Research Round-Up: April 2011

Do we adequately respect the potential of routine primary health care services in reducing neonatal mortality in developing countries? The example of the Denizli cohort.* Uner S, Cakir B, Yildirak K. Cahiers de sociologie et de démographie médicales, 50(4):477-99.

This study aimed to examine the burden of neonatal deaths in Denizli province, Turkey, over a 5-year period and to investigate the role of "routine" primary health care (PHC) services provided to mothers and infants by the Ministry of Health in reducing neonatal deaths, while controlling for major confounding factors. A retrospective cohort study was conducted based on the health records of the Provincial Health Directorate of Denizli, Turkey. Data were collected from the 5-year records of a total of 119 PHC units responsible for providing comprehensive PHC services to all residents of the province. A random-effect Poisson panel regression was employed to investigate the association between "monitoring services (for mothers and babies) provided by PHC unit personnel" and the neonatal mortality. According to the results of study the final model revealed that "monitoring", i.e., the joint factor for the average number of regular visits of the mother (during pregnancy and over puerperium) and that of the babies over the neonatal period was found to have a positive impact on decreasing the neonatal infant mortality rate. In the final model, controlling for the total number of live births in the health care service area, neonatal mortality was detected to be negatively associated with total populations per nurse, total populations per midwife, presence of prematurity and presence of low birth weight whereas having deliveries in the hospital setting decreased the risk of neonatal deaths significantly. The findings of the study are important, revealing that the neonatal mortality rates could be decreased significantly by increasing the number of regular health visits of mothers and newborn babies to PHC units, with no need for specialized health personnel or additional costs.

Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study. E Ekirapa-Kiracho, P Waiswa, MH Rahman, F Makumbi, N Kiwanuka, O Okui, E Rutebemberwa, J Bua, A Mutebi, G Nalwadda, D Serwadda, GW Pariyo, DH Peters. BMC International Health and Human Rights, 11(Suppl 1):S11; 2011.

Background: Geographical inaccessibility, lack of transport, and financial burdens are some of the demand side constraints to maternal health services in Uganda, while supply side problems include poor quality services related to unmotivated health workers and inadequate supplies. Most public health interventions in Uganda have addressed only selected supply side issues, and universities have focused their efforts on providing maternal services at tertiary hospitals. To demonstrate how reforms at Makerere University College of Health Sciences (MakCHS) can lead to making systemic changes that can improve maternal health services, a demand and supply side strategy was developed by working with local communities and national stakeholders. Methods: This quasi-experimental trial is conducted in two districts in Eastern Uganda. The supply side component includes health worker refresher training and additions of minimal drugs and supplies, whereas the demand side component involves vouchers given to pregnant women for motorcycle transport and the payment to service providers for antenatal, delivery, and postnatal care. The trial is ongoing, but early analysis from routine health information systems on the number of services used is presented. Results: Motorcyclists in the community organized themselves to accept vouchers in exchange for transport for antenatal care, deliveries and postnatal care, and have become actively involved in ensuring that women obtain care. Increases in antenatal, delivery, and postnatal care were demonstrated, with the number of safe deliveries in the intervention area immediately jumping from <200 deliveries/month to over 500 deliveries/month in the intervention arm. Voucher revenues have been used to obtain needed supplies to improve quality and to pay health workers, ensuring their availability at a time when workloads are increasing. Conclusions: Transport and service vouchers appear to be a viable strategy for rapidly increasing maternal care. MakCHS can design strategies together with stakeholders using a learning-by-doing approach to take advantage of community resources.

The Influence of Distance and Level of Care on Delivery Place in Rural Zambia: A Study of Linked National Data in a Geographic Information System. S Gabrysch, S Cousens, J Cox, OMR Campbell. PLoS Medicine; 2011.

