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Yemen was affected by a major cholera epidemic in 2016, while a civil war, which has devastated the country since March 2015, has exacerbated the humanitarian situation. Cholera is a disease caused by the bacterium Vibrio cholera, thus this study aims to analyze the epidemiological features of the outbreak and explore the relation of the outbreak to the current armed conflict situation. The data were obtained from the national surveillance system in Yemen. This contains details of 15,074 cases registered as suspected cholera patients per governorate from week 39 to 52 in 2016. In addition to the data concerning cholera, other data on conflict-related injuries, and population movement (numbers of Internally Displaced Persons - IDPs - and number of displaced returnees) were used to assess the correlation using Spearman's rho analysis. The data analysis shows the intensity of the conflict as measured by the total casualties per governorate (conflict-related injuries and death) is significantly correlated with the number of cholera cases per governorate (r 0.483, P = 0.026). The analysis also shows a positive, but not significant correlation between cholera cases, and both the number of conflict internal displaced people (IDPs) (r 0.389, P = 0.081), and number of returnees (r = 432, P = 0.050).

BACKGROUND: Adverse childhood experiences (ACEs) and intimate partner violence (IPV) are recognized global health problems. Both ACEs and IPV have been linked to adverse physical and mental health problems for both mothers and infants. The aim of this study was to determine the prevalence of physical and/or sexual ACEs and IPV and their association to symptoms of postpartum depression among postpartum women in sub-Saharan Africa. METHODS: A cross-sectional survey was conducted in three health centers in the three districts of Dar es Salaam, comprising Ilala, Kinondoni and Temeke. A total of 500 women were interviewed by two trained midwife nurses during their routine postnatal care. The women were asked about their experiences of adverse childhood experiences, intimate partner violence and symptoms of postpartum depression. RESULTS: Of the 500 women who were interviewed, 39.4% (n = 197) reported to have experienced physical and/or sexual ACE and 18.8% (n = 94) experienced physical and/or sexual IPV during their index pregnancy. Physical ACE (AOR 2.6, 95% CI: 1.50-4.57), sexual ACE (AOR 2.7, 95% CI: 1.35-5.41), physical IPV (AOR 5.8, 95% CI: 2.98-11.43) and Sexual IPV (AOR 5.5, 95%CI: 2.51, 12.09) were significantly associated with symptoms of postpartum depression. CONCLUSION: Four out of ten women reported to have experienced ACEs and two out of ten women reported IPV in the index pregnancy which was significantly associated with symptoms of postpartum depression. These results are alarming and call upon the attention of health workers and the community at large in prevention, screening and early intervention of ACEs, IPV and symptoms of postpartum depression.

Given the current low contraceptive use and corresponding high levels of unwanted pregnancies leading to induced abortions and poor maternal health outcomes among rural populations, a detailed understanding of the factors that limit contraceptive use is essential. Our study investigated household and health facility factors that influence contraceptive use decisions among rural women in rural Burkina Faso. We collected data on fertile non-pregnant women in 24 rural districts in 2014. Of 8,657 women, 1,098 used a modern contraceptive. Women having a living son, a child younger than one year, and household wealth were more likely to use modern contraceptives. Women in polygamous marriages and women living at least 5 kilometers from a health facility were less likely to use contraception. We conclude that modern contraceptive use remains weak, hence, programs aiming to encourage contraceptive use must address barriers at both the health facility and the household level.

Die Weltgesundheitsorganisation initiierte im Jahre 1988 ein Programm zur globalen Eradikation der Poliomyelitis. Mithilfe von Routine- und Massenimpfungen insbesondere von Vorschulkindern konnte die Erkrankung zuletzt auf 3 endemische Lander (Afghanistan, Pakistan und Nigeria) zuruckgedrangt werden. Allerdings kommt es – begunstigt durch Reisebewegungen, Konflikte und unterentwickelte Gesundheitssysteme – seit dem Beginn des 21. Jahrhunderts immer wieder zu Sekundarepidemien in zahlreichen Landern. Hinzu kommen technische (z. B. Ruckmutationen des oralen Impfvirus zu Quasi-Wildviren) sowie sozio-politische (z. B. Ablehnung der Impfung von muslimischen Bevolkerungsgruppen in Nigeria und Pakistan) Probleme mit dem Impfstoff in den verbliebenen Endemielandern. Es erscheint daher fraglich, ob das Ziel einer globalen Eradikation dieser Erkrankung im Rahmen des aktuellen Ausrottungsprogramms in absehbarer Zeit erreichbar ist.

