The Pathway to Improved Maternal and Newborn Health Outcomes: Use of data for maternal and newborn health in Gombe State, Nigeria

This leaflet describes the process of mapping innovations of projects funded by the Bill & Melinda Gates Foundation, which contribute to Gombe State maternal and newborn health provision. The process was discussed and agreed at a meeting in Abuja in January 2016 and this leaflet represents their work at that time. Participants at the meeting were from the Gombe State Primary Health Care Development Agency, Bill & Melinda Gates Foundation grantees operating in the State: the Society for Family Health, Pact’s SAQIP project, Champions for Change, MamaYe and IDEA

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

Ocena i porównanie skuteczności hipotensyjnej i tolerancji maleinianu amlodypiny i benzenosulfonianu amlodypiny u chorych z nadciśnieniem tętniczym pierwotnym

Wstęp Celem przeprowadzonego, wieloośrodkowego, trwającego sześć miesięcy badania była ocena skuteczności hipotensyjnej i tolerancji maleinianu amlodypiny u chorych na nadciśnienie tętnicze. Materiał i metody W pierwszej części badania porównano skuteczność hipotensyjną maleinianu amlodypiny (Tenox, Krka) i benzenosulfonianu amlodypiny (Norvasc, Pfizer) w trwającym trzy miesiące badaniu przeprowadzonym metodą podwójnie ślepej próby w grupach równoległych. W drugiej części badania oceniano skuteczność hipotensyjną i tolerancję maleinianu amlodypiny w trwającym sześć miesięcy badaniu przeprowadzonym metodą otwartą. Badaniem objęto 245 chorych (w pierwszej części) i 202 chorych (w drugiej części) z nadciśnieniem tętniczym zdefiniowanym jako rozkurczowe ciśnienie tętnicze 95–114 mm Hg. Kryterium skuteczności leczenia było obniżenie ciśnienia rozkurczowego do wartości 89 mm Hg i mniej lub obniżenie ciśnienia rozkurczowego o 10 mm Hg i więcej. Do drugiej części badania włączono chorych u których uzyskano zadawalającą kontrolę ciśnienia tętniczego w pierwszej części. Wyniki W trakcie pierwszej części badania leczenie obydwoma lekami było związane z istotnym, porównywalnym obniżeniem ciśnienia tętniczego. Leczenie benzenosulfonianem amlodypiny związane było z większym obniżeniem rozkurczowego ciśnienia tętniczego o 1,27 mm Hg w porównaniu z leczeniem maleinianem amlodypiny (różnica ta była jednak nieistotna stastycznie i mieściła się w 90% przedziale ufności braku różnic pomiędzy porównywanymi lekami). Nie zaobserwowano różnic pomiędzy chorymi leczonymi badanymi solami amlodypiny w odniesieniu do częstości osiągnięcia docelowych wartości rozkurczowego ciśnienia tętniczego(90,91% i 89,52% odpowiednio dla maleinianu i benzenosulfonianu amlodypiny). W drugiej części badania, po 6 miesiącach, leczenie maleinianem amlodypiny związane było z obniżeniem rozkurczowego i skurczowego ciśnienia tętniczego o –17,5/–21,2 mm Hg w porównaniu z wartościami wyjściowymi. W trakcie pierwszej części badania u 35 chorych w grupie otrzymującej maleinian amlodypiny i 47 chorych w grupie otrzymującej benzenosulfonian amlodypiny wystąpiły zdarzenia niepożądane (28,9% vs. 37,9%, p = NS). Częstość występowania zdarzeń niepożądanych w drugiej części badania wynosiła 8,4%. Wnioski Uzyskanie wyniki wskazują, że maleinian amlodypiny i benzenosulfonian amlodypiny stosowane w monoterapii u chorych z łagodnym i umiarkowanym nadciśnieniem tętniczym charakteryzują się porównywalną wysoką skutecznością hipotensyjną i porównywalną częstością zdarzeń niepożądanych. Leczenie maleinianem amlodypiny przez dalsze sześć miesięcy charakteryzowało się wysoką skutecznością hipotensyjną i dobrą tolerancją.Background A nine-month follow-up, multicenter study was carried out to assess the efficacy and safety of amlodipine maleate, a recently launched amlodipine salt in 263 patients with essential hypertension. Material and methods In the first phase of the trial, a 3-month equivalence assessment with the reference besylate salt has been carried out in a randomised doubleblind fashion including placebo run-in period. The equivalence margins were set to be ± 4 mm Hg. The second phase was a 6-month open non-comparative extension of the equivalence phase to provide additional information on clinical efficacy and acceptability during prolonged treatment with amlodipine maleate. Essential hypertension was defined as a sitting diastolic blood pressure (DBP) being within the range of 95–114 mm Hg and systolic blood pressure below 180 mm Hg. An adequate blood pressure control defined as reaching the target DBP of 89 mm Hg or at least 10 mm Hg reduction of DBP compared to the baseline values, was the inclusion criterion for the second phase. The primary endpoint was the mean absolute reduction of DBP at the end of the active treatment in relation to the baseline. Results Altogether, 245 patients were analyzed in the equivalence comparative part, while 202 patients were included in the analysis of the open follow-up period. Both drugs have significantly lowered DBP and SBP after 3 months of treatment compared with the baseline values while heart rate has not been significantly changed in any of the treatment groups. The difference in these parameters between the salts was not significant. The difference in DBP reduction between the treatments was 1.27 mm Hg in favour of the besylate salt and the 90% confidence interval fell entirely within the equivalence margins. There was no difference between the salts in the percentage of patients reaching the target DBP (90.91% and 89.52% for maleate and besylate, respectively). The DBP/SBP reduction after the amlodipine maleate at the end of the 6-month second phase was –17.5/–21.2 mm Hg compared to the baseline values (paired t test, p < 0.0001). Blood pressure control was adequate during the second phase. Thirty-five patients in the amlodipine maleate group and 47 patients in the amlodipine besylate group reported adverse reactions during the 3-month comparative (28.9% and 37.9%, for maleate and besylate, respectively, p = NS). The overall incidence of amlodipine maleate-related adverse events during the second phase was 8.4%. Conclusions In conclusion, amlodipine maleate was shown to be equivalent to the reference besylate salt in terms of antihypertensive efficacy, and safety profiles of the two salts were not significantly different. Amlodipine maleate enabled adequate blood pressure control and was shown to be well tolerated during the entire 9-month follow-up

