Maternal mortality in the rural Gambia, a qualitative study on access to emergency obstetric care

BACKGROUND: Maternal mortality is the vital indicator with the greatest disparity between developed and developing countries. The challenging nature of measuring maternal mortality has made it necessary to perform an action-oriented means of gathering information on where, how and why deaths are occurring; what kinds of action are needed and have been taken. A maternal death review is an in-depth investigation of the causes and circumstances surrounding maternal deaths. The objectives of the present study were to describe the socio-cultural and health service factors associated with maternal deaths in rural Gambia. METHODS: We reviewed the cases of 42 maternal deaths of women who actually tried to reach or have reached health care services. A verbal autopsy technique was applied for 32 of the cases. Key people who had witnessed any stage during the process leading to death were interviewed. Health care staff who participated in the provision of care to the deceased was also interviewed. All interviews were tape recorded and analyzed by using a grounded theory approach. The standard WHO definition of maternal deaths was used. RESULTS: The length of time in delay within each phase of the model was estimated from the moment the woman, her family or health care providers realized that there was a complication until the decision to seeking or implementing care was made. The following items evolved as important: underestimation of the severity of the complication, bad experience with the health care system, delay in reaching an appropriate medical facility, lack of transportation, prolonged transportation, seeking care at more than one medical facility and delay in receiving prompt and appropriate care after reaching the hospital. CONCLUSION: Women do seek access to care for obstetric emergencies, but because of a variety of problems encountered, appropriate care is often delayed. Disorganized health care with lack of prompt response to emergencies is a major factor contributing to a continued high mortality rate

History and importance of antimalarial drug resistance

The definitive version is available at www3.interscience.wiley.comThe emergence of Plasmodium falciparum resistance to widely used antimalarial drugs such as chloroquine (CQ) has made malaria control and treatment much more difficult. This is particularly dramatic for Africa, as few affordable alternatives are available. Drug pressure has been identified as one of the key factors for the emergence and spread of resistance. The contribution of the extensive use and misuse of antimalarial drugs to the selection of resistant parasites became particularly evident during the Global Malaria Eradication campaign, launched by World Health Organization (WHO) in 1955. The first reports confirming P. falciparum resistance to CQ came almost simultaneously in the early 1960s from South America and South-East Asia, where direct or indirect (through use of medicated cooking salt) mass drug administration (MDA) had been implemented. Similar approaches were very limited in Africa, where P. falciparum resistance to CQ was first reported from the eastern region in the late 1970s and spread progressively west. Most African countries still rely heavily on CQ as first-line treatment despite various levels of resistance, although some states have changed to sulphadoxine-pyrimethamine (SP) as the first-line drug. Unfortunately, the predicted SP useful therapeutic life might be very short, probably because of its prolonged half-life, causing a higher probability of selecting resistant strains and a consequent fast development of resistance. CQ resistance is not evenly distributed and important differences can be found within and between countries. It seems to have spread more rapidly in East than in West Africa. Considering the high level of CQ use in West Africa, other factors such as intensity of transmission, population immunity or population movements should be considered when explaining the different levels of resistance. Understanding such factors may help us in devising strategies to contain the spread of drug resistance

Skilled attendance at childbirth: let us go beyond the rhetorics [editorial]

The definitive version is available at www3.interscience.wiley.co