Childhood malnutrition remains a major challenge to public health in poor countries. Data on malnutrition determinants in African children are scarce. A cross-sectional survey was performed in eight villages of Burkina Faso in June 2009, including 460 children aged 6-31 months. Demographic, socioeconomic, parasitological, clinical and anthropometric characteristics were collected. The main outcome variable was weight-for-length (WFL) z-score (i.e. wasting). A multiple regression model identified village, age group, religion and the presence of younger siblings as significantly associated with wasting. Villages differed in their mean WFL z-score by up to one unit. Compared with younger children, the mean WFL z-score of children aged 24-35 months was 0.63 units higher than the WFL z-score in younger children. This study confirms the still unacceptable high level of malnutrition in young children of rural West Africa and supports the fact that childhood malnutrition is a complex phenomenon highly influenced by contextual variables.

Summary Germany has become a visible actor in global health in the past 10 years. In this Series paper, we describe how this development complements a broad change in perspective in German foreign policy. Catalysts for this shift have been strong governmental leadership, opportunities through G7 and G20 presidencies, and Germany's involvement in managing the Ebola virus disease outbreak. German global health engagement has four main characteristics that are congruent with the health agenda of the Sustainable Development Goals; it is rooted in human rights, multilateralism, the Bismarck model of social protection, and a link between development and investment on the basis of its own development trajectory after World War 2. The combination of momentum and specific characteristics makes Germany well equipped to become a leader in global health, yet the country needs to accept additional financial responsibility for global health, expand its domestic global health competencies, reduce fragmentation of global health policy making, and solve major incoherencies in its policies both nationally and internationally.

Background Unmet need for family planning has implications for women and their families, such as unsafe abortion, physical abuse, and poor maternal health. Contraceptive knowledge has increased across low-income settings, yet unmet need remains high with little information on the factors explaining it. This study assessed factors associated with unmet need among pregnant women in rural Burkina Faso. Method We collected data on pregnant women through a population-based survey conducted in 24 rural districts between October 2013 and March 2014. Multivariate multilevel logistic regression was used to assess the association between unmet need for family planning and a selection of relevant demand- and supply-side factors. Results Of the 1309 pregnant women covered in the survey, 239 (18.26%) reported experiencing unmet need for family planning. Pregnant women with more than three living children [OR = 1.80; 95% CI (1.11–2.91)], those with a child younger than 1 year [OR = 1.75; 95% CI (1.04–2.97)], pregnant women whose partners disapproves contraceptive use [OR = 1.51; 95% CI (1.03–2.21)] and women who desired fewer children compared to their partners preferred number of children [OR = 1.907; 95% CI (1.361–2.672)] were significantly more likely to experience unmet need for family planning, while health staff training in family planning logistics management (OR = 0.46; 95% CI (0.24–0.73)] was associated with a lower probability of experiencing unmet need for family planning. Conclusion Findings suggest the need to strengthen family planning interventions in Burkina Faso to ensure greater uptake of contraceptive use and thus reduce unmet need for family planning.

BACKGROUND: Intimate partner violence (IPV) during pregnancy and postpartum is a serious global health problem affecting millions of women worldwide. This study sought to determine the prevalence of different forms of IPV during pregnancy and postpartum and associated factors among women in Dar es Salaam, Tanzania. METHODS: We conducted a cross-sectional study among 500 women at one to nine months postpartum in three health facilities in the three districts of Dar es Salaam: Temeke, Kinondoni and Illala. Two trained research assistants administered the questionnaire, which aimed to examine sociodemographic characteristics and different forms of IPV. RESULTS: Of the 500 women who were interviewed, 18.8% experienced some physical and/or sexual violence during pregnancy. Forty-one women (9%) reported having experienced some physical and/or sexual violence at one to nine months postpartum. Physical and/or sexual IPV during pregnancy was associated with cohabiting (AOR 2.2, 95% CI 1.24-4.03) and having a partner who was 25 years old or younger (AOR 2.7, 95% CI 1.08-6.71). Postpartum, physical and/or sexual IPV was associated with having a partner who was 25 years old or younger (AOR 4.4, 95% CI 1.24-15.6). CONCLUSION: We found that IPV is more prevalent during pregnancy than during the postpartum phase. There is also continuity and maintenance of IPV during and after pregnancy. These results call for policy and interventions to be tailored for pregnant and postpartum women. Language: en