Nine month follow-up of amlodipine maleate and amlodipine besylate treatment in patients with essential hypertension: does the salt form matter?

Wstęp Celem przeprowadzonego, wieloośrodkowego, trwającego sześć miesięcy badania była ocena skuteczności hipotensyjnej i tolerancji maleinianu amlodypiny u chorych na nadciśnienie tętnicze. Materiał i metody W pierwszej części badania porównano skuteczność hipotensyjną maleinianu amlodypiny (Tenox, Krka) i benzenosulfonianu amlodypiny (Norvasc, Pfizer) w trwającym trzy miesiące badaniu przeprowadzonym metodą podwójnie ślepej próby w grupach równoległych. W drugiej części badania oceniano skuteczność hipotensyjną i tolerancję maleinianu amlodypiny w trwającym sześć miesięcy badaniu przeprowadzonym metodą otwartą. Badaniem objęto 245 chorych (w pierwszej części) i 202 chorych (w drugiej części) z nadciśnieniem tętniczym zdefiniowanym jako rozkurczowe ciśnienie tętnicze 95&#8211;114 mm Hg. Kryterium skuteczności leczenia było obniżenie ciśnienia rozkurczowego do wartości 89 mm Hg i mniej lub obniżenie ciśnienia rozkurczowego o 10 mm Hg i więcej. Do drugiej części badania włączono chorych u których uzyskano zadawalającą kontrolę ciśnienia tętniczego w pierwszej części. Wyniki W trakcie pierwszej części badania leczenie obydwoma lekami było związane z istotnym, porównywalnym obniżeniem ciśnienia tętniczego. Leczenie benzenosulfonianem amlodypiny związane było z większym obniżeniem rozkurczowego ciśnienia tętniczego o 1,27 mm Hg w porównaniu z leczeniem maleinianem amlodypiny (różnica ta była jednak nieistotna stastycznie i mieściła się w 90% przedziale ufności braku różnic pomiędzy porównywanymi lekami). Nie zaobserwowano różnic pomiędzy chorymi leczonymi badanymi solami amlodypiny w odniesieniu do częstości osiągnięcia docelowych wartości rozkurczowego ciśnienia tętniczego(90,91% i 89,52% odpowiednio dla maleinianu i benzenosulfonianu amlodypiny). W drugiej części badania, po 6 miesiącach, leczenie maleinianem amlodypiny związane było z obniżeniem rozkurczowego i skurczowego ciśnienia tętniczego o &#8211;17,5/&#8211;21,2 mm Hg w porównaniu z wartościami wyjściowymi. W trakcie pierwszej części badania u 35 chorych w grupie otrzymującej maleinian amlodypiny i 47 chorych w grupie otrzymującej benzenosulfonian amlodypiny wystąpiły zdarzenia niepożądane (28,9% vs. 37,9%, p = NS). Częstość występowania zdarzeń niepożądanych w drugiej części badania wynosiła 8,4%. Wnioski Uzyskanie wyniki wskazują, że maleinian amlodypiny i benzenosulfonian amlodypiny stosowane w monoterapii u chorych z łagodnym i umiarkowanym nadciśnieniem tętniczym charakteryzują się porównywalną wysoką skutecznością hipotensyjną i porównywalną częstością zdarzeń niepożądanych. Leczenie maleinianem amlodypiny przez dalsze sześć miesięcy charakteryzowało się wysoką skutecznością hipotensyjną i dobrą tolerancją.Background A nine-month follow-up, multicenter study was carried out to assess the efficacy and safety of amlodipine maleate, a recently launched amlodipine salt in 263 patients with essential hypertension. Material and methods In the first phase of the trial, a 3-month equivalence assessment with the reference besylate salt has been carried out in a randomised doubleblind fashion including placebo run-in period. The equivalence margins were set to be &#177; 4 mm Hg. The second phase was a 6-month open non-comparative extension of the equivalence phase to provide additional information on clinical efficacy and acceptability during prolonged treatment with amlodipine maleate. Essential hypertension was defined as a sitting diastolic blood pressure (DBP) being within the range of 95-114 mm Hg and systolic blood pressure below 180 mm Hg. An adequate blood pressure control defined as reaching the target DBP of 89 mm Hg or at least 10 mm Hg reduction of DBP compared to the baseline values, was the inclusion criterion for the second phase. The primary endpoint was the mean absolute reduction of DBP at the end of the active treatment in relation to the baseline. Results Altogether, 245 patients were analyzed in the equivalence comparative part, while 202 patients were included in the analysis of the open follow-up period. Both drugs have significantly lowered DBP and SBP after 3 months of treatment compared with the baseline values while heart rate has not been significantly changed in any of the treatment groups. The difference in these parameters between the salts was not significant. The difference in DBP reduction between the treatments was 1.27 mm Hg in favour of the besylate salt and the 90% confidence interval fell entirely within the equivalence margins. There was no difference between the salts in the percentage of patients reaching the target DBP (90.91% and 89.52% for maleate and besylate, respectively). The DBP/SBP reduction after the amlodipine maleate at the end of the 6-month second phase was &#8211;17.5/&#8211;21.2 mm Hg compared to the baseline values (paired t test, p < 0.0001). Blood pressure control was adequate during the second phase. Thirty-five patients in the amlodipine maleate group and 47 patients in the amlodipine besylate group reported adverse reactions during the 3-month comparative (28.9% and 37.9%, for maleate and besylate, respectively, p = NS). The overall incidence of amlodipine maleate-related adverse events during the second phase was 8.4%. Conclusions In conclusion, amlodipine maleate was shown to be equivalent to the reference besylate salt in terms of antihypertensive efficacy, and safety profiles of the two salts were not significantly different. Amlodipine maleate enabled adequate blood pressure control and was shown to be well tolerated during the entire 9-month follow-up

Antihypertensive efficacy and safety of amlodipine maleate in the treatment of patients with mild to moderate essential hypertension : comparison with amlodipine besylate

