Research Round-Up: March 2011

A prospective study on neonatal mortality and its predictors in a rural area in Burkina Faso: Can MDG-4 be met by 2015? AH Diallo, N Meda, WT Ouédraogo, S Cousens, T Tylleskar. Journal of Perinatology; advance online publication 3 March 2011.

Objective: To measure the neonatal mortality rate (NMR) and investigate its predictors in a rural area of Burkina Faso. Study Design: A cohort of infants born in 24 villages in Banfora region was followed until the children were 6 months old. We estimated the risk of neonatal death and used logistic regression to identify its predictors. Result: Among 864 live births followed to day 28, there were 40 neonatal deaths, a NMR of 46.3 per 1000 live births (95% confidence intervals (CI): 22 to 70). Multivariable regression identified twin birth (OR=11.5, 95%CI: 4.5 to 29.8), having a nulliparous mother (odds ratio (OR)=4.3, 95% CI: 1.5 to 12.1), and birth into a polygynous household (OR=2.1, 95% CI: 1.0 to 4.7) as main predictors of neonatal death. Conclusion: The burden of neonatal mortality in rural Burkina Faso is very high and the observed NMRs in a predominantly rural country suggest that it is unlikely Burkina will meet fourth Millennium Development Goal (MDG-4) by 2015.

Can non-monetary incentives increase health facility deliveries? The experience in Thyolo District, Malawi.* T.Van den Akker, G. Radge, A. Mateyu, B. Mwagomba, M. Bemelmans, Tony Reid. International Health; In Press, Corrected Proof.

Attendance for intrapartum care in Thyolo District, Malawi, was studied following implementation of a locally valued, non-monetary incentive. The number of facility-based deliveries per month was compared between the fourth quarter of 2007 and the third quarter of 2009, before and after introducing the incentive that included soap, a baby blanket and a traditional baby wrap. The number of deliveries in health facilities increased by 78% over the 2-year period. The increase was larger in peripheral rural facilities compared with the district hospital (94% vs. 38%). Locally developed incentives may lead to more women receiving professional maternity care in Malawi, particularly in rural areas.

Choosing the appropriate neonatal resuscitation device for village midwives.* I Ariawan, M Agustini, Y Seamans, V Tsu, MS Kosim. Journal of Perinatology; advance online publication, February 2011.

Objective: An appropriate neonatal resuscitation device for village midwives in Indonesia is chosen. Study Design: The study compared four neonatal resuscitation devices: Ambu neonate bag and mask, Topster bag and mask, Laerdal pediatric pocket mask and Tekno tube and mask. Functionality was tested by 40 village midwives who were also interviewed about ease of use. Ventilation volume was tested using a mannequin and computer interface. Other features were assessed by PATH engineers. Result: There was no significant difference in the ventilation volumes among the four devices or any difference in acceptability to midwives or infection prevention ability, but the tube and mask devices were considered easier to clean. Conclusion: Given the similarity in functionality, ease of use, infection prevention, and portability and the significant difference in price, public health experts and neonatologists chose the local tube and mask device for use by village midwives.

Factors in health initiative success: Learning from Nepal’s newborn survival initiative.* SL Smith, S Neupane. Social Science & Medicine, 72(4), February 2011, 568-575.

What shapes the level of political priority for alleviation of significant health problems in low-income countries? We investigate this question in the context of the significantly increasing political priority for newborn survival in Nepal since 2000. We use a process-tracing methodology to investigate causes of this shift, drawing on twenty-nine interviews with individuals close to newborn health policy making in Nepal and extensive document analysis. Shifts in the political context (commitments to the child health MDG), the strength of concerned actors (emergence of collective action, leadership, resources) and the power of ideas (problem status, existence of contextually relevant solutions, agreement on these points) surrounding the issue have been instrumental in elevating priority for newborn survival, if not institutionalizing that priority to ensure long-term support. The findings highlight the significance of political fragmentation in war-torn areas for impeding priority generation. Additionally, theories of social construction provide important insights to the roles of ideas in shaping health initiative success.

Maternal and Neonatal Health Expenditure in Mumbai Slums (India): A Cross Sectional Study. J Skordis-Worrall, N Pace, U Bapat, S Das, NS More, W Joshi, AM Pulkki-Brannstrom, D Osrin. BMC Public Health; March 2011.

Background: The cost of maternity care can be a barrier to access that may increase maternal and neonatal mortality risk. We analyzed spending on maternity care in urban slum communities in Mumbai to better understand the equity of spending and the impact of spending on household poverty. Methods: We used expenditure data for maternal and neonatal care, collected during post-partum interviews. Interviews were conducted in 2005-2006, with a sample of 1200 slum residents in Mumbai (India). We analysed expenditure by socio-economic status (SES), calculating a Kakwani Index for a range of spending categories. We also calculated catastrophic health spending both with and without adjustment for coping strategies. This identified the level of catastrophic payments incurred by a household and the prevalence of catastrophic payments in this population. The analysis also gave an understanding of the protection from medical poverty afforded by coping strategies (for example saving and borrowing). Results: A high proportion of respondents spent catastrophically on care. Lower SES was associated with a higher proportion of informal payments. Indirect health expenditure was found to be (weakly) regressive as the poorest were more likely to use wage income to meet health expenses, while the less poor were more likely to use savings. Overall, the incidence of catastrophic maternity expenditure was 41%, or 15% when controlling for coping strategies. We found no significant difference in the incidence of catastrophic spending across wealth quintiles, nor could we conclude that total expenditure is regressive. Conclusions: High expenditure as a proportion of household resources should alert policymakers to the burden of maternal spending in this context. Differences in informal payments, significantly regressive indirect spending and the use of savings versus wages to finance spending, all highlight the heavier burden borne by the most poor. If a policy objective is to increase institutional deliveries without forcing households deeper into poverty, these inequities will need to be addressed. Reducing out-of-pocket payments and better regulating informal payments should have direct benefits for the most poor. Alternatively, targeted schemes aimed at assisting the most poor in coping with maternal spending (including indirect spending) could reduce the household impact of high costs.