SUMMARY This paper reports on a study, which assessed coverage with malaria control interventions in rural Burkina Faso, namely insecticide-treated mosquito nets (ITN) ownership, intermittent preventive treatment (IPTp) for pregnant women and artemisinin-based combination therapy (ACT) for under-five children. The study also addressed the distributional impact of such interventions, with specific reference to equity. The study used data from a representative household survey conducted on 1106 households in the Nouna Health District in 2010. Findings indicated that 59% of all households owned at least one ITN, 66% of all pregnant women received IPT at least once and 34% of under-five children reporting a malaria case were treated with ACT. Multivariate logistic regression revealed that higher socio-economic status, ownership of at least one radio and living in a village within a Health and Demographic Surveillance System were significantly positively associated with ITN, IPTp and ACT coverage. ITN coverage was higher among households in villages, which had previously hosted an ITN trial and/or the most favourable arm of a trial. Comparing current findings with previous estimates suggests that the country has made substantial progress towards scaling up malaria control interventions but that current coverage rates are still far from achieving the universal coverage targets set by the Roll Back Malaria Partnership. In addition, current coverage patterns reveal the existence of multiple inequities across groups, suggesting that current policies are inadequate to achieve equitable scaling up. Future planning of malaria control interventions ought to take into consideration current inadequacies and lead to programmes better designed to overcome them. Copyright © 2012 John Wiley & Sons, Ltd.

objective The objective is to investigate the effect of malaria control with insecticide-treated mosquito nets (ITNs) regarding possible higher mortality in children protected during early infancy, due to interference with immunity development, and to assess long-term effects on malaria prevalence and morbidity. methods Between 2000 and 2002, a birth cohort was enrolled in 41 villages of a malaria holoendemic area in north-western Burkina Faso. All neonates (n = 3387) were individually randomised to ITN protection from birth (group A) vs. ITN protection from age 6 months (group B). Primary outcome was all-cause mortality. In 2009, a survey took place in six sentinel villages, and in 2010, a census was conducted in all study villages. results After a median follow-up time of 8.3 years, 443 ⁄ 3387 (13.1%) children had migrated out of the area and 484 ⁄ 2944 (16.4%) had died, mostly at home. Long-term compliance with ITN protection was good. There were no differences in mortality between study groups (248 deaths in group A, 236 deaths in group B; rate ratio 1.05, 95% CI: 0.889–1.237, P = 0.574). The survey conducted briefly after the rainy season in 2009 showed that more than 80% of study children carried asexual malaria parasites and up to 20% had clinical malaria. conclusion Insecticide-treated mosquito net protection in early infancy is not a risk factor for mortality. Individual ITN protection does not sufficiently reduce malaria prevalence in high-transmission areas. Achieving universal ITN coverage remains a major challenge for malaria prevention in Africa.