Wstęp Amlodipina należy do jednych z najdłużej działających antagonistów wapnia, charakteryzuje się łagodnym początkiem działania hipotensyjnego i długotrwałym efektem hipotensyjnym, przekraczającym 24 godziny. Celem przeprowadzonego badania III fazy było porównanie skuteczności hipotensyjnej i tolerancji dwóch form amlodipiny - maleinianu amlodipiny i benzenosulfonianu amlodipiny - u chorych z łagodnym i umiarkowanym nadciśnieniem tętniczym pierwotnym. Materiał i metody Badanie o charakterze prospektywnym, randomizowanym, przeprowadzonym metodą podwójnie ślepej próby w grupach równoległych, wykonano w 7 ośrodkach w Polsce. Do programu włączano chorych z nadciśnieniem tętniczym pierwotnym, z ciśnieniem rozkurczowym mieszczącym się w zakresie 95-114 mm Hg i ciśnieniem skurczowym poniżej 180 mm Hg. Po okresie wstępnym, w trakcie którego chorzy otrzymywali placebo, 250 losowo chorych przydzielono do dwóch grup - grupy otrzymującej lek oceniany, maleinian amlodipiny (Tenox, Krka) w dawce 5 mg, lub do grupy otrzymującej lek referencyjny, benzenosulfonian amlodipiny (Norvasc, Pfizer) w dawce 5 mg. Po 6 tygodniach leczenia u chorych, u których nie uzyskano obniżenia wartości ciśnienia rozkurczowego poniżej 90 mm Hg, zwiększano dawkę leku do 10 mg maleinianu lub benzenosulfonianu amlodipiny. Głównym kryterium oceny badania było porównanie względnego średniego obniżenia rozkurczowego ciśnienia tętniczego w badanych grupach, wyrażonego jako różnica pomiędzy ciśnieniem rozkurczowym na początku i na końcu 12-tygodniowego okresu leczenia. Dodatkowymi kryteriami oceny badania było porównanie względnego średniego obniżenia skurczowego ciśnienia tętniczego i częstości akcji serca w badanych grupach, wyrażonych jako różnica pomiędzy wartościami tych parametrów zmierzonymi na początku i na końcu 12-tygodniowego okresu leczenia. Dokonano także oceny skuteczności hipotensyjnej ocenianej uzyskaniem docelowych wartości rozkurczowego ciśnienia tętniczego. Wyniki Końcowej analizie skuteczności hipotensyjnej leku, ocenianego i referencyjnego benzenosulfonianu amlodipiny, poddano 219 chorych (średnia wieku 45,5 roku - 154 mężczyzn i 65 kobiet), odpowiednio 110 i 109 chorych w badanych grupach. Po 6 tygodniach leczenia u 47 chorych leczonych maleinianem amlodipiny (43% tej grupy) i u 51 chorych leczonych benzenosulfonianem amlodipiny (47% tej grupy) należało zwiększyć dawkę leku do 10 mg. Oceniając główne kryterium badania, wykazano, że chorzy leczeni maleinianem i benzenosulfonianem amlodipiny charakteryzowali się podobnym obniżeniem rozkurczowego ciśnienia tętniczego po 12 tygodniach leczenia, wynoszącym odpowiednio - 17,5 &plusmn; 6,1 mm Hg i &#8211;18,4 &plusmn; 5,4 mm Hg (p =NS). W odniesieniu do pozostałych kryteriów oceny - obniżenie skurczowego ciśnienia tętniczego (-21,1 &plusmn; 12,3 vs. -21,1 &plusmn; 12,7 mm Hg; p = NS), obniżenie częstości akcji serca, osiągnięcie docelowego rozkurczowego ciśnienia tętniczego (93,6% vs. 92,7%) - nie zaobserwowano