Background: Maternal and perinatal mortality could be reduced if all women delivered in settings where skilled attendants could provide emergency obstetric care (EmOC) if complications arise. Research on determinants of skilled attendance at delivery has focussed on household and individual factors, neglecting the influence of the health service environment, in part due to a lack of suitable data. The aim of this study was to quantify the effects of distance to care and level of care on women’s use of health facilities for delivery in rural Zambia, and to compare their population impact to that of other important determinants. Methods and Findings: Using a geographic information system (GIS), we linked national household data from the Zambian Demographic and Health Survey 2007 with national facility data from the Zambian Health Facility Census 2005 and calculated straight-line distances. Health facilities were classified by whether they provided comprehensive EmOC (CEmOC), basic EmOC (BEmOC), or limited or substandard services. Multivariable multilevel logistic regression analyses were performed to investigate the influence of distance to care and level of care on place of delivery (facility or home) for 3,682 rural births, controlling for a wide range of confounders. Only a third of rural Zambian births occurred at a health facility, and half of all births were to mothers living more than 25 km from a facility of BEmOC standard or better. As distance to the closest health facility doubled, the odds of facility delivery decreased by 29% (95% CI, 14%–40%). Independently, each step increase in level of care led to 26% higher odds of facility delivery (95% CI, 7%–48%). The population impact of poor geographic access to EmOC was at least of similar magnitude as that of low maternal education, household poverty, or lack of female autonomy. Conclusions: Lack of geographic access to emergency obstetric care is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care. Addressing geographic and quality barriers is crucial to increase service use and to lower maternal and perinatal mortality. Linking datasets using GIS has great potential for future research and can help overcome the neglect of health system factors in research and policy.

Prevention of Malaria during Pregnancy: Assessing the Effect of the Distribution of IPTp Through the National Policy in Benin.* A Le Port, G Cottrell, C Dechavanne, V Briand, A Bouraima, J Guerra, I Choudat, A Massougbodji, B Fayomi, F Migot-Nabias, A Garcia, M Cot. American Journal of Tropical Medicine & Hygiene, 84(2), 2011, pp. 270-275.

The efficiency of malaria prevention during pregnancy was compared between three studies in Benin for malaria infection of the placenta (MIP) and low birth weight (LBW). The first was carried out when chloroquine prophylaxis was still recommended, the second was an intermittent preventive treatment in pregnancy (IPTp) clinical trial comparing sulfadoxine pyrimetamine (SP) versus mefloquine, and the third was an observational study after SP-IPTp national implementation. We showed an association between the use of IPTp and the reduction of LBW (10% with national IPTp and 8.7% in IPTp trial versus 15.7% in pre-trial study). The effect on MIP was better in the trial (2.9% versus 11.2% and 16.7% for national IPTp and pre-trial studies, respectively). In spite of a good overall compliance with the national IPTp (with 84% of women taking at least one dose of SP), there are still failures in adherence to the directly observed therapy(DOT) scheme and needs for better training of health staff.

Symphysiotomy: Is it obsolete?* S Basak, S Kanungo, C Majhi. Journal of Obstetrics and Gynaecology Research, March 2011.

Aim: To compare the maternal and neonatal outcomes of symphysiotomy (SYM) and cesarean section (CS), when they were performed in women presenting with obstructed labor. Material and Methods: This was a prospective comparative cohort study. Symphysiotomy was performed in 25 women who presented with obstructed labor. The controls were 50 women on whom CS was performed due to obstructed labor. Maternal mortality and morbidity due to postpartum hemorrhage (PPH), sepsis, genitourinary trauma, pelvic pain and gait problems were analyzed and compared between cases and controls. Neonatal mortality and morbidity due to birth asphyxia, intracranial hemorrhage, cephalohematoma and hypoxic ischemic encephalopathy were also compared following the two procedures. Results: Maternal mortality was similar in both the cesarean section group (CSG) and symphysiotomy group (SG), but SYM has less morbidity than CS, and also preserves the uterus from scars. Transient pelvic pain was the most common maternal morbidity following SYM, whereas PPH and wound sepsis were the most common complications after CS. Neonatal mortality and morbidity were similar in both cases and controls. Lastly, SYM is a simple, low-cost and quicker procedure than CS. Conclusion: Symphysiotomy is an alternative management in women with obstructed labor. It has a role in low-resource settings, where CS is unaffordable, unavailable or unsafe. For the vast majority of the poor population, who may not have even have one proper meal a day, it can be of benefit to have a woman's pelvis made permanently adequate so that traditional birth attendants can conduct her subsequent labors.