Objective For measurement of progress towards the Millennium Development Goal (MDG) 1, reliable data on nutrition indicators of specific countries are essential. Malnutrition is also the main determinant for childhood mortality, which is addressed in MDG 4. Methods In the health and demographic surveillance area of Kossi Province in north-western Burkina Faso, nutritional parameters were compared in two cohorts of young children of the same age range from eight villages. Surveys took place in June and December of the year 1999 and 2009. A multivariate model was used to control for confounding variables. Results For the 1999 study, data were analysed for 179 and 197 children who took part in the June and December survey respectively. In 2009, corresponding data were analysed for 460 and 409 children. Prevalence of underweight was highest in December 1999 (42.6%) and lowest in December 2009 (34.1%). After adjustment for age, sex and village, there was a slight but not always significant improvement in the z-scores of weight-for-age, weight-for-length, length-for-age, and mid-arm circumference over time. Conclusions The findings from this study confirm the still unacceptable high prevalence of malnutrition in young children of rural sub-Saharan Africa (SSA). Progress in the reduction of malnutrition remains slow on this continent making it rather unlikely that the corresponding MDGs will be achieved. Large-scale multi-sectoral community-based interventions are urgently needed for a sustainable improvement of child health in SSA. Objectif: Pour la mesure des progres realises vers l’Objectif du Millenaire pour le Developpement (OMD) 1, des donnees fiables sur les indicateurs de nutrition specifiques des pays sont essentielles. La malnutrition est egalement le principal determinant de la mortalite infantile, qui est aborde dans l’OMD 4. Methodes: Dans la zone de surveillance demographique et de sante de la province de Kossi, dans le nord-ouest du Burkina-Faso, les parametres nutritionnels ont ete compares dans deux cohortes de jeunes enfants de la meme tranche d’âge provenant de huit villages. Les enquetes ont eu lieu en juin et decembre 1999 et 2009. Un modele multivarie a ete utilise pour controler pour les variables confusionnelles. Resultats: Pour l’etude de 1999, les donnees ont ete analysees pour 179 et 197 enfants qui ont participe respectivement a l’enquete de juin et decembre. En 2009, les donnees correspondantes ont ete analysees pour 460 et 409 enfants. La prevalence de l’insuffisance ponderale etait la plus elevee en decembre 1999 (42,6%) et la plus faible en decembre 2009 (34,1%). Apres ajustement pour l’âge, le sexe et le village, il y avait une legere amelioration, mais pas toujours significative dans les z-scores du poids pour l’âge, le poids pour la taille, la taille pour l’âge et le perimetre brachial, au cours le temps. Conclusions: Les resultats de cette etude confirment la prevalence toujours elevee et inacceptable de la malnutrition chez les jeunes enfants des regions rurales de l’Afrique subsaharienne. Les progres realises dans la reduction de la malnutrition restent lents sur ce continent, rendant plutot improbable l’atteinte des OMD correspondants. Des interventions multisectorielles a grande echelle basees sur la communaute sont urgemment necessaires pour une amelioration durable de la sante de l’enfance en Afrique subsaharienne. Objetivo: Para medir el progreso hacia el Objetivo de Desarrollo del Milenio (ODM) 1, es esencial contar con datos fiables sobre los indicadores nutricionales para paises especificos. La desnutricion es tambien el principal determinante de mortalidad infantil, del cual se ocupa el ODM 4. Metodos: En el area de seguimiento sanitario y demografico de la provincia de Kossi, al noroeste de Burkina Faso, se compararon los parametros nutricionales para dos cohortes de ninos pequenos, con el mismo rango de edad, pertenecientes a ocho poblados. Las encuestas se realizaron en Junio y Diciembre de los anos 1999 y 2009. Se utilizo un modelo multivariado para controlar variables de confusion. Resultados: Se analizaron datos del estudio de 1999 de 179 y 197 ninos, que participaron en las encuestas de Junio y Diciembre respectivamente. Para el 2009 se analizaron datos correspondientes a 460 y 409 ninos. La prevalencia de bajo peso era mayor en Diciembre de 1999 (42.6%) y menor en Diciembre del 2009 (34.1%). Despues de ajustar para edad, sexo y poblacion, habia una pequena pero no siempre significativa mejora en los z-scores de peso-por-edad, peso-por-altura, altura-por-edad, y circunferencia del brazo a lo largo del tiempo. Conclusiones: Los hallazgos de este estudio confirman que la desnutricion continua teniendo una prevalencia inaceptablemente alta entre ninos pequenos de zonas rurales del Africa subsahariana. El progreso de reduccion de la desnutricion continua siendo lento en este continente, lo cual hace que sea improbable que los ODM correspondientes puedan ser alcanzados. Se requiere urgentemente realizar intervenciones a gran escala, multisectoriales y basadas en la comunidad, para conseguir una mejora sostenible en la salud infantil en Africa subsahariana.