różnic pomiędzy pacjentami leczonymi badanymi solami amlodipiny. W trakcie badania zaobserwowano łącznie 129 działań niepożądanych, które wystąpiły u 35 chorych w grupie maleinianu amlodipiny i u 47 chorych w grupie benzenosulfonianu amlodipiny (28,9% vs. 37,9%; p = NS). Wnioski Uzyskane wyniki wskazują, że maleinian amlodipiny i benzenosulfonian amlodipiny stosowane w monoterapii u chorych z łagodnym i umiarkowanym nadciśnieniem tętniczym pierwotnym charakteryzują się porównywalną wysoką skutecznością hipotensyjną. Porównywane sole amlodipiny charakteryzują się porównywalną częstością działań niepożądanych w trakcie 12-tygodniowego okresu leczenia.Background As a long acting, slow onset and metabolically neutral compound, calcium channel blocker amlodipine is a well established drug for the treatment of essential hypertension. The aim of the study was to evaluate the efficacy and safety of amlodipine in the form of maleate salt compared with amlodipine in the form of besylate salt in patients with mild to moderate essential hypertension. Material and methods The study was carried out as a randomized, double blind and parallel trial. It was performed in seven study centers in Poland. Patients, aged 18 to 75 years, with diastolic blood pressure between 95 and 114 mm Hg were included in the study. All enrolled patients were given placebo once daily in a single blind fashion for two weeks. Then patients were randomly assigned to take whether amlodipine maleate or amlodipine besylate 5 mg once daily in a double blind fashion. After 6 weeks of treatment in patients whose diastolic blood pressure remained 90 mm Hg or higher, the dose of each drug was increased to 10 mg once daily. The primary efficacy variable was the mean change in diastolic blood pressure from the end of treatment measured after 12 weeks, to baseline values after placebo run-in period at week 2. Results 219 patients (mean age 45.5 lat - 154 male, 65 female) were included in the final per-protocol analysis of the efficacy of the studied drugs. After 6 weeks of treatment the drug dose was increased in 47 (43%) and 51 (47%) patients in the amlodipine maleate and amlodipine besylate groups respectively (p = NS). After 12 weeks of treatment the mean change in diastolic blood pressure in the amlodipine maleate group was &#8211;17.5 mm Hg compared to the &#8211;18.4 mm Hg in the amlodipine besylate group (p = NS). There was no difference in the percentage of patients reaching the goal of diastolic blood pressure lowering to 90 mm Hg between the studied groups (93.6% vs. 92.7%). 35 patients in the amlodipine maleate group and 47 patients in the amlodipine besylate group reported adverse reactions (28.9% vs. 37.9%, p = NS). Conclusions Amlodipine maleate and amlodipine besylate were equally effective in the treatment of patients with mild to moderate essential hypertension. During 12 weeks of treatment incidence of adverse reactions was comparable in the studied groups

