René Tonglet

Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?

Ten years of Safe Motherhood Initiative notwithstanding, many developing countries still experience maternal mortality levels similar to those of industrialized countries in the early 20th century. This paper analyses the conditions under which the industrialized world has reduced maternal mortality over the last 100 years. Preconditions appear to have been early awareness of the magnitude of the problem, recognition that most maternal deaths are avoidable, and mobilization of professionals and the community. Still, there were considerable differences in the timing and speed of reduction of maternal mortality between countries, related to the way professionalization of delivery care was determined: firstly, by the willingness of the decision‐makers to take up their responsibility; secondly, by making modern obstetrical care available to the population (particularly by encouragement or dissuasion of midwifery care); and thirdly, by the extent to which professionals were held accountable for addressing maternal health in an effective way. Reduction of maternal mortality in developing countries today is hindered by limited awareness of the magnitude and manageability of the problem, and ill‐informed professionalization strategies focusing on antenatal care and training of traditional birth attendants. These strategies have by and large been ineffective and diverted attention from development of professional first‐line midwifery and second‐line hospital delivery care.

Deprivation and mortality: the implications of spatial autocorrelation for health resources allocation.

This paper aims at investigating whether the relationship between mortality and socio-economic deprivation is affected by the spatial autocorrelation of ecological data. A simple model is used in which mortality (all-ages and premature) is the dependent variable, and deprivation, morbidity and other socio-economic indicators are the explanatory variables. Deprivation is measured by the Townsend index; the other socio-economic variables are the median income, unequal income distribution (Gini coefficient) and population density. Morbidity is estimated on the basis of hospital admission rates and overweight prevalence. Spatial autocorrelation is measured by the Morans I coefficient. All mortality and morbidity variables have significant, positive, and moderate-to-high spatial autocorrelation. Two multivariate models are explored: a weighted least-squares model ignoring spatial autocorrelation and a simultaneous autoregressive model. The paper concludes that spatial autocorrelation has a significant impact on the relationship between mortality and socio-economic variables. Future ecological models intended to inform health resources allocation need to pay greater attention to the spatial dimension of the data used.

Substantial use of primary health care by prisoners: epidemiological description and possible explanations.

Objectives: To describe the use of primary care services by a prisoner population so as to understand the great number of demands and therefore to plan services oriented to the specific needs of these patients. Design: Retrospective cohort study of a sample of prisoners’ medical records. Setting: All Belgian prisons (nu200a=u200a33). Patients: 513 patients over a total of 182 patient years, 3328 gneral practitioner (GP) contacts, 3655 reasons for encounter. Main results: Prisoners consulted the GP 17 times a year on average (95%CI 15 to 19.4). It is 3.8 times more than a demographically equivalent population in the community. The most common reasons for encounter were administrative procedures (22%) followed by psychological (13.1%), respiratory (12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). Psychological reasons for consultations (nu200a=u200a481) involved mainly (71%) feeling anxious, sleep disturbance, and prescription of psychoactive drugs. Many other visits concerned common problems that in other circumstances would not require any physician intervention. Conclusion: The most probable explanations for the substantial use of primary care in prison are the health status (many similarities noted between health problems at the admission and reasons for consultations during the prison term: mental health problems and health problems related to drug misuse), lack of access to informal health services (many contacts for common problems), prison rules (many consultations for administrative procedures), and mental health problems related to the difficulties of life in prison.

Association of HIV infection and Mycobacterium ulcerans disease in Benin.

We investigated the association between Buruli ulcer and HIV by comparing the HIV-1/2 seroprevalence in a series of 426 Buruli ulcer patients and a sample of 613 residents of southern Benin. The overall HIV prevalence was 2.6% (11/426) among patients and 0.3% among controls (2/613), giving an odds ratio for the association between HIV and Buruli ulcer of 8.1 (95% confidence interval = 1.8–75; P = 0.003).

Chronic hepatitis B infection: long term comparison of children receiving interferon alpha and untreated controls.

Objectives: To investigate the virological outcome of chronic hepatitis B (CH-B) in children who received interferon alpha (IFN) compared with no treatment. Methods: Seventy-four children with CH-B (median age, 6.1 years; 44 boys) selected from a cohort of 158 cases were included and divided into two groups: IFN-treated (n = 37) and control (n = 37). The controls were matched with the treated children by baseline alanine aminotransferase (ALT) levels, sex and age. The Kaplan-Meier method was performed to estimate the time to clearance of hepatitis B e antigen (HbeAg) and hepatitis B surface antigen (HbsAg). Results: Mean duration of follow-up was comparable in two groups (5.2 ± 3.8 years in treatment group versus 5.2 ± 3.7 years in control group, NS). HBeAg and HBsAg loss occurred in 20 (54.1%) and three treated children versus 13 (35.1%) and one untreated children (NS), respectively. The 7-year cumulative HBeAg and HBsAg clearance rates were 47.5% and 8.9% after the first visit in the treatment group versus 33.5% and 4.0% in untreated children (NS), respectively. Elevated baseline ALT (two times upper limit of normal) had a significant effect on the long-term cumulative rate of HBeAg seroconversion in treated patients (P = 0.01) but not in the untreated group. Conclusions: These findings show that the overall long-term virological outcome does not differ significantly between IFN-treated and untreated children but that a significant benefit of treatment on the long term rate of HBeAg seroconversion is obtained in children with higher baseline ALT levels.

