Making stillbirths count, making numbers talk - issues in data collection for stillbirths.

BACKGROUND: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care. DISCUSSION: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings. SUMMARY: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems

High maternal mortality estimated by the sisterhood method in a rural area of Mali

<p>Abstract</p> <p>Background</p> <p>Maternal mortality is high in Mali. Nevertheless, there are few studies on this topic from rural areas, and current estimates are mostly based on studies from urban settings. Our objective was to estimate the maternal mortality ratio in Kita, rural Mali.</p> <p>Methods</p> <p>Using the "sisterhood method", we interviewed participants aged 15-50 years from 20 villages in Kita, Mali, and thereby created a retrospective cohort of their sisters in reproductive age. Based on population and fertility estimates, we calculated the lifetime risk of maternal death, and from that the estimated approximate maternal mortality ratio.</p> <p>Results</p> <p>The 2,039 respondents reported 4,628 sisters who had reached reproductive age. Of these 4,628 sisters, almost a third (1,233; 27%) had died, and 429 (9%) had died during pregnancy or childbirth. This corresponded to a lifetime risk of maternal death of 20% and a maternal mortality ratio of 3,131 per 100,000 live births (95% confidence interval 2,967-3,296), with a time reference around 1999.</p> <p>Conclusions</p> <p>We found a very high maternal mortality in rural Mali and this highlights the urgent need for obstetric services in the remote rural areas.</p

Why caretakers bypass Primary Health Care facilities for child care - a case from rural Tanzania

<p>Abstract</p> <p>Background</p> <p>Research on health care utilization in low income countries suggests that patients frequently bypass PHC facilities in favour of higher-level hospitals - despite substantial additional time and financial costs. There are limited number of studies focusing on user's experiences at such facilities and reasons for bypassing them. This study aimed to identify factors associated with bypassing PHC facilities among caretakers seeking care for their underfive children and to explore experiences at such facilities among those who utilize them.</p> <p>Methods</p> <p>The study employed a mixed-method approach consisting of an interviewer administered questionnaires and in-depth interviews among selected care-takers seeking care for their underfive children at Korogwe and Muheza district hospitals in north-eastern Tanzania.</p> <p>Results</p> <p>The questionnaire survey included 560 caretakers. Of these 30 in-depth interviews were conducted. Fifty nine percent (206/348) of caretakers had not utilized their nearer PHC facilities during the index child's sickness episode. The reasons given for bypassing PHC facilities were lack of possibilities for diagnostic facilities (42.2%), lack of drugs (15.5%), closed health facility (10.2%), poor services (9.7%) and lack of skilled health workers (3.4%). In a regression model, the frequency of bypassing a PHC facility for child care increased significantly with decreasing travel time to the district hospital, shorter duration of symptoms and low disease severity.</p> <p>Findings from the in-depth interviews revealed how the lack of quality services at PHC facilities caused delays in accessing appropriate care and how the experiences of inadequate care caused users to lose trust in them.</p> <p>Conclusion</p> <p>The observation that people are willing to travel long distances to get better quality services calls for health policies that prioritize quality of care before quantity. In a situation with limited resources, utilizing available resources to improve quality of care at available facilities could be more appropriate for improving access to health care than increasing the number of facilities. This would also improve equity in health care access since the poor who can not afford travelling costs will then get access to quality services at their nearer PHC facilities.</p

Determinants of early child development in rural Tanzania

Abstract Background It has been estimated that more than 200 million children under the age of five do not reach their full potential in cognitive development. Much of what we know about brain development is based on research from high-income countries. There is limited evidence on the determinants of early child development in low-income countries, especially rural sub-Saharan Africa. The present study aimed to identify the determinants of cognitive development in children living in villages surrounding Haydom, a rural area in north-central Tanzania. Methods This cohort study is part of the MAL-ED (The Interactions of Malnutrition & Enteric Infections: Consequences for Child Health and Development) multi-country consortium studying risk factors for ill health and poor development in children. Descriptive analysis and linear regression analyses were performed. Associations between nutritional status, socio-economic status, and home environment at 6 months of age and cognitive outcomes at 15 months of age were studied. The third edition of the Bayley Scales for Infant and Toddler Development was used to assess cognitive, language and motor development. Results There were 262 children enrolled into the study, and this present analysis included the 137 children with data for 15-month Bayley scores. Univariate regression analysis, weight-for-age and weight-for-length z-scores at 6 months were significantly associated with 15-month Bayley gross motor score, but not with other 15-month Bayley scores. Length-for-age z-scores at 6 months were not significantly associated with 15-month Bayley scores. The socio-economic status, measured by a set of assets and monthly income was significantly associated with 15-month Bayley cognitive score, but not with language, motor, nor total 15-month Bayley scores. Other socio-economic variables were not significantly associated with 15-month Bayley scores. No significant associations were found between the home environment and 15-month Bayley scores. In multivariate regression analyses we found higher Bayley scores for girls and higher Bayley scores in families with more assets. Adjusted R-squared of this model was 8%. Conclusion We conclude that poverty is associated with a slower cognitive development in children and malnutrition is associated with slower gross motor development. This information should encourage authorities and other stakeholders to invest in improved welfare and nutrition programmes for children from early infancy

