Albrecht Jahn

Use pattern of maternal health services and determinants of skilled care during delivery in southern Tanzania: Implications for achievement of MDG-5 targets.

BackgroundAlmost two decades since the initiation of the Safe motherhood Initiative, Maternal Mortality is still soaring high in most developing countries. In 2000 WHO estimated a life time risk of a maternal death of 1 in 16 in Sub- Saharan Africa while it was only 1 in 2800 in developed countries. This huge discrepancy in the rate of maternal deaths is due to differences in access and use of maternal health care services. It is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality. For this reason, the proportion of births attended by skilled health personnel is one of the indicators used to monitor progress towards the achievement of the MDG-5 of improving maternal health.MethodsCross sectional study which employed quantitative research methods.ResultsWe interviewed 974 women who gave birth within one year prior to the survey. Although almost all (99.8%) attended ANC at least once during their last pregnancy, only 46.7% reported to deliver in a health facility and only 44.5% were assisted during delivery by a skilled attendant. Distance to the health facility (OR = 4.09 (2.72–6.16)), discussion with the male partner on place of delivery (OR = 2.37(1.75–3.22)), advise to deliver in a health facility during ANC (OR = 1.43 (1.25–2.63)) and knowledge of pregnancy risk factors (OR 2.95 (1.65–5.25)) showed significant association with use of skilled care at delivery even after controlling for confounding factors.ConclusionUse of skilled care during delivery in this district is below the target set by ICPD + of attaining 80% of deliveries attended by skilled personnel by 2005. We recommend the following in order to increase the pace towards achieving the MDG targets: to improve coverage of health facilities, raising awareness for both men and women on danger signs during pregnancy/delivery and strengthening counseling on facility delivery and individual birth preparedness.

Determinants of utilisation of maternal care services after the reduction of user fees: A case study from rural Burkina Faso

OBJECTIVE To identify determinants of utilisation for antenatal care (ANC) and skilled attendance at birth after a substantial reduction in user fees. METHODS The study was conducted in the Nouna Health District in north-western Burkina Faso in early 2009. Data was collected by means of a representative survey on a sample of 435 women who reported a pregnancy in the prior 12 months. Two independent logit models were used to assess the determinants of (a) ANC utilisation (defined as having attended at least 3 visits) and (b) skilled assistance at birth (defined as having delivered in a health facility). RESULTS 76% of women had attended at least 3 ANC visits and 72% had delivered in a facility. Living within 5 km from a facility was positively associated, while animist religion, some ethnicities, and household wealth were negatively associated with ANC utilisation. Some ethnicities, living within 5 km from a health facility, and having attended at least 3 ANC visits were positively associated with delivering in a facility. CONCLUSIONS User fee alleviation secured equitable access to care across socio-economic groups, but alone did not ensure that all women benefited from ANC and from skilled attendance at birth. Investments in policies to address barriers beyond financial ones are urgently needed.

Risk factors of infant and child mortality in rural Burkina Faso.

OBJECTIVE The aim of the study was to quantify the effect of risk factors for childhood mortality in a typical rural setting in sub-Saharan Africa. METHODS We performed a survival analysis of births within a population under demographic surveillance from 1992 to 1999 based on data from a demographic surveillance system in 39 villages around Nouna, western Burkina Faso, with a total population of about 30000. All children born alive in the period 1 January 1993 to 31 December 1999 in the study area (n = 10 122) followed-up until 31 December 1999 were included. All-cause childhood mortality was used as outcome variable. FINDINGS Within the observation time, 1340 deaths were recorded. In a Cox regression model a simultaneous estimation of hazard rate ratios showed death of the mother and being a twin as the strongest risk factors for mortality. For both, the risk was most pronounced in infancy. Further factors associated with mortality include age of the mother, birth spacing, season of birth, village, ethnic group, and distance to the nearest health centre. Finally, there was an overall decrease in childhood mortality over the years 1993-99. CONCLUSION The study supports the multi-causation of childhood deaths in rural West Africa during the 1990s and supports the overall trend, as observed in other studies, of decreasing childhood mortality in these populations. The observed correlation between the factors highlights the need for multivariate analysis to disentangle the separate effects. These findings illustrate the need for more comprehensive improvement of prenatal and postnatal care in rural sub-Saharan Africa.

Can Mothers Afford Maternal Health Care Costs? User Costs of Maternity Services In Rural Tanzania

Following the difficult economic situation various countries introduced health sector reforms, including user charges to finance the system. The assessment of user costs for maternity services in Tanzania was part of a larger study, which covered inputs, outputs and efficiency of services. The study was carried out from October 1997 to January 1998 in Mtwara urban and rural district in South Tanzania. One hundred and seven women attending a quarter of government health facilities were randomly selected and interviewed. Twenty one key informants were also interviewed and service procedures observed. Users of maternity services pay mainly for admission, drugs, other supplies and travel costs. Travel costs represent about half of these financial costs. The average total costs vary between US

Methylene blue for malaria in Africa: results from a dose-finding study in combination with chloroquine

11.60 for antenatal consultation and US

Maternity care in rural Nepal: a health service analysis

135.40 for caesarean section at the hospital. Unofficial payments are not included in the calculation. The amounts vary and payment is irregular. We therefore conclude that time costs are constantly higher than financial costs. High direct payments and the fear of unofficial costs are acute barriers to the use of maternity services. User costs can substantially be reduced by the re-organisation of service delivery especially at antenatal consultation.

