Disease-specific mortality burdens in a rural Gambian population using verbal autopsy, 1998-2007.

OBJECTIVE: To estimate and evaluate the cause-of-death structure and disease-specific mortality rates in a rural area of The Gambia as determined using the InterVA-4 model. DESIGN: Deaths and person-years of observation were determined by age group for the population of the Farafenni Health and Demographic Surveillance area from January 1998 to December 2007. Causes of death were determined by verbal autopsy (VA) using the InterVA-4 model and ICD-10 disease classification. Assigned causes of death were classified into six broad groups: infectious and parasitic diseases; cancers; other non-communicable diseases; neonatal; maternal; and external causes. Poisson regression was used to estimate age and disease-specific mortality rates, and likelihood ratio tests were used to determine statistical significance. RESULTS: A total of 3,203 deaths were recorded and VA administered for 2,275 (71%). All-age mortality declined from 15 per 1,000 person-years in 1998-2001 to 8 per 1,000 person-years in 2005-2007. Children aged 1-4 years registered the most marked (74%) decline from 27 to 7 per 1,000 person-years. Communicable diseases accounted for half (49.9%) of the deaths in all age groups, dominated by acute respiratory infections (ARI) (13.7%), malaria (12.9%) and pulmonary tuberculosis (10.2%). The leading causes of death among infants were ARI (5.59 per 1,000 person-years [95% CI: 4.38-7.15]) and malaria (4.11 per 1,000 person-years [95% CI: 3.09-5.47]). Mortality rates in children aged 1-4 years were 3.06 per 1,000 person-years (95% CI: 2.58-3.63) for malaria, and 1.05 per 1,000 person-years (95% CI: 0.79-1.41) for ARI. The HIV-related mortality rate in this age group was 1.17 per 1,000 person-years (95% CI: 0.89-1.54). Pulmonary tuberculosis and communicable diseases other than malaria, HIV/AIDS and ARI were the main killers of adults aged 15 years and over. Stroke-related mortality increased to become the leading cause of death among the elderly aged 60 years or more in 2005-2007. CONCLUSIONS: Mortality in the Farafenni HDSS area was dominated by communicable diseases. Malaria and ARI were the leading causes of death in the general population. In addition to these, diarrhoeal disease was a particularly important cause of death among children under 5 years of age, as was pulmonary tuberculosis among adults aged 15 years and above

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

Strengthening the emergency healthcare system for mothers and children in The Gambia

A system to improve the management of emergencies during pregnancy, childbirth, infancy and childhood in a region of The Gambia (Brikama) with a population of approximately 250,000 has been developed

Availability and quality of emergency obstetric care in Gambia's main referral hospital: women-users' testimonies

<p>Abstract</p> <p>Background</p> <p>Reduction of maternal mortality ratio by two-thirds by 2015 is an international development goal with unrestricted access to high quality emergency obstetric care services promoted towards the attainment of that goal. The objective of this qualitative study was to assess the availability and quality of emergency obstetric care services in Gambia's main referral hospital.</p> <p>Methods</p> <p>From weekend admissions a group of 30 women treated for different acute obstetric conditions including five main diagnostic groups: hemorrhage, hypertensive disorders, dystocia, sepsis and anemia were purposively selected. In-depth interviews with the women were carried out at their homes within two weeks of discharge.</p> <p>Results</p> <p>Substantial difficulties in obtaining emergency obstetric care were uncovered. Health system inadequacies including lack of blood for transfusion, shortage of essential medicines especially antihypertensive drugs considerably hindered timely and adequate treatment for obstetric emergencies. Such inadequacies also inflated the treatment costs to between 5 and 18 times more than standard fees. Blood transfusion and hypertensive treatment were associated with the largest costs.</p> <p>Conclusion</p> <p>The deficiencies in the availability of life-saving interventions identified are manifestations of inadequate funding for maternal health services. Substantial increase in funding for maternal health services is therefore warranted towards effective implementation of emergency obstetric care package in The Gambia.</p

Serogroup W135 meningococcal disease, The Gambia, 2012.

