Ann Fitzmaurice

The familial technique for linking maternal death with poverty

BACKGROUND Recognition of the synergy between health and poverty is now apparent in the development strategies of many low-income countries, and markers are needed to monitor progress towards poverty-relevant goals. Maternal mortality has been proposed as a possible candidate but evidence is lacking on the link with poverty at the level of individuals. We introduce a new approach to exploring the relation--the familial technique. METHODS We used data from 11 household surveys in ten developing countries to create percentage distributions of women according to their poverty-related characteristics and survival status (alive, non-maternal death, maternal death). These women were identified as the sisters of the adult female respondents in the surveys, and were assigned the same poverty status as their respondent sibling. FINDINGS The analysis showed significant associations, across a diverse set of countries, between womens poverty status (proxied by educational level, source of water, and type of toilet and floor) and survival. These associations indicated a gradient within and across the survival categories. With increasing poverty, the proportion of women dying of non-maternal causes generally increased, and the proportion dying of maternal causes increased consistently. Further analysis reported here for one of the countries--Indonesia, revealed that about 32-34% of the maternal deaths occurred among women from the poorest quintile of the population. The risk of maternal death in this country was around 3-4 times greater in the poorest than the richest group. INTERPRETATION This new method makes efficient use of existing survey data to explore the relation between maternal mortality and poverty, and has wider potential for examining the poor-rich gap.

Revealing the burden of maternal mortality: a probabilistic model for determining pregnancy-related causes of death from verbal autopsies

BackgroundSubstantial reductions in maternal mortality are called for in Millennium Development Goal 5 (MDG-5), thus assuming that maternal mortality is measurable. A key difficulty is attributing causes of death for the many women who die unaided in developing countries. Verbal autopsy (VA) can elicit circumstances of death, but data need to be interpreted reliably and consistently to serve as global indicators. Recent developments in probabilistic modelling of VA interpretation are adapted and assessed here for the specific circumstances of pregnancy-related death.MethodsA preliminary version of the InterVA-M probabilistic VA interpretation model was developed and refined with adult female VA data from several sources, and then assessed against 258 additional VA interviews from Burkina Faso. Likely causes of death produced by the model were compared with causes previously determined by local physicians. Distinction was made between free-text and closed-question data in the VA interviews, to assess the added value of free-text material on the models output.ResultsFollowing rationalisation between the model and physician interpretations, cause-specific mortality fractions were broadly similar. Case-by-case agreement between the model and any of the reviewing physicians reached approximately 60%, rising to approximately 80% when cases with a discrepancy were reviewed by an additional physician. Cardiovascular disease and malaria showed the largest differences between the methods, and the attribution of infections related to pregnancy also varied. The model estimated 30% of deaths to be pregnancy-related, of which half were due to direct causes. Data derived from free-text made no appreciable difference.ConclusionInterVA-M represents a potentially valuable new tool for measuring maternal mortality in an efficient, consistent and standardised way. Further development, refinement and validation are planned. It could become a routine tool in research and service settings where levels and changes in pregnancy-related deaths need to be measured, for example in assessing progress towards MDG-5.

The impact of economic recession on maternal and infant mortality: lessons from history.

BackgroundThe effect of the recent world recession on population health has featured heavily in recent international meetings. Maternal health is a particular concern given that many countries were already falling short of their MDG targets for 2015.MethodsWe utilise 20th century time series data from 14 high and middle income countries to investigate associations between previous economic recession and boom periods on maternal and infant outcomes (1936 to 2005). A first difference logarithmic model is used to investigate the association between short run fluctuations in GDP per capita (individual incomes) and changes in health outcomes. Separate models are estimated for four separate time periods.ResultsThe results suggest a modest but significant association between maternal and infant mortality and economic growth for early periods (1936 to 1965) but not more recent periods. Individual country data display markedly different patterns of response to economic changes. Japan and Canada were vulnerable to economic shocks in the post war period. In contrast, mortality rates in countries such as the UK and Italy and particularly the US appear little affected by economic fluctuations.ConclusionsThe data presented suggest that recessions do have a negative association with maternal and infant outcomes particularly in earlier stages of a countrys development although the effects vary widely across different systems. Almost all of the 20 least wealthy countries have suffered a reduction of 10% or more in GDP per capita in at least one of the last five decades. The challenge for todays policy makers is the design and implementation of mechanisms that protect vulnerable populations from the effects of fluctuating national income.

Incidence of adverse outcomes associated with gestational diabetes mellitus in low- and middle-income countries

The contribution of medical conditions such as diabetes mellitus to maternal and neonatal ill‐health in low‐ and middle‐income countries is not well documented.

