Did the strategy of skilled attendance at birth reach the poor in Indonesia?

Objective To assess whether the strategy of “a midwife in every village” in Indonesia achieved its aim of increasing professional delivery care for the poorest women. Methods Using pooled Demographic and Health Surveys (DHS) data from 1986–2002, we examined trends in the percentage of births attended by a health professional and deliveries via caesarean section. We tested for effects of the economic crisis of 1997, which had a negative impact on Indonesia’s health system. We used logistic regression, allowing for time-trend interactions with wealth quintile and urban/rural residence. Findings There was no change in rates of professional attendance or caesarean section before the programme’s full implementation (1986–1991). After 1991, the greatest increases in professional attendance occurred among the poorest two quintiles – 11% per year compared with 6% per year for women in the middle quintile ( P = 0.02). These patterns persisted after the economic crisis had ended. In contrast, most of the increase in rates of caesarean section occurred among women in the wealthiest quintile. Rates of caesarean deliveries remained at less than 1% for the poorest two-fifths of the population, but rose to 10% for the wealthiest fifth. Conclusion The Indonesian village midwife programme dramatically reduced socioeconomic inequalities in professional attendance at birth, but the gap in access to potentially life-saving emergency obstetric care widened. This underscores the importance of understanding the barriers to accessing emergency obstetric care and of the ways to overcome them, especially among the poor

Traditional preparations used as uterotonics in Sub‐Saharan Africa and their pharmacologic effects

BackgroundLittle is known about the use of traditional preparations for uterotonic effects at or near delivery in Sub‐Saharan Africa.ObjectiveTo describe (1) use of traditional preparations in Sub‐Saharan Africa intended to have uterotonic effects at or near birth; and (2) results of pharmacologic investigations of the uterotonic properties of such preparations.Search strategyStructured review of 13 databases.Selection criteriaArticles describing use of traditional preparations in Sub‐Saharan Africa with primary data, published in English between January 1, 1980 and June 30, 2010.Data collection and analysisFull‐text review using standard spreadsheet templates.Main resultsObjective 1 analysis identified 208 plant species used for uterotonic effects at or near delivery. The most common use was labor induction/augmentation (n = 185). Other uses were to expel the placenta, shorten the third stage of labor, manage retained placenta (n = 61), and prevent/manage postpartum hemorrhage (n = 20). Objective 2 analysis identified 82 species with uterotonic activity confirmed through pharmacologic evaluation. Studies also identified potentiating/inhibiting effects of extracts on pharmaceutical uterotonics.ConclusionNumerous plants are used for uterotonic effects in Sub‐Saharan Africa; uterotonic activity has been confirmed in many through pharmacologic evaluation. Such use may increase the risk of adverse outcomes. Further research is needed on the uterotonic efficacy of traditional preparations and on interventions to address use during labor.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135671/1/0-mmc1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135671/2/ijgo16.pd

Development and Validation of an Index to Measure the Quality of Facility-Based Labor and Delivery Care Processes in Sub-Saharan Africa.

High quality care is crucial in ensuring that women and newborns receive interventions that may prevent and treat birth-related complications. As facility deliveries increase in developing countries, there are concerns about service quality. Observation is the gold standard for clinical quality assessment, but existing observation-based measures of obstetric quality of care are lengthy and difficult to administer. There is a lack of consensus on quality indicators for routine intrapartum and immediate postpartum care, including essential newborn care. This study identified key dimensions of the quality of the process of intrapartum and immediate postpartum care (QoPIIPC) in facility deliveries and developed a quality assessment measure representing these dimensions. Global maternal and neonatal care experts identified key dimensions of QoPIIPC through a modified Delphi process. Experts also rated indicators of these dimensions from a comprehensive delivery observation checklist used in quality surveys in sub-Saharan African countries. Potential QoPIIPC indices were developed from combinations of highly-rated indicators. Face, content, and criterion validation of these indices was conducted using data from observations of 1,145 deliveries in Kenya, Madagascar, and Tanzania (including Zanzibar). A best-performing index was selected, composed of 20 indicators of intrapartum/immediate postpartum care, including essential newborn care. This index represented most dimensions of QoPIIPC and effectively discriminated between poorly and well-performed deliveries. As facility deliveries increase and the global community pays greater attention to the role of care quality in achieving further maternal and newborn mortality reduction, the QoPIIPC index may be a valuable measure. This index complements and addresses gaps in currently used quality assessment tools. Further evaluation of index usability and reliability is needed. The availability of a streamlined, comprehensive, and validated index may enable ongoing and efficient observation-based assessment of care quality during labor and delivery in sub-Saharan Africa, facilitating targeted quality improvement