This letter was published in The Lancet [© 2017 Lancet Publishing Group] and the definitive version is available at : http://doi.org/10.1016/S0140-6736(17)31445-9 The Journal's website is at: https://www.sciencedirect.com/science/article/pii/S0140673617314459?via%3Dihub

OBJECTIVE: To study the current legislation and trends in terminations of pregnancy in the European Union (EU).DESIGN: Data were collected on legislation and statistics for terminations of pregnancy.SETTING: Population-based statistics from the EU member states.POPULATION: Women in reproductive age in the 27 EU member states.METHODS: Information on legislation was collected for all 27 EU member states. Statistical information until 2008 was compiled from international (n = 24) and national sources (n = 17). Statistical data were not available for Austria, Cyprus and Luxembourg.MAIN OUTCOMES MEASURES: Terminations of pregnancy per 1000 women aged 15-49 years.RESULTS: Ireland, Malta and Poland have restrictive legislation. Luxembourg permits termination of pregnancy on physical and mental health indications; Cyprus, Finland, and the UK further include socio-economic indications. In all other EU member states termination of pregnancy can be performed in early pregnancy on a women's request. In general, the rates of termination of pregnancy have declined in recent years. In total, 10.3 terminations were reported per 1000 women aged 15-49 years in the EU in 2008. The rate was 12.3/1000 for countries requiring a legal indication for termination, and 11.0/1000 for countries allowing termination on request. Northern Europe (10.9/1000) and Central and Eastern Europe (10.8/1000) had higher rates than Southern Europe (8.9/1000). Northern Europe, however, had substantially higher rates of termination of pregnancy among teenagers.CONCLUSION: A more consistent and coherent reporting of terminations of pregnancy is needed in the EU. The large variation of termination rates between countries suggests that termination of pregnancy rates may be reduced in some countries without restricting women's access to termination. Sexual education and provision of access to reliable and affordable contraception are essential to achieve low rates of termination of pregnancy.

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.

E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population’s health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation.

ObjectiveDespite the short-term and long-term health implications of gestational diabetes mellitus (GDM), opinions are divided on selective vis-à-vis universal screening. We validated the accuracy of screening tests for GDM.Research design and methodsPregnant women (n=491) were recruited to this prospective, blind comparison with a gold standard study. We did selective screening between 13 and 20 weeks using reagent-strip glycosuria, random capillary blood glucose (RBG) and the presence of ≥1 risk factor(s). Between 20 and 34 weeks, we did universal screening following the ‘one-step’ approach using glycated hemoglobin (HbA1c), fasting venous plasma glucose (FPG), and the 1-hour and the ‘gold standard’ 2-hour oral glucose tolerance test (OGTT). Tests accuracy was estimated following the WHO and the National Institute for Health and Care Excellence (NICE) diagnostic criteria. Overall test performance was determined from the area under the receiver operating characteristic curve (AUC).ResultsGDM prevalence per 2-hour OGTT was 9.0% for the WHO criteria and 14.3% for the NICE criteria. Selective screening using glycosuria, RBG and risk factors missed 97.4%, 87.2% and 45.7% of cases, respectively. FPG threshold ≥5.1 mmol/L had the highest clinically relevant sensitivity (68%) and specificity (81%), but FPG threshold ≥5.6 mmol/L had higher positive predictive value. Although sensitivity of 1-hour OGTT was 39.5%, it had the highest accuracy and diagnostic OR. Regarding test performance, 1-hour OGTT and FPG were very good (AUC>0.8), RBG was poor (AUC≈0.60), whereas HbA1c was invaluable (AUCConclusionsSelective screening using glycosuria and random blood glucose is unnecessary due to its low sensitivity. Fasting glucose ≥5.1 mmol/L could be applicable for screening at the population level. Where 2-hour OGTT is not available, FPG ≥5.6 mmol/L, complemented by the presence of risk factors, could be useful in making therapeutic decision.

Background: This study aims to describe the community perceptions regarding an insecticide-treated bed net (ITN) programme in Burkina Faso, where communities were randomised to either ITN social marketing combined with free ITN distribution through antenatal care services (intervention A) or ITN social marketing only (intervention B). Methods: For this descriptive qualitative study data were collected through a total of 20 focus group discussions (FGD), 10 FGD with women and men respectively. FGD were conducted in 8 purposefully selected villages of the study area and in Nouna town. Findings: The ITN free distribution was well known to and highly appreciated in the intervention area A. Awareness of the ITN social marketing distribution was however low in both intervention areas, except in the urban part (Nouna town) of intervention area B. Women were reported to be able to purchase ITNs independent of their husbands. Poverty and frequent unavailability of ITN for purchase were the main barriers for ITN ownership. ITN information was mainly received through personal communication with health workers and through radio messages. Conclusion: While the free ITN distribution was highly appreciated by the population, the social marketing approach alone appeared not be sufficient to reach the goal of high ITN coverage, mainly due to prevailing poverty and the insufficient availability of ITN for purchase.