Task shifting in maternal and child health care: An evidence brief for Uganda.* H Nabudere, D Asiimwe, R Mijumbi. International Journal of Technology Assessment in Health Care, Available on CJO doi:10.1017/S0266462311000055.

The Problem: There is a shortage and maldistribution of medically trained health professionals to deliver cost-effective maternal and child health (MCH) services. Hence, cost-effective MCH services are not available to over half the population of Uganda and progress toward the Millennium Development Goals for MCH is slow. Optimizing the roles of less specialized health workers (“task shifting”) is one strategy to address the shortage and maldistribution of more specialized health professionals. Policy Options: (i) Lay health workers (community health workers) may reduce morbidity and mortality in children under five and neonates; and training for traditional birth attendants may improve perinatal outcomes and appropriate referrals. (ii) Nursing assistants in facilities might increase the time available from nurses, midwives, and doctors to provide care that requires more training. (iii) Nurses and midwives to deliver cost-effective MCH interventions in areas where there is a shortage of doctors. (iv) Drug dispensers to promote and deliver cost-effective MCH interventions and improve the quality of the services they provide. The costs and cost-effectiveness of all four options are uncertain. Given the limitations of the currently available evidence, rigorous evaluation and monitoring of resource use and activities is warranted for all four options. Implementation Strategies: A clear policy on optimizing health worker roles. Community mobilization and reduction of out-of-pocket costs to improve mothers’ knowledge and care-seeking behaviors, continuing education, and incentives to ensure health workers are competent and motivated, and community referral and transport schemes for MCH care are needed.

Tracking progress towards safe motherhood: meeting the benchmark yet missing the goal? An appeal for better use of health-system output indicators with evidence from Zambia and Sri Lanka.* S Gabrysch, P Zanger, HR Seneviratne, R Mbewe, OMR Campbell. Tropical Medicine & International Health, Feb 2011.

Objectives: Indicators of health-system outputs, such as Emergency Obstetric Care (EmOC) density, have been proposed for monitoring progress towards reducing maternal mortality, but are currently underused. We seek to promote them by demonstrating their use at subnational level, evaluating whether they differentiate between a high-maternal-mortality country (Zambia) and a low-maternal-mortality country (Sri Lanka) and assessing whether benchmarks are set at the right level. Methods: We compared national and subnational density of health facilities, EmOC facilities and health professionals against current benchmarks for Zambia and Sri Lanka. For Zambia, we also examined geographical accessibility by linking health facility data to population data. Results: Both countries performed similarly in terms of EmOC facility density, implying this indicator, as currently used, fails to discriminate between high- and low-maternal-mortality settings. In Zambia, the WHO benchmarks for doctors/midwives were met overall, but distribution between provinces was highly unequal. Sri Lanka overshot the suggested benchmarks by three times for midwives and over 30 times for doctors. Geographical access in Zambia – which is much less densely populated than Sri Lanka – was poor, less than half the population lived within 15 km of an EmOC facility. Conclusions: Current health-system output indicators and benchmarks on EmOC need revision to enhance discriminatory power and should be adapted for different population densities. Subnational disaggregation and assessing geographical access can identify gaps in EmOC provision and should be routinely considered. Increased use of an improved set of output indicators is crucial for guiding international efforts towards reducing maternal mortality.

Utility of local health registers in measuring perinatal mortality: A case study in rural Indonesia. Burke L, Suswardany DL, Michener K, Mazurki S, Adair T, Elmiyati C, Rao C. BMC Pregnancy and Childbirth; March 2011.