A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe

Setting: 10 districts and 3 cities in Zimbabwe Objective: To compare the yield and relative cost of identifying a case of tuberculosis (TB) if the National TB Programme (NTP) used one of three World Health Organisation (WHO)-recommended algorithms (2c,2d,3b) instead of Zimbabwe’s active case finding (ACF) algorithm Design: Cross-sectional study using data from the Zimbabwe ACF project. Results: 38,574 people were screened from April-December 2017 and 488 (1.3%) were diagnosed with TB. WHO-2d had the least number of people needing a chest X-ray (CXR) at 13,710 (35.5%) and bacteriological confirmation at 2,595 (6.7%). If the NTP had used the WHO recommended algorithms, fewer TB cases would have been diagnosed - 18% (88 cases) with algorithm 2b, 25% (122 cases) algorithm 2d, and only 7% (34 cases) with algorithm 3b. The relative cost-per-case of TB diagnosed for the Zimbabwe algorithm at $565 was over three times that of WHO 3b algorithm ($180) which was the cheapest. Conclusion: The Zimbabwe ACF algorithm had the highest yield but at a considerable cost when compared to WHO algorithms. The trade-off between cost and yield needs to be reviewed by the NTP and changing to use algorithm 3d considered

High prevalence of tuberculosis diagnosed during autopsy examination at Muhimbili National Hospital in Dar es Salaam, Tanzania

The primary aims of tuberculosis (TB) control programmes is early diagnosis and prompt treatment of infectious cases to limit transmission. Failure to diagnose and adequately treat TB could lead to premature death and unrecognized transmission of Mycobacterium tuberculosis . The proportion of missed TB cases has not been reported in Tanzania. The objective of this study was to quantify the number of cases of TB identified by autopsy. Deceased morbid bodies from Muhimbili National Hospital were involved. Retrieval of admission, diagnostic and other important records used to manage the patient after admission was done. Demographic information, site and type of disease, past medical history, chest x-ray report, clinical diagnosis and cause of death reported upon death certification were recorded. Lung tissues, lymphnodes and blood clots for HIV testing were collected. Biopsy tissues were processed through Ziehl Nielsen staining and examined by microscopy. The study involved 74 deceased individuals where 56 (75.7%) were males. Information for duration of seeking health care before death was available for 41(55.4%) subjects. Thirty-four (45.9%) cases received diagnosis before death. The main diagnoses were pneumonia 10(13.5%), heart failure 6(8.1%), AIDS-related illnesses 6 (6.8%) and malaria 5 (6.8%). The main clinical findings were wasting (51/74 (68.9%)) and abnormal fluid collection in different body cavities, 61(50.8%). In 24 out of 71(33.8%) biopsies acid fast bacilli (AFB) were detected. Records of lymphnodes examination were available in 63 cases and 22 of them had AFB. Twenty-two (34.9%) from the paratracheal and hilar lymphnodes were observed to have AFB. HIV was detected by ELISA in 19 (33.3%) out of 57 deceased, and 12 (63.2%) of the HIV positive deceased were co-infected with TB. Out of the 22 cases positive for AFB on tissue-biopsies 12 (54.5%) were HIV positive. There is a high number of TB cases diagnosed after death that could not be detected before they died. There is a need for increased awareness and to include postmortem data in the annual statistics of TB for precise reporting of the magnitude of the TB burden in the country

Making progress towards food security: evidence from an intervention in three rural districts of Rwanda

Objective: Determining interventions to address food insecurity and poverty, as well as setting targets to be achieved in a specific time period have been a persistent challenge for development practitioners and decision makers. The present study aimed to assess the changes in food access and consumption at the household level after one-year implementation of an integrated food security intervention in three rural districts of Rwanda. Design: A before-and-after intervention study comparing Household Food Insecurity Access Scale (HFIAS) scores and household Food Consumption Scores (FCS) at baseline and after one year of programme implementation. Setting: Three rural districts of Rwanda (Kayonza, Kirehe and Burera) where the Partners In Health Food Security and Livelihoods Program (FSLP) has been implemented since July 2013. Subjects All 600 households enrolled in the FSLP were included in the study. Results: There were significant improvements (P<0·001) in HFIAS and FCS. The median decrease in HFIAS was 8 units (interquartile range (IQR) −13·0, −3·0) and the median increase for FCS was 4·5 units (IQR −6·0, 18·0). Severe food insecurity decreased from 78 % to 49 %, while acceptable food consumption improved from 48 % to 64 %. The change in HFIAS was significantly higher (P=0·019) for the poorest households. Conclusions: Our study demonstrated that an integrated programme, implemented in a setting of extreme poverty, was associated with considerable improvements towards household food security. Other government and non-government organizations’ projects should consider a similar holistic approach when designing structural interventions to address food insecurity and extreme poverty

Persistent 'hotspots' of lymphatic filariasis microfilaraemia despite 14 years of mass drug administration in Ghana.

Among the 216 districts in Ghana, 98 were declared endemic for lymphatic filariasis in 1999 after mapping. Pursuing the goal of elimination, WHO recommends annual treatment using mass drugs administration (MDA) for at least 5 years. MDA was started in the country in 2001 and reached national coverage in 2006. By 2014, 69 districts had 'stopped-MDA' (after passing the transmission assessment survey) while 29 others remained with persistent microfilaraemia (mf) prevalence (≥1%) despite more than 11 years of MDA and were classified as 'hotspots'. An ecological study was carried out to compare baseline mf prevalence and anti-microfilaria interventions between hotspot and stopped-MDA districts. Baseline mf prevalence was significantly higher in hotspots than stopped-MDA districts (p<0.001). After three years of MDA, there was a significant decrease in mf prevalence in hotspot districts, but it was still higher than in stopped-MDA districts. The number of MDA rounds was slightly higher in hotspot districts (p<0.001), but there were no differences in coverage of MDA or long-lasting-insecticide-treated nets. The main difference in hotspots and stopped-MDA districts was a high baseline mf prevalence. This finding indicates that the recommended 5-6 rounds annual treatment may not achieve interruption of transmission