This preliminary report from Malawi describes a process of developing standards for maternity care together with a multidisciplinary team of health professionals.Conventionally standards for maternity care are developed by a panel of experts (usually obstetricians) and then implemented by a multidisciplinary team. The present study concerns the feasibility of involving health professionals of all grades in the establishment standards for obstructed labour in Malawi. Standards for obstructed labour were developed by a multidisciplinary team involving all cadres of health professionals working in maternity units, as well as hospital managers and policy makers, using evidence from Malawi national guidelines, World Health Organisation manuals and peer-reviewed journals. The standards addressed different aspects of the management of obstructed labour, namely early recognition of prolonged labour by labouring women and traditional birth attendants, early arrival of women to health facilities during labour, proper use of partograph by healthcare providers, proper management of prolonged labour, proper management of obstructed labour, appropriate management of uterine rupture and early delivery of the baby.
Equitable health services
The study aimed to evaluate health facility and health worker readiness to deliver new artemetherlumefantrine (AL) treatment policy for uncomplicated malaria in Kenya, using a cross-sectional survey at health facilities in four sentinel districts in Kenya. All government facilities in study districts and all health workers performing outpatient consultations were involved in the study. The availability of any tablets of AL , sulfadoxine-pyrimethamine and amodiaquine was nearly universal on the survey day. However, only 61% of facilities stocked all four weight-specific packs of AL. In the past six months, 67% of facilities had stock-out of at least one AL tablet pack and 15% were out of stock for all four packs at the same time. Duration of stock-out was substantial for all AL packs (median range: 27-39% of time). During the same period, the stock-outs of sulfadoxine-pyrimethamine and amodiaquine were rare. Only 19% of facilities had all AL wall charts displayed, AL in-service training was provided to 47% of health workers and 59% had access to the new guidelines. Health facility and health worker readiness to implement AL policy is not yet optimal. Continuous supply of all four AL pack sizes and removal of not-recommended antimalarials is needed. Further coordinated efforts through the routine programmatic activities are necessary to improve delivery of AL at the point of care.
This paper identifies priorities for disease control as an input into the Copenhagen Consensus effort for 2008 (CC08). The analysis builds on the results of the Disease Control Priorities Project (DCPP). The DCPP engaged over 350 authors and among its outputs were estimates of the cost-effectiveness of 315 interventions. These estimates vary a good deal in their thoroughness and in the extent to which they provide region-specific estimates of both cost and effectiveness. Taken as a whole, however, they represent a comprehensive canvas of disease control opportunities. Some interventions are clearly low priority. Others are attractive and worth doing but either address only a small proportion of disease burden or are simply not quite as attractive as a few key interventions. This paper identifies seven priority interventions in terms of their cost-effectiveness, the size of the disease burden they address, and other criteria.
TB control is hampered by the dual HIV epidemic, and is one of the main reasons for the rapid increase in TB in South Africa, compounded by escalating rates of multidrug resistance (MDR) and the emergence of extensively drug-resistant TB (XDR-TB) in all nine provinces. Rapid diagnosis of drug-resistant TB has been identified as one of the key efforts to find a solution to the control of MDR-TB. A demonstration study under field conditions involving 20,000 TB patients at risk of MDR-TB was conducted in four provinces in South Africa, evaluating the effectiveness of a new molecular test for rapid diagnosis of MDR-TB. Outcomes of this study showed that the test has the potential to revolutionise the control of MDR-TB and its use in TB control programmes has been endorsed by the World Health Organisation. The study showed that the test is highly effective in diagnosing MDR-TB and can be used in laboratory settings in developing countries. Although specialised laboratory facilities and specially trained personnel are required, the test is easy to perform in the laboratory and results are accurate and reproducible. This is very likely one of few instances that global policy for poverty-related disease is driven by evidence generated by scientists and institutions from high-burden countries, such as South Africa, with full credit for the results. The test will be rolled out to all provinces in South Africa, following the acceptance of a new diagnostic algorithm by the National TB Control Programme.
A lack of laboratory facilities, transport and skilled medical workers is reported to be hampering efforts to tackle an outbreak of visceral leishmaniasis, a parasitic disease also known as kala azar or black fever, in northern Kenya’s Isiolo and Wajir districts, officials said. According to public health officials in the district prevention and management of the disease is limited by the availability of trained personnel.
KwaZulu-Natal seems to be winning the battle against malaria in the province, with only about 1,000 cases reported in the province in the past malarial season. According to Prof. Maureen Coetzee, an entomologist from the University of the Witwatersrand, in a paper presented to the International Congress of Entomology in Durban, the situation in the province and the country is favourable because of reduced rainfall and the changes made to malaria control programmes, with use of two insecticides to control mosquitoes and a change to the drug for treatment of the parasite. Similar control programmes have also been introduced in Mozambique. The use of fungi to kill mosquitoes is being tested and research at Wits University showed that mosquitoes exposed to
fungi died within 12 to 14 days after exposure.
People in low-resource countries who are ill with multidrug-resistant TB (MDR-TB) will get a faster diagnosis and a new treatment regime, thanks to two new initiatives unveiled by the World Health Orgqnisation, the Stop TB Partnership, UNITAID and the Foundation for Innovative New Diagnostics (FIND). On diagnosis, the method gives results in two days rather than the standard two to three months. At present it is estimated that only 2% of MDR-TB cases worldwide are being diagnosed and treated appropriately, mainly because of inadequate laboratory services. The initiatives should increase the proportion diagnosed and treated at least seven-fold over the next four years, to 15% or more.
Scaling up the implementation of new health care interventions can be challenging and demand intensive training or retraining of health workers. This paper reports on the results of testing the effectiveness of two different kinds of face-to-face facilitation methods used in conjunction with a well-designed educational package in the scaling up of mother care. A previous trial illustrated that the implementation of a new health care intervention could be scaled up by using a carefully designed educational package, combined with face-to-face facilitation by respected resource persons. This study demonstrated that the site of facilitation, either on site or at a centre of excellence, does not affect implementation abilities at the hospital service level. The choice of outreach strategy should be guided by local circumstances, cost and the availability of skilled facilitators.
Although evidence-based interventions to reach the Millennium Development Goals for Maternal and Neonatal mortality reduction exist, they have not yet been operationalised and scaled up in Sub-Saharan African cultural and health systems. A key concern is whether these internationally recommended practices are acceptable and will be demanded by the target community. The researchers explored the acceptability of these interventions in two rural districts of Uganda; conducted ten focus group discussions consisting of mothers, fathers, grand parents and child minders (older children who take care of other children); and ten key informant interviews with health workers and traditional birth attendants. Most maternal and newborn recommended practices are acceptable to both the community and to health service providers. However, health system and community barriers were prevalent and will need to be overcome for better neonatal outcomes. Pregnant women did not comprehend the importance of attending antenatal care early or more than once unless they felt ill. Women prefer to deliver in health facilities but most do not do so because they cannot afford the cost of drugs and supplies which are demanded in a situation of poverty and limited male support. Postnatal care is non-existent. For the newborn, delayed bathing and putting nothing on the umbilical cord were neither acceptable to parents nor to health providers, requiring negotiation of alternative practices. Communities associate the need for antenatal care attendance with feeling ill, and postnatal care is non-existent in this region. Health promotion programs to improve newborn care must prioritise postnatal care, and take into account the local socio-cultural situation and health systems barriers including the financial burden. Male involvement and promotion of waiting shelters at selected health units should be considered in order to increase access to supervised deliveries. Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation.
Maternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policy-makers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios. The researchers conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. In this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement.