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birth weight is vital to the development potential of the newborn. Abnormal birth weight (such as low birth weight and macrosomia) is an important determinant of child survival, disabilities, stunting, and long-term adverse consequences for the onset of non-communicable diseases in the life course and therefore demands appropriate public health interventions. Stillbirths are also considered one of the most important, but most poorly understood and documented adverse outcomes of pregnancy. Therefore, this study aimed to assess the prevalence of abnormal birth weight and related maternal risk factors, as well as pregnancy outcomes, such as stillbirth.a retrospective study design was used to analyze 4262 delivery records for singleton pregnancies from January 2013 to December 2014 seen at the Hohoe municipal hospital, Volta region in Ghana. The data on birth weight and related factors were derived from the delivery book. Data was analyzed using STATA. Multinomial logistic regression was used to assess the association between maternal factors such as parity, age and intermittent preventive treatment of malaria, sex of infant and abnormal birth weight. Association between stillbirth and related factors was assessed using logistic regression.prevalence of low birth weight (2.5kg) was 9.69% and macrosomia (≥4.0kg) was 3.03%. There was an increased risk of a first born being of low birth weight than second or third born (RR; 2.04, CI; 1.59-2.64, p0.0001). There were also an increased risks of mothers20 years giving birth to low-birthweight infants (RR; 1.46, CI; 1.11-1.93, p=0.007) compared to mothers who were within the age ranges of 20-30 years and also among those who took only one (RR; 1.57, CI; 1.02-2.39, p=0.039) or no intermittent preventive treatment for malaria during pregnancy (RR; 1.57, CI; 1.24-1.98, p=0.0001) compared to those who took three doses. Risk of macrosomic birth was particularly high among 5th born (RR; 2.66, CI; 1.43-4.95, p=0.002) compared to first or second born. Stillbirth rate was 27/1000 births. Thirty-two percent of the stillbirths (n=38) had low birth weight whereas 6.8% (n=8) were macrosomic. There was a greater than fivefold (AOR; 5.6, CI; 3.6-8.7) and greater than twofold (AOR; 2.4, CI; 1.1-5.3, p=0.025) increase in odds for stillbirth among low birth weight and macrosomic infants respectively.macrosomia and low birth weight co-existed among infants in Hohoe municipality, both of which are associated with adverse pregnancy outcome such as stillbirth. Given the apparent association between maternal age20 years and increased risk, health promotion strategies aimed at preventing pregnancies among teenagers could be implemented to aid the reduction of stillbirth rates.

OBJECTIVES: To identify the main issues midwives reportedly counsel pregnant women on, the influence of counseling on pregnancy outcomes and the implementation gaps. METHODS: Mixed method design was used. Quantitative data included interviews with 299 pregnant women above 27 gestational weeks randomly recruited from five hospitals in Ghana who had four or more antenatal care (ANC) visits. Their maternal health record books were reviewed for documented counseling sessions. Where half of the recommended topics were discussed, it was considered as adequate counseling (AC). Binary logistic regression was modeled in STATA to estimate the unadjusted odds ratio (OR) of AC on pregnancy outcomes. For the qualitative data, in-depth were conducted with 15 midwives and exit interviews with all the women and analyzed thematically. RESULTS: According to the women, the most discussed topics were usage of insecticide-treated nets (60.5%), personal/environmental hygiene (57.5%) and breastfeeding (52.3%). Conversely, the midwives documented discussing mostly nutrition/anaemia (37.6%), danger signs in pregnancy (30.1%) and birth preparedness/complication readiness (29.9%). Most women disliked group counseling and cited non-tailoring of advice. Main implementation gaps were heavy work schedules, inadequate staff, limited time for counseling and hefty documentation. The 45% who were adequately counseled significantly reduced their likelihood for poor dietary intake (OR: 0.54, 95% CI: 0.32–0.90), incidence of malaria (OR: 0.22, 95% CI: 0.06–0.78), preeclampsia (OR: 0.25 CI: 0.06–0.99) and need for neonatal intensive care (OR: 0.29 CI: 0.09–0.94) while increasing the newborn's birth weight (OR: 1.85 CI: 1.08–3.19). CONCLUSIONS: Strengthening ANC, training midwives to counsel effectively using different skills in varying situations and adopting peer counsellors would facilitate client-centred nutrition education and empower women to take healthier actions, thus promoting behaviour change. FUNDING SOURCES: None.

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.