Characterising innovations in maternal and newborn health based on a common theory of change: lessons from developing and applying a characterisation framework in Nigeria, Ethiopia and India.

Government leadership is key to enhancing maternal and newborn survival. In low/middle-income countries, donor support is extensive and multiple actors add complexity. For policymakers and others interested in harmonising diverse maternal and newborn health efforts, a coherent description of project components and their intended outcomes, based on a common theory of change, can be a valuable tool. We outline an approach to developing such a tool to describe the work and the intended effect of a portfolio of nine large-scale maternal and newborn health projects in north-east Nigeria, Ethiopia and Uttar Pradesh in India. Teams from these projects developed a framework, the 'characterisation framework', based on a common theory of change. They used this framework to describe their innovations and their intended outcomes. Individual project characterisations were then collated in each geography, to identify what innovations were implemented where, when and at what scale, as well as the expected health benefit of the joint efforts of all projects. Our study had some limitations. It would have been enhanced by a more detailed description and analysis of context and, by framing our work in terms of discrete innovations, we may have missed some synergistic aspects of the combination of those innovations. Our approach can be valuable for building a programme according to a commonly agreed theory of change, as well as for researchers examining the effectiveness of the combined work of a range of actors. The exercise enables policymakers and funders, both within and between countries, to enhance coordination of efforts and to inform decision-making about what to fund, when and where

Improving maternal and newborn health services in Northeast Nigeria through a government-led partnership of stakeholders: a quasi-experimental study.

OBJECTIVES: This study aimed to quantify change in the coverage, quality and equity of essential maternal and newborn healthcare interventions in Gombe state, Northeast Nigeria, following a four year, government-led, maternal and newborn health intervention. DESIGN: Quasi-experimental plausibility study. Repeat cross-sectional household and linked health facility surveys were implemented in intervention and comparison areas. SETTING: Gombe state, Northeast Nigeria. PARTICIPANTS: Each household survey included a sample of 1000 women aged 13-49 years with a live birth in the previous 12 months. Health facility surveys comprised a readiness assessment and birth attendant interview. INTERVENTIONS: Between 2016-2019 a complex package of evidence-based interventions was implemented to increase access, use and quality of maternal and newborn healthcare, spanning the six WHO health system building blocks. OUTCOME MEASURES: Eighteen indicators of maternal and newborn healthcare. RESULTS: Between 2016 and 2019, the coverage of all indicators improved in intervention areas, with the exception of postnatal and postpartum contacts, which remained below 15%. Greater improvements were observed in intervention than comparison areas for eight indicators, including coverage of at least one antenatal visit (71% (95% CI 62 to 68) to 88% (95% CI 82 to 93)), at least four antenatal visits (46% (95% CI 39 to 53) to 69% (95% CI 60 to 75)), facility birth (48% (95% CI 37 to 59) to 64% (95% CI 54 to 73)), administration of uterotonics (44% (95% CI 34 to 54) to 59% (95% CI 50 to 67)), delayed newborn bathing (44% (95% CI 36 to 52) to 62% (95% CI 52 to 71)) and clean cord care (42% (95% CI 34 to 49) to 73% (95% CI 66 to 79)). Wide-spread inequities persisted however; only at least one antenatal visit saw pro-poor improvement. CONCLUSIONS: This intervention achieved improvements in life-saving behaviours for mothers and newborns, demonstrating that multipartner action, coordinated through government leadership, can shift the needle in the right direction, even in resource-constrained settings

Assessing quality of care provided by Indonesian village midwives with a confidential enquiry.