Resonance classification of mixed assemblages of fish with swimbladders using a modified commercial broadband acoustic echosounder at 1–6 kHz

Author Posting. © The Authors, 2012. This article is posted here by permission of NRC Research Press for personal use, not for redistribution. The definitive version was published in Canadian Journal of Fisheries and Aquatic Sciences 69 (2012): 854-868, doi:10.1139/f2012-013.Recently developed broadband acoustic methods were used to study mixed assemblages of fish spanning a wide range of lengths and species. Through a combination of resonance classification and pulse-compression signal processing, which provides for high-range resolution, a modified commercial broadband echosounder was demonstrated to provide quantitative information on the spatial distribution of the individual size classes within an assemblage. In essence, this system spectrally resolves the different size classes of fish that are otherwise not resolved spatially. This method reveals new insights into biological processes, such as predator–prey interactions, that are not obtainable through the use of a conventional narrowband high-frequency echosounder or previous broadband systems. A recent study at sea with this system revealed aggregations containing bladdered fish 15–30 cm in length (Atlantic herring (Clupea harengus) and silver hake (Merluccius bilinearis)) and a variety of species of smaller fish 2–5 cm in length. These observations infer that the smaller 2–5 cm fish can be colocated in the same aggregations as their predator, the larger silver hake, as well as pre-spawning herring. While this technological advancement provides more information, there remain challenges in interpreting the echo spectra in terms of meaningful biological quantities such as size distribution and species composition.This research was supported by the US Office of Naval Research (grant Nos. N00014-04-1-0440 and N00014-10-1-0127), NOAA – National Marine Fisheries Service; and the J. Seward Johnson Chair of the WHOI Academic Programs Office

Improving coverage measurement for reproductive, maternal, neonatal and child health: gaps and opportunities.

BACKGROUND: Regular monitoring of coverage for reproductive, maternal, neonatal, and child health (RMNCH) is central to assessing progress toward health goals. The objectives of this review were to describe the current state of coverage measurement for RMNCH, assess the extent to which current approaches to coverage measurement cover the spectrum of RMNCH interventions, and prioritize interventions for a novel approach to coverage measurement linking household surveys with provider assessments. METHODS: We included 58 interventions along the RMNCH continuum of care for which there is evidence of effectiveness against cause-specific mortality and stillbirth. We reviewed household surveys and provider assessments used in low- and middle-income countries (LMICs) to determine whether these tools generate measures of intervention coverage, readiness, or quality. For facility-based interventions, we assessed the feasibility of linking provider assessments to household surveys to provide estimates of intervention coverage. RESULTS: Fewer than half (24 of 58) of included RMNCH interventions are measured in standard household surveys. The periconceptional, antenatal, and intrapartum periods were poorly represented. All but one of the interventions not measured in household surveys are facility-based, and 13 of these would be highly feasible to measure by linking provider assessments to household surveys. CONCLUSIONS: We found important gaps in coverage measurement for proven RMNCH interventions, particularly around the time of birth. Based on our findings, we propose three sets of actions to improve coverage measurement for RMNCH, focused on validation of coverage measures and development of new measurement approaches feasible for use at scale in LMICs