Northern Nigeria Maternal, Newborn and Child Health Programme: Selected Analyses from Population-Based Baseline Survey. HV. Doctor, R. Bairagi, SE. Findley, S. Helleringer, T. Dahir. The Open Demography Journal, 2011.

Maternal mortality in Northern Nigeria is among the highest in the world. To guide programme planning we interviewed 7,442 women in April and May 2009 in three northern states (Katsina, Yobe, and Zamfara) to understand patterns of antenatal care and delivery. Here, we present findings from a population-based survey conducted under the PRRINN-MNCH Programme to provide evidence-base programmatic interventions aimed at improving maternal and child health indicators. In the paper, we outline the health challenges facing northern Nigeria, describe the PRRINN-MNCH Programme, describe the baseline survey design, implementation, and subsequent data. We provide a series of maternal and child health indicators in order to address two key important policy issues: (1) the importance of visits to health care facilities to enable women get proper maternal care, and (2) the importance of having access to skilled personnel at birth. We further describe how these data can be used to develop appropriate strategies for integrated programmes to increase awareness of pregnancy and delivery complications and to reduce the barriers to assessing risk and accessing the facilities in a timely manner. Appropriate strategies and interventions are necessary to address the existing health challenges. To a large extent, these data also provide an opportunity to measure the impact of the programme in assisting Nigeria attain the health Millennium Development Goals of maternal and child health.

Randomized study of vaginal and neonatal cleansing with 1% chlorhexidine.* L Pereira, T Chipato, A Mashu, V Mushangwe, S Rusakaniko, SI Bangdiwala, OS Chidede, GL Darmstadt, L Gwanzura, G Kandawasvika, S Madzime, P Lumbiganon, JE Tolosa. International Journal of Gynecology & Obstetrics, 112(3), 234-238, March 2011.

Objective: To determine the safety, acceptability, and antimicrobial effect of 1% chlorhexidine (CHX) vaginal washing of women in labor and their neonates. Methods: Randomized controlled trial of 1% CHX vaginal and neonatal washing compared with no washing (usual care [UC]). The study included 502 women (334 CHX, 168 UC) who delivered 508 liveborn neonates (335 CHX, 173 UC). Main outcome measures were the incidence of maternal adverse effects, the incidence of neonatal skin rash, the axillary temparature before and after neonatal wiping, and vaginal culture results. Results: Maternal demographics did not differ between the groups. No case of maternal rash occured; 4% of women experienced vaginal burning. An axillary temperature drop of more than 1°C after CHX cleansing occurred in 8 neonates; 2 neonates had a minor rash. In the subset of women with positive vaginal cultures as baseline, 1% CHX eliminated culture growth in 56% after 1 wash, and in 86% after 2 washes. Conclusions: Use of 1% CHX is safe for neonates, well tolerated by laboring mothers, and effective in treating vaginal infections during labor. A randomized controlled trial using 1% CHX and powered for a reduction in neonatal septic mortality is justified based on these data.

Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency obstetric care.* A Gessessew, GA Barnabas, N Prata, K Weidert. International Journal of Gynecology & Obstetrics In Press, Corrected Proof.

Objective: To assess the contribution of nonphysician clinicians (NPCs) to comprehensive emergency obstetric care (CEmOC) in Tigray, Ethiopia. Methods: We conducted a retrospective review of the obstetric records of all women treated from January 1, 2006, to December 31, 2008, at the 11 hospitals and 2 health centers with CEmOC status in Tigray. Data were collected using 2 questionnaires, one concerning the facility and the other concerning the patient. Results: During the studied period 25,629 deliveries and 11,059 obstetric procedures (3369 of which were major surgical interventions) were performed at these 13 institutions. Overall, NPCs performed 63.3% of these procedures, which included 1574 (55.5%) of a total of 2835 cesarean deliveries. Whereas the cesarean deliveries performed by physicians were more often elective, those performed by NPCs were more often indicated by an emergency. Maternal deaths, fetal deaths, and length of hospital stay did not statistically differ by type of attending staff. Conclusion: Not only do NPCs perform a significant proportion of emergency obstetric procedures in Tigray, but the postoperative outcomes achieved under their care are similar to those attained by physicians. Strengthening NPC training programs in emergency obstetric surgery should further reduce maternal and fetal mortality and morbidity in Ethiopia.

*Journal subscription required for full access