Lessons regarding the use of birth kits in low resource countries

OBJECTIVE To synthesise implementation lessons regarding birth kits in terms of the context, the user, requirements for use and the logistics of supplying kits. DESIGN The scoping review was informed through a systematic literature review; a call for information distributed to experts in maternal and child health, relevant research centres and specialist libraries; a search of the web sites of groups working in the area of maternal and child health; and data extraction from DHS surveys. Data synthesis involved the production of a simple descriptive summary of the state of knowledge regarding birth kits. PARTICIPANTS The 28 articles included in the review described a total of 21 birth kits used in 40 different countries and in many cases the kits were part of a package of interventions. FINDINGS Although birth kits are available in more than 50 low resource countries, evidence regarding implementation is limited. Levels of birth kit use vary considerably (8-99%); with higher levels being reported where birth kits are distributed free as part of a research programme. Identifying the user of the birth kit was difficult in most reports and the evidence regarding training requirements for birth kit use was conflicting. Limited information exists regarding facilitators and barriers to birth kit use, and how birth kits fit within the wider service delivery of maternal and child health. CONCLUSION Despite widespread use of birth kits, implementation lessons are hard to identify. The fact that birth kits are predominantly used in non-facility settings, and probably by non-skilled attendants, poses further challenges in synthesising the evidence. It would seem logical that government run programmes would increase utlisation rates; however in these countries national level data are not yet available. Such data are crucial to identifying how women obtain and use birth kits. The importance of context cannot be over emphasised, and better descriptive methods are needed to capture contextual factors that may impact on the implementation process. IMPLICATIONS FOR PRACTICE Birth kits are a promising technology to achieve MDG 5, however further research is needed before making recommendations to scale up mother held birth kits or to expand kit contents.

Do medical students want to learn about global health

Background One objective of the United Nations Global Strategy for Womens and Childrens Health relates to ensuring a sufficiently skilled workforce. To prepare future healthcare professionals for their role in the 21st century as members of this workforce, awareness of global health is essential, but few studies have explored student perspectives on such education. The main objectives of this study were to establish the views of medical students on learning about womens and childrens health in low-income countries, to identify the nature and extent of learning already experienced, and to assess the demand for such learning. Design A questionnaire survey was conducted at three meetings of the International Federation of Medical Students Associations (IFMSA). Questionnaires were distributed to 500 participants from 75 countries and 336 medical schools, and 492 usable questionnaires were returned. Data were analysed using SPSS Version 20 and statistical analysis was undertaken using Fishers exact test. Results There were 492 questionnaires included in the analysis. Forty-eight per cent of participants were from low–middle income countries and 52% were from high-income countries. Less than half (43%) of the respondents had received some teaching on womens and childrens health in low-income countries. Teaching received was primarily (96%) through lectures in the second year of study. Ninety-one per cent of respondents thought such teaching would be important and stated that group work (66%) would be the preferred method. In total, only 14% thought they had received sufficient teaching on global health and on womens and childrens health in low-income countries. Conclusions This study has revealed a high demand among medical students for global health teaching, particularly on womens and childrens health in low-income countries. The timing and methods of existing teaching on these topics does not match that desired by medical students. To help address this gap, a collaborative approach is proposed which includes students’ views in the processes for revitalising medical curricula to meet the needs of the 21st century.

Randomized controlled trial comparing couple satisfaction with appointment and telephone follow-up consultation after unsuccessful IVF/ICSI treatment.

Couples undergoing in vitro fertilization and intracytoplasmic sperm injection (IVF/ICSI) at Aberdeen Maternity Hospital come from a wide geographical area. Increasingly, telephone discussions after unsuccessful treatment have replaced appointments for those who do not live locally. The aim of this study was to compare patient satisfaction with telephone follow-up discussions versus clinic appointments. Couples were separated into those undergoing their first treatment cycle (100 couples) and those undergoing their second or subsequent treatment cycle (85 couples), and then randomized to either a telephone or appointment follow-up. Satisfaction was assessed by a postal questionnaire and analysis conducted on an ‘intention to treat’ basis. An overall response rate of 91% was achieved. Analysis indicated no statistically significant difference between telephone and appointment groups with regard to the degree of satisfaction. However, there was an association between the type of follow-up and the duration of discussion (P<0.001): telephone follow-up discussions were significantly shorter than appointment follow-ups. There is the potential for significant savings in costs, both to the service and to patients, by providing telephone follow-up consultations. The savings may be achieved without compromising patient satisfaction as long as clinic appointments remain available as an option for those couples who prefer them.

The epidemiology of pregnancy outcomes in rural Burkina Faso: Pregnancy outcomes in rural Burkina Faso

Objectives  To describe levels and causes of pregnancy‐related mortality and selected outcomes after pregnancy (OAP) in two districts of Burkina Faso.

The epidemiology of pregnancy outcomes in rural Burkina Faso

Objectives  To describe levels and causes of pregnancy‐related mortality and selected outcomes after pregnancy (OAP) in two districts of Burkina Faso.