In 2012, an outbreak of Neisseria meningitidis serogroup W135 occurred in The Gambia. The attack rate was highest among young children. The associated risk factors were male sex, contact with meningitis patients, and difficult breathing. Enhanced surveillance facilitates early epidemic detection, and multiserogroup conjugate vaccine could reduce meningococcal epidemics in The Gambia

Maternal mortality in the Gambia : contributing factors and what can be done to reduce them

Rationale for the Study: The Gambia is a small West African state of about 10,680 square kilometers with a population of just over 1.2 million inhabitants. It is a densely populated country with approximately 97 people per square kilometer. The Gambia depends largely on agriculture, trade and tourism for her economy. It is ranked among the poorest countries in the world with a Gross Domestic Product (GDP) of US $340. The Gambian government considers health as a key pillar to development and spending on the health sector has increased substantially over the years. The health share of the recurrent expenditure rose from 11.5% in 1998 to 13.6% in 2001 and in the same period public health expenditure as a proportion of GDP also rose from 1.7% to 3.3%. Access to health facilities is good with over 85% of the population living within 3 kilometers of a primary health care or outreach health post and 97% of the population within 5 kilometers. Levels of maternal mortality in the Gambia are unacceptably high estimated at 1,050 per 100,000 live births. Medical causes of maternal deaths are well documented. However, little attention is paid on the contributing factors to maternal deaths in the country. In an effort to prevent maternal deaths in the Gambia it is necessary to look at contributing factors, also known as “avoidable factors”. Objectives: To identify and describe the socio-cultural, economic and health service factors contributing to maternal deaths. Materials and Methods: A retrospective population-based study combining both qualitative and quantitative methods was used. Verbal autopsy and confidential inquiry techniques were utilized reviewing all maternal death cases that occurred in Upper and Central River Divisions of the Gambia between January to September 2002. Each case was reviewed following the “road to maternal death” concept. In all the cases the health records were retrieved and reviewed. Verbal autopsy was also performed on the majority of maternal deaths identified. Three reviewers performed independent classification of cause of death and contributing factors to these deaths. A descriptive analysis of the data was made and was presented in two separate papers: quantitative and qualitative. Results: A total of 42 maternal deaths were identified. Of these, 39 died at the referral hospital, one at a major health center, one on the road to the hospital and another one at home. In the same corresponding period a total of 876 live births were recorded at the hospital. This gives a hospital-based maternal mortality ratio of 4,452 per 100,000 live births. Direct obstetrical deaths accounted for 28 (67%) of the cases. Hemorrhage was the most prominent cause of death accounting for 10 of the cases. Fourteen of the cases were indirect obstetric deaths. Anemia accounted for 12 out of those 14 deaths. All the cases identified contacted or were in contact with the health system when the obstetrical complication developed. Substandard health care for obstetrical referrals, low quality primary health care, obstructions in receiving urgent care and delay in reaching a medical facility were identified as contributing factors to these deaths. Verbal autopsy was performed in 32 cases. Applying the Three Delay Model in the analysis of the qualitative data generated from the key informants indicated a delayed decision to seek medical care in 7 of the cases. Twenty-seven in 32 of the women had delay in reaching an appropriate obstetric care facility once the decision to seek care was made. However, even after reaching an appropriate obstetric care facility, 31 out of the 32 cases had not received the obstetric care services they needed. Looking at the phases of delay cases, 7 of the 32 cases had all three delays; 21 in 32 experienced two phases of delays and 3 experienced only one type of delay. In only one case no delay could be associated with the death. Conclusion: Health service factors were the most frequently identified contributing factors to maternal deaths in this study. It is therefore believed that improving the quality of and accessibility to emergency obstetrical care services will significantly contribute to the reduction of maternal deaths in the area. Keywords: Maternal mortality, Three Delay Model, Emergency obstetric care, Verbal autopsy, contributing factors, Underlying causes, Road to death, The Gambi

Health & Demographic Surveillance System Profile: Farafenni Health and Demographic Surveillance System in The Gambia.

The Farafenni Health and Demographic Surveillance System (Farafenni HDSS) is located 170 km from the coast in a rural area of The Gambia, north of the River Gambia. It was set up in 1981 by the UK Medical Research Council Laboratories to generate demographic and health information required for the evaluation of a village-based, primary health care programme in 40 villages. Regular updates of demographic events and residency status have subsequently been conducted every 4 months. The surveillance area was extended in 2002 to include Farafenni Town and surrounding villages to support randomized, controlled trials. With over three decades of prospective surveillance, and through specific scientific investigations, the platform (population ≈ 50,000) has generated data on: morbidity and mortality due to malaria in children and during pregnancy; non-communicable disease among adults; reproductive health; and levels and trends in childhood and maternal mortality. Other information routinely collected includes causes of death through verbal autopsy, and household socioeconomic indicators. The current portfolio of the platform includes tracking Millennium Development Goal 4 (MDG4) attainments in rural Gambia and cause-of-death determination