV in women with GDM is strongly associated with an increased risk of TTN in their newborns. MPV, being a simple and cost-effective parameter obtained from routine blood counts, could serve as a predictive marker for TTN. However, due to limitations such as the retrospective design and single-center data, further multi-center cohort studies are recommended to validate these findings and establish MPV as a reliable predictor for adverse neonatal outcomes in GDM pregnancies.

Full text

172 Rawal Medical Journal: Vol. 50, No. 1, Jan-Mar 2025
Original Article
Prevalence and negative impacts of traditional treatment practices in child
malnutrition: in South Darfur State, Sudan
Elghazaly A. Elghazaly,1.2 Khalid Alawad A. Mohammed,3 Abuobaida E. E. Abukhelaif4
Elfatih Mirghani M. Salih,3,5 Amir A. Bashir,6,7 Mujtaba A. Ali,8 Isameldin M. Abdalla6
1Department of Anatomy, Faculty of Medicine and Health Sciences, OIU, Sudan, 2Department of Anatomy,
Faculty of Medicine, Al-Baha University, KSA, 3Department of Pediatrics, Faculty of Medicine, Al-Baha
University, Al-Baha, Saudi Arabia, 4Department of Pathology, Faculty of Medicine, Al-Baha University, Al-
Baha, KSA, 5Department of Pediatrics, Faculty of Medicine, Dongola University, Dongola, Sudan, 6Department
of Physiology, Faculty of Medicine, Al-Baha University, KSA, 7Department of Physiology, Faculty of Medicine,
El-Imam El-Mahdi University, Sudan and 8Department of Surgery, Faculty of Medicine, Al-Baha University,
KSA.
Objective: To assess the prevalence and patterns of the
traditional treatment practices (TTPs) in South Darfur
state, Sudan, and correlate them with the
sociodemographic factors of participants.
Methodology: This prospective descriptive cross-
sectional hospital study was conducted from December
2020 and April 2021 and included 135 malnourished
children with their mothers who presented for treatment
of malnutrition at Nyala Teaching Hospital, South
Darfur State, Sudan. A detailed examination was
performed to look for signs of TTPs, then some
photographs were taken using a digital camera. The
sociodemographic characteristics of the respondents’
mothers were taken using a questionnaire.
Results: We found that 49.6% mothers were from rural
areas, 80% were aged between 20 to 39 years and 63.7%
were illiterate. Of the respondents’ mothers, 48.9%
were using pure TTPs. It was high in an area where
health centers are available. The commonest patterns of
TTPs were Tefessed (43.0%), followed by Abu Rafaf
(30.4%) and Abu Kass(16.3%), while removal of the
uvula and Reeh were in 6.6% and 3.7%, respectively.
The negative impacts following the use of TTPs were
infections, burns, damage to the palate, bleeding, and
death.
Conclusion: The high prevalence of TTPs indicates
that it is embedded in the cultural beliefs of the South
Darfur State, despite its various negative impacts. There
are unique traditional practices in the South Darfur State
community used for the treatment of malnutrition in
children under five years of age, such as Tefessid, Abu
Kass and Abu-Rafaf.
Keywords: Traditional treatment practices,
malnutrition, South Darfur, Sudan.
INTRODUCTION
Malnutrition is a serious health problem facing children,
especially in developing countries, causing a high
mortality rate in children under five years of age.1,2
Severe acute malnutrition (SAM) affects about 20 million
children under the age of 5 years and is associated with
1-2 million deaths each year.3 The population in
developing countries still depends mainly on alternative
methods of traditional treatment practices (TTPs) to treat
SAM.4,5 In Sudan, several health programs and
organizations are working to improve the nutritional
status of children under 5 years of age; however, many of
them die.5 The reason may be a lack of awareness of the
population in rural areas for the need to treat malnutrition
or local cultural practices that pay a great amount of
attention to policy formulation regarding the treatment of
malnutrition.