OBJECTIVE: to conduct a confidential enquiry to assess the quality of care provided by Indonesian village midwives and to identify opportunities for improvement. METHODS: local health-care practitioners assessed village-based care in obstetric emergencies in 13 cases of maternal death and near-miss from rural villages in West Java. The study focused on clinical quality of care, but also investigated the influence of the health system and social factors. The reviews were based on transcripts of interviews with health-care providers, family and community members involved in the cases. Both favourable and adverse factors were identified in order to recognise positive contributions, where they occurred. At the end of a series of case reviews, recommendations for practice were generated and disseminated. FINDINGS: in the cases reviewed, midwives facilitated referral effectively, reducing delays in reaching health facilities. Midwives' emergency diagnostic skills were accurate but they were less capable in the clinical management of complications. Coverage was poor; in some locations, midwives were responsible for up to five villages. Village midwives were also perceived as unacceptable to women and their families. Families and communities did not prepare for emergencies with finances or transport, partly due to a poorly understood health insurance system. The enquiry had learning effects for those involved. KEY CONCLUSIONS: village midwives should: receive appropriate support for the management of obstetric emergencies; engage with communities to promote birth preparedness; and work in partnership with formal and informal providers in the community. The enquiry was a diagnostic tool to identify opportunities for improving care. Practitioners had a unique insight into factors that contribute to quality care and how feasible interventions might be made

Management of pulmonary tuberculosis in Tajikistan: which factors determine hospitalization-.

OBJECTIVE: To assess predictors for tuberculosis hospitalization and treatment outcome in Tajikistan. METHODS: Stratified, single stage cluster sample survey of 1495 adult patients with pulmonary TB during 2 calendar years (2005-2006) from the registries of 10 TB centres chosen by simple random sampling. The primary outcome was referral to hospital. Logistic regression was conducted to test associations with the study outcome using linearization and a variance formula. RESULTS: Prevalence of hospitalization for tuberculosis was 58%. The odds of patients with smear-positive tuberculosis being referred were three times those of smear-negative patients [OR 2.99 (95% CI 1.81-4.96)]. Other predictors for hospitalization were the availability of TB hospital beds within the same district [OR 2.15 (95% CI 1.22-3.76)] and male gender [OR 1.46 (95% CI 1.07-2.48)]. The overall treatment success was 80%. CONCLUSIONS: Hospitalization of patients with pulmonary tuberculosis was determined by positive sputum smear, supply of hospital beds, and gender. Reducing hospitalization with support of national guidelines is not expected to have a negative impact on treatment outcome and spread of disease, but could lead to improved efficiency and effectives of health service delivery for pulmonary tuberculosis in Tajikistan

Midwifery provision in two districts in Indonesia: how well are rural areas served?

Attention has focused recently on the importance of adequate and equitable provision of health personnel to raise levels of skilled attendance at delivery and thereby reduce maternal mortality. Indonesia has a village-based midwife programme that was intended to increase the rate of professional delivery care and redress the urban/rural imbalance in service provision by posting a trained midwife in every village in the country. We present findings on the distribution of midwifery provision in our study area: 10% of villages do not have a midwife but a nurse as a midwifery provider; there is a deficit in midwife density in remote villages compared with urban areas; those assigned to remote areas are less experienced; midwives manage few births and this may compromise their capacity to maintain professional skills; over 90% of non-hospital deliveries take place in the woman's (64%) or the midwife's (28%) home; three-quarters of midwives did not make regular use of the fee exemption scheme; midwives who live in their assigned village spend more days per month on clinical work there. We conclude that adequate provider density is an important factor in effective health care and that efforts should be made to redress the imbalance in provision, but that this can only contribute to reducing maternal mortality in the context of a supportive professional environment and timely access to emergency obstetric care