Ultrasound technology has achieved almost universal coverage in industrialised countries with particular importance in antenatal surveillance. Its routine use has, however, been viewed critically from medical as well as from sociological perspectives. Studies on women's perception of ultrasound underline the crucial role of client provider communication supporting the technical procedure. Ultrasound is now increasingly available in developing countries. Little is known about how clients in these settings perceive the technology. This study was concerned with women's experience of ultrasound scanning in an African district hospital setting and how their experience concurs with the health professionals' views about the new technology. The study was qualitative and used semi-structured in-depth interviews with 41 clients and structured non-participant observation of the examination process, as well as semistructured interviews with health staff. Most women viewed ultrasound as being beneficial. Some expressed considerable fear. The quality of client-provider interaction played a decisive role in how the procedure was perceived. Many statements, however, reflect women's overestimation of the diagnostic power of ultrasound and prenatal therapeutic possibilities. Technology and its often expatriate providers tend to be mystified and at the same time non-technological procedures provided by local staff in the context of normal history taking and antenatal care undervalued. Health staff expressed very positive views of ultrasound. They admitted, however, that since the availability of ultrasound they were tempted to take histories and physical examinations less thoroughly than before. Irrational expectations from the clients' side and unindicated overuse of ultrasound by health professionals may in the long run interact in a way that possibly undermines the quality and rational utilisation of antenatal care and respective referral guidelines. Indications for the use of ultrasound must be clearly specified within specific societal contexts and mechanism of ensuring adherence to these criteria be established. Communication with patients and appropriate information about the benefits and limitations of ultrasound are essential to alleviate fear, and to discourage irrational expectations and demand.

1702 www.thelancet.com Vol 382 November 23, 2013 research projects of universities beside bilateral and multilateral monetary contributions. Only few German institutions such as the Public Health Institute, Heidelberg University, had a clear focus on health systems research and capacity building and developed close ties with institutions in developing countries while interacting with German development agencies and international organisations. If Germany is to live up to its responsibility in global health, it needs to substantially invest in capacity building, domestically (eg, creating the fi rst Centre of Global Health Research) and internationally (eg, promoting a sustainable Global Health Fund), beside a serious engagement in global health governance. In analogy to a recent Comment from the Prime Minister of Japan, we hope to see soon a commentary in The Lancet from the recently elected German Government emphasising its commitment to global health.

The report of the High-Level Panel appointed by the UN SecretaryGeneral to advise on the global development framework beyond 2015 has been rightly acknowledged by Michel Sidibe and Kent Buse (June 22, p 2147) for its inclusiveness and its emphasis on global partnerships and accountable institutions. However, universal health coverage was not included as a goal or target, despite its emergence as a unifying theme among the global health community. The targets proposed by the High-Level Panel are expressed along specific health challenges, interventions, and diseases, which might further deepen the current fragmentation of health delivery platforms, already seen by many as an undesired side-eff ect of the current Millennium Development Goals. While we fully share the HighLevel Panel’s concern for sexual and reproductive health, why emphasise the notion of universal access with respect to one health area only? Would it not make more sense to invest in comprehensive health-care delivery platforms? We fear that the proposed targets will lead different advocacy networks to aim for clearer and more ambitious targets for the issues of their concern, and thus they will be pitted against each other, while universal health coverage anchored in the right to health would allow united advocacy. It has been argued that universal health coverage is difficult to measure. That might be true, but the same holds for several goals and targets proposed by the High-Level Panel. If we can fi nd good indicators for proposed target 1c—“Cover x% of people who are poor and vulnerable with social protection systems”—we should be able to fi nd good indicators for universal health coverage. One of the targets proposed—to reduce the maternal mortality ratio— could in fact be useful for universal health coverage. Why do we support universal health coverage? Simply because we share the High-Level Panel’s vision of a world where the principles of equity, sustainability, solidarity, respect for human rights, and shared responsibilities in accordance with respective capabilities, have been brought to life. And, as FuenzalidaPuelma and Scholle Connor concluded after examining the right to health in the constitutions of several countries for the Pan American Health Organization, the right to health would be better understood as a right to health protection, including two components: a right to health care and a right to healthy conditions. That is why we propose one health goal—the realisation of the right to health for everyone—and two targets: comprehensive universal health coverage anchored in the right to health and a healthy social and natural environment for all, as proposed in the recent Go4Health report.

We compared children with and without severe anaemia for the number of falciparum malaria episodes (fever plus >/= 5.000 Plasmodium falciparum per microL) over the 6-month observation period for the prevalence of falciparum malaria within 10 days before the December survey and for their mean HAZ/WAZ/WHZ SD scores. In logistic regression analyses (adjusted for age and sex) anaemia was not associated with the frequency of malaria episodes nor with malaria prevalence. However it was significantly associated with malnutrition defined as HAZ WAZ and WHZ of –2 or less). (excerpt)