Despite the medical services offered by the Sudan
Ministry of Health and Health organizations in South
Darfur State, TTPs are still widely used in children under
5 years of age in many areas, especially in internally
displaced people (IDP) during Darfur State conflicts.6
Unfortunately, the children who were treated
traditionally developed a lot of complications.7 Most of
these require hospital care, long support, and care after
discharge.7,8
In South Darfur State, Sudan, TTPs for the treatment of
child malnutrition are still widely used, not only among
illiterates but also among educated people based on their
perceptions and previous experiences. It is important to
assess the possible adverse effects of these practices. This
study aimed to assess the prevalence and patterns of TTPs
in South Darfur state, Sudan, and correlate them with the
sociodemographic status of participant mothers.

Prevalence and negative impacts of traditional treatment practices in child malnutrition: in South Darfur State, Sudan
173 Rawal Medical Journal: Vol. 50, No. 1, Jan-Mar 2025
METHODOLOGY
This was a prospective
descriptive cross-
sectional hospital-
based study conducted
at Nyala Teaching
Hospital, South Darfur
State, Sudan from
December 2020 and
April 2021. It was
approved by the
Research Committee,
Nyala Teaching
Hospital in South
Darfur State, Sudan,
and the Ministry of
Health in South Darfur
State. Patient verbal
informed consent was
provided by all
mothers.
The study included
135 malnourished
children with their
Table 1: Sociodemographic characteristics of the respondents (N=135).
Characteristics
Frequency
%
Characteristics
Frequency
%
Ages of children (months)
Mother Age (years)
6- < 12 months
11
8.1%
< 20 years
14
10.4%
12- < 24 months
55
40.7%
20-29 years
65
48.1%
24- < 36 months
47
34.8%
30–39 years
43
31.9%
36- < 48 months
14
10.5%
> 40 years
13
9.6%
48- < 60 months
8
5.9%
Mothers Residence
The educational level of the mothers
Displaced
45
33.3%
Illiterate
86
63.7%
Rural areas
67
49.6%
Primary – middle
44
32.6%
Urban areas
23
17.1%
High
5
3.7%
Number of children in the family
Socioeconomic status of the family
< 5 children
43
31.8%
Low
75
55.6%
5- 10 Children
83
61.5%
Middle
36
26.7%
>10 children
9
6.7%
High
24
17.8
mothers admitted to the
Therapeutic Feeding Center of
hospital with SAM. The sample
size was convenient including
all severely malnourished
children under 5 years. We
included malnourished children
under 5 years of age with signs
of TTPs and SAM. Children
older than 5 years, without signs
of TTPs due to SAM treatment,
or those known to have
malnutrition due to other
causes, such as malabsorption,
congenital heart disease,
secondary malnutrition, and
without medical complications,
were excluded.
After hospital admission, a
detailed examination was
performed to look for signs of
malnutrition, then the growth
parameters were taken and
plotted on the percentile charts
to assess and classify the degree
of malnutrition, then the data
was collected using an
interview questionnaire to the
mothers. The questionnaire
Table 2: Types, treatment options, and outcomes of the traditional treatment.
Characteristics
Frequency
%
Treatment options
Used pure traditional treatment practices
66
48.9%
Used both traditional practices and medical treatments
43
31.9%
Used medical treatment only
18
13.3%
Used other options (stay at home without seeking
medical or traditional treatment)
8
5.9%
Total
135
100%
Types of traditional treatment practices used
Tefessed
47
43.0%
Abu Rafaf
33
30.4%
Abu Kass
18
16.3%
Removal of the uvula
7
6.6%
Reeh
4
3.7%
Total
109
100
Outcomes of traditional treatment practices
Improved
22
20%
Improved with complications
69
63.7%
Death
18
16.3%
Total
109
100%

Prevalence and negative impacts of traditional treatment practices in child malnutrition: in South Darfur State, Sudan
174 Rawal Medical Journal: Vol. 50, No. 1, Jan-Mar 2025
consisted of two parts the first part
was directed toward the
sociodemographic data (five
questions): Age, residence, family
socioeconomic status, educational
level, and number of children in the
family. The second part assessed the
maternal attitude toward seeking
advice, either medical or traditional,
as follows: Using traditional
Table 3: Factors affecting traditional treatment practice among mothers
(N=135).