Routine screening for intrauterine growth retardation in Germany : low sensitivity and questionable benefit for diagnosed cases

The development of safe, effective and affordable drug combinations against malaria in Africa is a public health priority. Methylene blue (MB) has a similar mode of action as chloroquine (CQ) and has moreover been shown to selectively inhibit the Plasmodium falciparum glutathione reductase. In 2004, an uncontrolled dose-finding study on the combination MB-CQ was performed in 435 young children with uncomplicated falciparum malaria in Burkina Faso (CQ monotherapy had a > 50% clinical failure rate in this area in 2003). Three serious adverse events (SAE) occurred of which one was probably attributable to the study medication. In the per protocol safety analysis, there were no dose specific effects. The overall clinical and parasitological failure rates by day 14 were 10% [95% CI (7.5%, 14.0%)] and 24% [95% CI (19.4%, 28.3%)], respectively. MB appears to have efficacy against malaria, but the combination of CQ-MB is clearly not effective in the treatment of malaria in Africa.

Why Do At-Risk Mothers Fail To Reach Referral Level? Barriers Beyond Distance and Cost

Summary This study assesses the performance of maternity care and its specific service components (preventive interventions in antenatal care, antenatal screening, referral, obstetric care) in Banke District, Nepal, using a set of structure, process, and output/outcome indicators. Data sources included health service documents in 14 first level health units and two hospitals, covering 1378 pregnancies and 1323 deliveries, structured observations, antenatal exit interviews (n = 136) and interviews with maternity users (n = 146). Coverage of antenatal care (28%) and skilled delivery care (16%) was low. In antenatal care, preventive interventions were only partially implemented (effective iron supplementation in 17% of users). On average one minute was spent on individual counselling per consultation. 41% of pregnancies were identified as high risk and 15% received referral advice, which was followed in only 32%. Hospital deliveries accounted for 9.8% of all deliveries. Hospital‐based maternal mortality was 6.8/1000 births and the stillbirth rate 70/1000. High rates of stillbirth were observed in breech delivery (258/1000 births), caesarean section (143/1000) and twin delivery (133/1000). The risk of stillbirth was higher for rural women (RR 2.3; 95% CI 1.51–3.50) and appeared to be related to low socio‐economic status. Emergency admissions were rare and accounted for 3.4% of hospital deliveries or only 0.4% of all expected deliveries. There was hardly any accumulation of high‐risk pregnancies at hospital. The population‐based rate of caesarean section was 1.1% (urban 2.3%, rural 0.2%). The estimated unmet obstetric need was high (82 cases or 61% of expected live‐threatening maternal conditions did not receive appropriate intervention). The limited effectiveness of maternity care is the result of deficiencies of all service components. We propose a two‐pronged approach by starting quality improvement of maternity care from both ends of maternity services: preventive interventions for all women and hospital‐based obstetric care. Antenatal screening needs to be rationalized by reducing inflated risk catalogues that result in stereotypical and often rejected referral advice.

Obstetric care in southern Tanzania: does it reach those in need?

BACKGROUND Antenatal screening for fetal growth retardation has proven effective in detecting at-risk pregnancies under study conditions. It is also widely believed to improve pregnancy outcomes. We assessed sensitivity of antenatal screening routines for intrauterine growth retardation under routine service conditions in Germany. We then compared pregnancy management and outcome in small for gestational age neonates with antenatally diagnosed growth retardation to neonates whose growth retardation had remained undetected. METHODS Historical prospective study covering all 2378 singleton pregnancies with antenatal records delivered within a one-year period at a tertiary level maternity hospital in Germany. Antenatal records were linked with pregnancy outcome data. RESULTS The sensitivity of screening routines based on ultrasound and non-systematic follow-up investigations was 32% as compared to 80-90% reported for ultrasound screening under study conditions. An antenatal diagnosis of intrauterine growth retardation was associated with a 5 times higher rate of preterm delivery (p<0.001), mainly as a consequence of medical interventions to avoid fetal compromise, when compared to new-borns with growth retardation not detected before delivery; admission rates to neonatal care unit were 3 times higher (p<0.001). The proportion of low Apgar scores and low cord pH, indicating fetal distress, was not significantly different in detected and undetected cases. CONCLUSION Screening routines for intrauterine growth retardation currently used in Germany miss the majority of cases and do not contribute towards improved pregnancy outcome in detected cases. A benefit of elective preterm delivery in the management of suspected intrauterine growth retardation was not evident.

Assessing health worker performance in malaria case management of underfives at health facilities in a rural Tanzanian district.

In southern Tanzania, few high-risk pregnancies are channeled through antenatal care to the referral level. We studied the influences that make pregnant women heed or reject referral advice. Semi-structured interviews with sixty mothers-to-be, twenty-six health workers and six key-informants to identify barriers to use of referral level were conducted. Expert-defined risk-status was found to have little influence on a womans decision to seek hospital care. Besides well known geographical and financial barriers, we found that pregnant women have different perceptions and interpretations of danger signs. Furthermore, rural women avoid the hospital because they fear discrimination. We conclude that a more individualised antenatal consultation could be provided by taking into account womens perception of risk and their explanatory models. Hospital services should be reorganised to address rural womens feelings of fear and insecurity.