Household survey of psychiatric morbidity in Cambodia.

Aims: To estimate the prevalence of psychiatric symptoms in the Kampong Cham province and to determine the association between these symptoms and an impaired social functioning. Methods: Cross-sectional cluster sample survey conducted among adults randomly selected within 50 clusters distributed over the province. Results: Of the respondents, 42.4% reported symptoms that met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria for depression, 53% displayed high anxiety symptoms and 7.3% met posttraumatic stress disorder (PTSD) criteria. Posttraumatic symptoms of intrusion and avoidance were present in 47.8% and 45.4% respectively. When reviewing comorbidities, 29.2% had depression and anxiety symptoms, 16.5% anxiety symptoms, 6.1% depression and 7.1% had triple comorbidity (PTSD, depression and anxiety). Regarding social functioning, 25.3% reported being socially impaired. Respondents with comorbid symptoms for depression, anxiety and PTSD were associated with an increased risk for social impairment compared with others. Being over 65 years and having experienced violent events were other factors associated with social impairment. Conclusion: Five years after the return of a more stable context in Cambodia, the prevalence of psychiatric symptoms in the community remains high. In addition, these symptoms are strongly associated with social impairment. This suggests that beyond psychosocial programs, the implementation of adapted clinical psychiatric care should be considered as a priority.

Serum albumin concentration, arm circumference, and oedema and subsequent risk of dying in children in central Africa.

OBJECTIVE--To measure the prognostic value of clinical, anthropometric, and biological indicators of protein energy malnutrition in hospitalised children. DESIGN--Hospital based follow up study from admission to discharge or death of a cohort of children. SETTING-Paediatric hospital in Zaire. SUBJECTS--1129 children consecutively admitted between August 1986 and October 1988. MAIN OUTCOME MEASURES--Height, weight, arm circumference, skinfold thicknesses, serum albumin concentration, and mortality. RESULTS--Mortality was higher in wasted children and in those with a mid-upper arm circumference < 125 mm, a serum albumin concentration < 16 g/l, and oedema. After multivariate analysis, serum albumin concentration was the best predictor of subsequent risk of dying. Mid-upper arm circumference and oedema, however, still contributed considerably to evaluation of mortality. CONCLUSIONS--In this specific environment of central Africa an isolated clinical sign such as oedema is not enough to detect children with a high risk of dying among those admitted to paediatric wards with severe protein energy malnutrition. Measurement of additional indicators such as arm circumference and serum albumin concentration seems to be of crucial importance.

How useful are anthropometric, clinical and dietary measurements of nutritional status as predictors of morbidity of young children in central Africa?

Summary objectiveu2002u2002To identify useful predictors of morbidity of young children in central Africa.

Causes of locomotor disability and need for orthopaedic devices in a heavily mined Taliban‐controlled province of Afghanistan: issues and challenges for public health managers

We conducted a locomotor disability survey on a heavily mined Taliban‐controlled province of Afghanistan to document the problem of locomotor disability and to assess the need for orthopaedic rehabilitation devices in a study population of 12065. Global prevalence of locomotor disability was 23/1000 (95% CI: 20–26). War‐related injuries were the leading cause of disability, affecting almost exclusively adult males. Leading causes of disability among women and children were medical and poliomyelitis. Devices most needed were lower limb ortheses (8.2 devices/1000 people; 95% CI: 5.9–10.4) and orthopaedic shoes (6.0/1000; 95% CI:4.1–8.0). The need for lower limb prostheses was less frequent (2.0/1000; 95% CI: 1.1–2.8). Most lower limb amputees (mainly victims of landmine injuries) were fitted with an artificial leg, while rehabilitation needs for other types of disability remained largely unmet. We estimated that it would take at least 3 years to provide enough orthopaedic shoes and 10 years for ortheses, whereas the need for lower limb prostheses could be met in less than 4 months. None of the 27 women with lower limb disability were equipped with an orthopaedic device, although this was the case for 31 of 89 men (35%). The problem of landmines should not divert attention from other causes of disability such as poliomyelitis or from other rehabilitation requirements. Immunization programmes and restoration of the public health infrastructure should be given high priority; rehabilitation services are largely insufficient and should be developed. Extreme gender difference in needs coverage is a matter of concern. Researching culturally sensitive strategies to tackle this problem should be a priority for donors and implementing agencies.

Association between haemoglobin variants S and C and Mycobacterium ulcerans disease (Buruli ulcer): a case-control study in Benin.

Risk factors for Buruli ulcer (BU) are poorly understood. We conducted a case‐control study in southern Benin to investigate the association between haemoglobin variants S or C and BU, and particularly the association between haemoglobinopathies HbSS/SC and BU osteomyelitis. We compared the haemoglobin genotype of 179 patients with BU and 44 with BU osteomyelitis to that of 242 community controls. We found no evidence of an increased risk of BU according to the presence of haemoglobin variants S and/or C [odds ratio adjusted for sex, age, region of residence and ethnicity: 1.24 (95%CI: 0.80–1.93), Pu2003=u20030.34]. Haemoglobin variants S and C are unlikely to play a role in the BU burden. However, haemoglobinopathies HbSS/SC were more frequent among BU osteomyelitis patients than among controls (6.8%vs. 1.0%, Fishers exact P‐valueu2003=u20030.045), which may suggest that those disorders facilitate growth of Mycobacterium ulcerans in the bone matrix.