Variable
Frequency
%
Maternal age ≥ 20 and ≤ 40 years
106
78.6%
Mothers who were illiterate and with a primary
educational level
116
86%
Displaced mothers and from a rural residence
103
76.3%
Fig. 1: Photographs show signs of
TTPs. A. Multiple skin scars on the
trunk of the child after TTPs of
Tefessid. B. Two skin scars below the
left nipple after the TTPs of Abu-
Rafaf. C. A burnt area around the
navel after the TTPs of Abu Kas. D.
The child after the removal of the
uvula. E. Scars and cautery marks on
the ankles and feet regions of the after
TTPs of Reeh. (Arrows show signs of
TTPs).
treatment, medical treatment, or both or neither of them,
type of traditional treatment used and outcomes of
traditional treatment practices.
Statistical Analysis: Data were analyzed using SPSS,
version 16.
RESULTS
Of all participants, 40.7% were males and 59.3% female
children. Of all mothers, 49.6% were from rural areas,
33.3% were referred from IDP camp clinics, 17.1% were
residents of Nyala town, 90.4% were under 40 years of
age, 63.7% were illiterate, 68.2% had more than five
children, and 82.3% were of lower to middle
socioeconomic status (Table 1).
The most common patterns of TTPs used for the
treatment of SAM by traditional healers were 43.0%
Tefessed followed by 30.4% Abu Rafaf and 16.3% Abu
Kass, while removal of the uvula and Reeh was 6.6%, 3.7,
respectively (Table 2). We found that 48.9% used pure
TTPs, 31.9% used TTPs and medical treatments, 13.3%

Prevalence and negative impacts of traditional treatment practices in child malnutrition: in South Darfur State, Sudan
175 Rawal Medical Journal: Vol. 50, No. 1, Jan-Mar 2025
used medical treatment only, and 5.9% used other options
(some mothers stay at home without seeking medical or
TTPs for their children) (Table 2).
The outcomes of the TTPs of malnutrition were variable:
20% improved, 63.7% improved with complications, and
16.3% died due to complications (Table 2). The TTPs
were more common among mothers belonging to the age
group ≥20 and ≤40 years (78.6%), mothers who were
illiterate and with primary educational level (86%), and
displaced mothers and from rural residence (76.3%)
(Table 3).
Types of the TTPs in the South Darfur community, Sudan
are described below.
Tefessid (skin incisions) is a multiple skin incision made
in the anterior aspect of the child's trunk using a local
metal surgical blade (Fig. A). Then, a powder (Eiare in
Arabic) made from the leaves and roots of Eiare plants,
some oils, and warm water are added to the incisional
site. This type treats the marasmus associated with
abdominal distention and muscle wasting. Healers
believe that abdominal distention is due to air and blood
accumulation and that the wounds would remove this air
and blood, while Eiare powder will heal the wounds.
Abu-Rafaf (skin incisions) is a skin incision made below
the left nipple, on the pulsation area of the heart, using a
metal surgical blade (Fig. B). This is used for the
treatment of visible heart pulsation. Healers believe that
the visible pulsations are due to the accumulation of bad
blood around the heart and that the wounds will remove
the bad blood, and the child's condition will improve.
Abu kas (Cupping) is a method in which a small glass
cup is placed around the child's umbilicus after being
heated with inflamed paper or boiled water (Fig. C). The
cup is left for about two to three minutes after ensuring
attachment to the skin, then removed, this process is
repeated two to five times. This is used to treat abdominal
pain. Healers believe that abdominal pain is due to the
accumulation of gases within the abdominal cavity, and
heated glass around the navel will absorb gases from the
abdomen.
Cutting of the Uvula is a traditional surgical practice in
which the whole uvula is removed using a locally made
metal surgical blade without using anesthesia (Fig. D).
This is used for the treatment of cough and vomiting. The
healer believes that cough and vomiting are due to
enlargement and elongation of the uvula, and removal of
the uvula would help stop cough and vomiting.
Reeh (Cauterization) (Al-Kaiy in Arabic) is a
cauterization that includes using a heated metal
instrument (nail or metal rod) for skin application in
edematous areas (Fig. E). This is used to treat edema,
especially in the lower extremities. Healers believe that
edema is due to the accumulation of air within these
areas; the heat generated by cauterization helps to leak
the air from the edematous areas.