Background: Perinatal mortality is an important indicator of obstetric and newborn care services. Although the vast majority of global perinatal mortality is estimated to occur in developing countries, there is a critical paucity of reliable data at the local level to inform health policy, plan health care services, and monitor their impact. This paper explores the utility of information from village health registers to measure perinatal mortality at the sub district level in a rural area of Indonesia. Methods: A retrospective pregnancy cohort for 2007 was constructed by triangulating data from antenatal care, birth, and newborn care registers in a sample of villages in three rural sub districts in Central Java, Indonesia. For each pregnancy, birth outcome and first week survival were traced and recorded from the different registers, as available. Additional local death records were consulted to verify perinatal mortality, or identify deaths not recorded in the health registers. Analyses were performed to assess data quality from registers, and measure perinatal mortality rates. Qualitative research was conducted to explore knowledge and practices of village midwives in register maintenance and reporting of perinatal mortality. Results: Field activities were conducted in 23 villages, covering a total of 1759 deliveries that occurred in 2007. Perinatal mortality outcomes were 23 stillbirths and 15 early neonatal deaths, resulting in a perinatal mortality rate of 21.6 per 1000 live births in 2007. Stillbirth rates for the study population were about four times the rates reported in the routine Maternal and Child Health program information system. Inadequate awareness and supervision, and alternate workload were cited by local midwives as factors resulting in inconsistent data reporting. Conclusions: Local maternal and child health registers are a useful source of information on perinatal mortality in rural Indonesia. Suitable training, supervision, and quality control, in conjunction with computerisation to strengthen register maintenance can provide routine local area measures of perinatal mortality for health policy, and monitoring of newborn care interventions. Similar efforts are required to strengthen routine health data in all developing countries, to guide planned progress towards reduction in the local, national and international burden from perinatal mortality.

Women-focused development intervention reduces delays in accessing emergency obstetric care in urban slums in Bangladesh: a cross-sectional study. Nahar S, M Banu, HE Nasreen. BMC Pregnancy and Childbirth 11(1): 11.

Background: Recognizing the burden of maternal mortality in urban slums, in 2007 BRAC (formally known as Bangladesh Rural Advancement Committee) has established a woman-focused development intervention, Manoshi (the Bangla abbreviation of mother, neonate and child), in urban slums of Bangladesh. The intervention emphasizes strengthening the continuum of maternal, newborn and child care through community, delivery centre (DC) and timely referral of the obstetric complications to the emergency obstetric care (EmOC) facilities. This study aimed to assess whether Manoshi DCs reduces delays in accessing EmOC. Methods: This cross-sectional study was conducted during October 2008 to January 2009 in the slums of Dhaka city among 450 obstetric complicated cases referred either from DCs of Manoshi or from their home to the EmOC facilities. Trained female interviewers interviewed at their homestead with structured questionnaire. Pearson's chi-square test, t-test and Mann-Whitney test were performed. Results: The median time for making the decision to seek care was significantly longer among women who were referred from home than referred from DCs (9.7 hours vs. 5.0 hours, p < 0.001). The median time to reach a facility and to receive treatment was found to be similar in both groups. Time taken to decide to seek care was significantly shorter in the case of life-threatening complications among those who were referred from DC than home (0.9 hours vs.2.3 hours, p = 0.002). Financial assistance from Manoshi significantly reduced the first delay in accessing EmOC services for life-threatening complications referred from DC (p = 0.006). Reasons for first delay include fear of medical intervention, inability to judge maternal condition, traditional beliefs and financial constraints. Role of gender was found to be an important issue in decision making. First delay was significantly higher among elderly women, multiparity, non life-threatening complications and who were not involved in income-generating activities. Conclusions: Manoshi program reduces the first delay for life-threatening conditions but not non-life-threatening complications even though providing financial assistance. Programme should give more emphasis on raising awareness through couple/family-based education about maternal complications and dispel fear of clinical care to accelerate seeking EmOC.

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