Dominance, Politics, and Physiology: Voters' Testosterone Changes on the Night of the 2008 United States Presidential Election

BACKGROUND: Political elections are dominance competitions. When men win a dominance competition, their testosterone levels rise or remain stable to resist a circadian decline; and when they lose, their testosterone levels fall. However, it is unknown whether this pattern of testosterone change extends beyond interpersonal competitions to the vicarious experience of winning or losing in the context of political elections. Women's testosterone responses to dominance competition outcomes are understudied, and to date, a clear pattern of testosterone changes in response to winning and losing dominance competitions has not emerged. METHODOLOGY/PRINCIPAL FINDINGS: The present study investigated voters' testosterone responses to the outcome of the 2008 United States Presidential election. 183 participants provided multiple saliva samples before and after the winner was announced on Election Night. The results show that male Barack Obama voters (winners) had stable post-outcome testosterone levels, whereas testosterone levels dropped in male John McCain and Robert Barr voters (losers). There were no significant effects in female voters. CONCLUSIONS/SIGNIFICANCE: The findings indicate that male voters exhibit biological responses to the realignment of a country's dominance hierarchy as if they participated in an interpersonal dominance contest

Measuring Coverage in MNCH: Validating Women’s Self-Report of Emergency Cesarean Sections in Ghana and the Dominican Republic

Background: Cesarean section is the only surgery for which we have nearly global population-based data. However, few surveys provide additional data related to cesarean sections. Given weaknesses in many health information systems, health planners in developing countries will likely rely on nationally representative surveys for the foreseeable future. The objective is to validate self-reported data on the emergency status of cesarean sections among women delivering in teaching hospitals in the capitals of two contrasting countries: Accra, Ghana and Santo Domingo, Dominican Republic (DR). Methods and Findings: This study compares hospital-based data, considered the reference standard, against women’s self-report for two definitions of emergency cesarean section based on the timing of the decision to operate and the timing of the cesarean section relative to onset of labor. Hospital data were abstracted from individual medical records, and hospital discharge interviews were conducted with women who had undergone cesarean section in two hospitals. The study assessed sensitivity, specificity, and positive predictive value of responses to questions regarding emergency versus non-emergency cesarean section and estimated the percent of emergency cesarean sections that would be obtained from a survey, given the observed prevalence, sensitivity, and specificity from this study. Hospital data were matched with exit interviews for 659 women delivered via cesarean section for Ghana and 1,531 for the Dominican Republic. In Ghana and the Dominican Republic, sensitivity and specificity for emergency cesarean section defined by decision time were 79% and 82%, and 50% and 80%, respectively. The validity of emergency cesarean defined by operation time showed less favorable results than decision time in Ghana and slightly more favorable results in the Dominican Republic. Conclusions: Questions used in this study to identify emergency cesarean section are promising but insufficient to promote for inclusion in international survey questionnaires. Additional studies which confirm the accuracy of key facility-based indicators in advance of data collection and which use a longer recall period are warranted

Stillbirths: Where? When? Why? How to make the data count?

Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible-not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2·65 million stillbirths (uncertainty range 2·08 million to 3·79 million) were estimated worldwide in 2008 (≥1000 g birthweight or ≥28 weeks of gestation). 98% of stillbirths occur in low-income and middle-income countries, and numbers vary from 2·0 per 1000 total births in Finland to more than 40 per 1000 total births in Nigeria and Pakistan. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. In total, an estimated 1·19 million (range 0·82 million to 1·97 million) intrapartum stillbirths occur yearly. Most intrapartum stillbirths are associated with obstetric emergencies, whereas antepartum stillbirths are associated with maternal infections and fetal growth restriction. National estimates of causes of stillbirths are scarce, and multiple (>35) classification systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specific perinatal certificates and revised International Classification of Disease codes, are needed. A simple, programme-relevant stillbirth classification that can be used with verbal autopsy would provide a basis for comparable national estimates. A new focus on all deaths around the time of birth is crucial to inform programmatic investment