The most common negative impacts observed for TTPs
in our study were infections (like gastroenteritis and
septicemia), burns, bleeding, disseminated intravascular
coagulopathy, persistent diarrhea and dehydration, injury
of the palate, malnutrition, and death.
DISCUSSION
The prevalence of TTPs in the South Darfur state was
found to be 48.9%. This high prevalence indicates that it
is embedded in the cultural beliefs of the South Darfur
State. TTPs were found to be more prevalent among
mothers aged 20-40 years old, illiterate and primary
educational level, and displaced mothers and from rural
residences. This is consistent with most of the previous
studies from Sudan, which found that most mothers used
TTPs for the treatment of child malnutrition in addition
to medical treatment.6,8 Therefore, TTPs in Sudan have a
long history of treating malnutrition disorders.
Several factors beyond the use of TTPs in South Darfur,
e.g., the nature of the Darfur community, education level
of the mothers, lack of health services in camps of IDPs,
family size, age of the marriage, and poverty. In addition,
mothers in Darfur are not familiar with the gradual
weaning of their children.9 Sudden weaning,
displacement, lack of health services, marriage age,
illiteracy, and poverty are considered the main causes of
the high prevalence of malnutrition among children in
these areas.
As shown in Table 3, it is logical that illiteracy and poor
level of education are associated with these TTPs. People
of rural communities in Sudan believe in these traditional
practices. The poor socio-economic status of the people
in the rural communities and the displaced sometimes
forced them to move to these TTPs due to the
unavailability of medical services as well as the cost. The
high rate of practicing traditional treatment in children to
mothers in the age group of 20-40 years as shown in
Table 3 may be not real as the number of malnourished
children to mothers below the age of 20 or above 40 was
a small number, so the obtained results may not be
trusted.
The current study found that the percentage of mothers
who used TTPs was high compared to those who used
medical treatments in a setting where health facilities are
easily accessible. It seems that accessibility to health
centers is not the cause, but the strong belief that
malnutrition diseases are treated more efficiently using
TTPs rather than medical treatment. These findings
consistant with studies of Ahmed et al,4 from Pakistan,
Ngere et al,5 from Western Kenya, and Abdalbasit et al,8

Prevalence and negative impacts of traditional treatment practices in child malnutrition: in South Darfur State, Sudan
176 Rawal Medical Journal: Vol. 50, No. 1, Jan-Mar 2025
from Sudan, Gudu et al,10 from Western Kenya and
Towns et al,11 from Western Africa. Therefore, the
health-seeking behavior among mothers in the Darfur
state for using TTPs for the treatment of malnutrition is a
cultural belief more than a cure, even educated mothers
choose the traditional practice as an option for the
treatment of malnutrition compared to illiterate.
Unfortunately, the traditional practices for the treatment
of malnutrition are part of the many ancient Sudanese
cultures used in most of its states in different patterns and
methods.8 Although many government programs and
non-government organizations are working to stop TTPs
for the treatment of malnutrition of children under five
years old, it still occurs away from health facilities. Many
complications were found concerning the measures taken
in the use of TTPs for the treatment of malnutrition in this
study, most of the children treated traditionally became
victims of one or more of these measures.
The most common TTPs used were Tefessid (43.0%) and
Abu-Rafaf (30.4%). These types were found associated
with several health complications, such as bleeding,
burns, infections, and even death. Therefore, Tefessid
and Abu-Rafaf worsen health conditions compared to the
use of plants, as reported in previous studies.12-14 Skin
integrity in malnourished children is important,
especially since they suffer from a deficiency of some
nutritional elements.
Reeh was found (3.7%) in this study. Reeh or
cauterization was used in Arab medicine for the treatment
of pain and swollen areas; it was also mentioned in the
Hadith prophet Mohammed (peace be upon him) (El-Safi
A 2007).15 Some studies have found negative impacts of
cauterization, e.g., deep burns, multiple abscesses, and
severe bleeding, while others found the opposite:
cauterization treats abdominal pain, headache, and
stomach and back pain.8,16,17 Although Reeh is extremely
rare to be used in Darfur State, as seen in this study, it
caused serious complications, including bleeding, burns,
infections, septicemia, and even death.
Cupping was found (16.3%) in this study. Cupping is
used to treat a wide variety of painful conditions, such as
muscle aches, abdominal pain, headaches, and
migraines.15 In Sudan, cupping is an old practice used to
extract corrupt blood from the body using a tool to suck
certain places of the body, such as the back, the occiput
of the head, the ankles, and the stomach, it is locally
known as Abu kas in Darfur state.8 Several negative
effects were found due to the use of Abu Kas in this study,
which ranged from burns, skin irritation and blistering.
This is consistent with the results of Moura CC, who
found that cupping therapy has many adverse effects on
skin integrity.18 Cupping is generally considered safe and
has many benefits, but it sometimes worsens skin
conditions. While the cutting uvula was found in (6.6%)
of the current study, it is considered lower compared to
Tefessid, Abu Rafaf, and Abu Kass, it was found
associated with a high incidence of death because it is
performed by unsterilized metal blades.
The TTPs develop many complications in children, such
as scar formation, skin inflammation, septic shock,
tetanus, liver encephalopathy, and death.5,19 In the current
study, 16.3% children died and 63.7% developed severe
complications, while the recovery rate is lower than the
standard acceptable ranges and the length of hospital stay
is prolonged. However, until now, the rationale behind
the use of TTPs has not been determined concerning the
treatment of malnutrition.
This study is subject to some limitations. The study did
not collect data on cultural beliefs or religion in this
setting. The study did not include other states to evaluate
the prior use of traditional practices for the treatment of
malnutrition among children under five years of age.
Therefore, there is a need for other studies, including all
Sudanese states, to provide evidence of the extent and
adverse effects of these practices. As the study was
hospital-based, we have not an equal distribution of
patients across the age groups, this can be considered as
one of the limitations of our study, as we can not judge
that maternal age was a risk factor for these TTPs.
CONCLUSION
The prevalence of TTPs in the South Darfur state was
found to be 48.9%. This high prevalence indicates to what
extent it is embedded in the cultural beliefs of the South
Darfur State, although it is associated with many negative
impacts. There is a strong correlation between
sociodemographic factors and the use of TTP since, it
was found that TTPs are more prevalent in illiterate
women, displaced women, and those living in rural areas.
Negative impacts associated with the use of TTP were
infections (like gastroenteritis and septicemia), burns,
bleeding, disseminated intravascular coagulopathy,
persistent diarrhea, dehydration, palate injury, and death.
Health authorities should take crucial measures and
actions to reduce and limit the use of TTPs for the
treatment of malnutrition or by increasing community
awareness, such as providing educational campaigns and
spreading them to rural areas through outreach clinics.

Prevalence and negative impacts of traditional treatment practices in child malnutrition: in South Darfur State, Sudan
177 Rawal Medical Journal: Vol. 50, No. 1, Jan-Mar 2025
Author Contributions:
Conception and design: Elghazaly A. Elghazaly, Khalid Alawad A.
Mohammed.
Collection and assembly of data: Elghazaly A. Elghazaly, Khalid Alawad
A. Mohammed, Amir A. Bashir, Mujtaba A. Ali, Isameldin M. Abdalla.
Analysis and interpretation of the data: Elghazaly A. Elghazaly, Khalid
Alawad A. Mohammed.
Drafting of the article: Elghazaly A. Elghazaly, Khalid Alawad A.
Mohammed, Abuobaida and Elfatih.
Critical revision of the article for important intellectual content.
Statistical expertise: Abuobaida and Elfatih, Elfatih Mirghani M. Salih.
Final approval and guarantor of the article: Elghazaly A. Elghazaly.
Corresponding Author Email: Elghazaly A. Elghazaly:
gazaly518@yahoo.com
Conflict of Interest: None declared.
Source of Funding: None disclosed.
Rec. Date: Oct 16, 2024 Revision Rec. Date: Nov 23, 2024 Accept Date:
Dec 12, 2024.
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