Background: Antenatal care services are well established in Germany, with at least 10 routine antenatal consultations per pregnancy. Although many individual antenatal screening procedures and tests have been assessed in clinical trials, little is known about the overall prevalence of suspicious findings in routine antenatal surveillance and about related effects on psychological maternal well-being. The objectives of this study were to evaluate the views of pregnant women on prevalence, type, and consequences of suspicious findings during antenatal care; to assess related worries and anxiety; and to compare the reports of risk factors by these women with the antenatal records. Methods: We enrolled 360 pregnant women participating in antenatal classes in the Rhein-Neckar area, Germany. They were followed up from the beginning of antenatal classes to the puerperium using self-administered structured questionnaires that covered previous antenatal consultations and related worries. The Spielberger State-Trait Anxiety Inventory was used to assess current and general levels of anxiety. Antenatal records were also analyzed. Postnatally, pregnancy outcomes were assessed by telephone interviews. Results: Two-thirds (67.2%) of antenatal care attendees reported suspicious or abnormal findings, almost half of which (45.1%) resulted from routine ultrasound scans. More than half (53.2%) of those with suspicious findings reported that they were acutely worried. The suspected problem often did not materialize: 13 (81.3%) of 16 suspected malformations and 34 (81%) of 42 suspected growth-retarded babies were in the normal range. Many suspicious findings reported by mothers were not documented in the antenatal records. Conclusions: Contrary to their expectation of reassurance, most antenatal care attendees are warned about possible abnormalities, which often lead to further investigations and cause considerable worries. More research is needed to evaluate the long-term impact and consequences of suspicious or false screening results in routine antenatal care. (BIRTH 35:1 March 2008)

The objective was to evaluate maternity care the feasibility of collecting the relevant data from hospital records and to assess the usefulness for district health planning in the Mtwara Region Tanzania. A prospective study running over 2 years using the unmet obstetric need concept in all four hospitals in the region covering all women undergoing major obstetric interventions. Data on indications interventions and pregnancy outcome were collected. Rates of major obstetric interventions performed for absolute maternal indications among all expected births in the study area were calculated to assess met and unmet need. Of 2404 interventions 91% were caesarean sections most commonly indicated by cephalopelvic disproportion (46%). The rate of major obstetric intervention for absolute maternal indications per 100 expected births was 1.8% overall with wide rural-urban disparities (1.4% vs. 3.3%). Based on the estimated need of at least 2% of births requiring of a major obstetric intervention seven of 20 divisions reached or surpassed this threshold seven had a level between 1% and 2% and six did not reach 1%. Data were collected as part of the regular activities of the health staff but external resources were needed for data management and analysis. We found a major unmet obstetric need in rural areas with a clear trend towards fewer interventions with longer distance from a hospital. Geographical mapping of the met obstetric need provided a detailed picture of deficiencies in the provision of maternity care and could be useful for priority setting and monitoring. (authors)

Because of the harsh terrain the mountain areas are less developed and have limited transportation and communication facilities which restricts movement by people and also hinders their products from reaching marketplaces. Only 7 percent of the population resides in the mountain areas. The hills region is relatively more advanced on all development fronts and accounts for about 44 percent of the population. It has a number of fertile valleys and places of interest that attract foreign tourists who bring revenue into the country. Almost half of the population (49 percent) lives in the plains region which accounts for 23 percent of the total land area and is the most fertile part of the country. The region became livable after the eradication of malaria and many people from the hills moved to settle there. This region is better off than the other two in terms of transportation and communication facilities and has attracted investors to establish industries. The countrys population doubled from11.6 million in 1971 to 23.2 million in 2001 and is likely to have doubled again by 2031 given the current rate of population growth (2.3 percent per year in 2001). The urban population has increased at a much faster pace than the general population because of internal migration and according to the 2001 census it accounted for 14 percent of the total population. (excerpt)

To assess the birth of twins in rural Burkina Faso with respect to prevalence, mortality, and provision of obstetric care.A descriptive demographic analysis of population-based and health service data was performed with multivariate modeling by Poisson regression. Health service data were derived from a document review in health facilities in the Nouna District for the years 1994-2001. The district hospital provides obstetric care for the entire district with its 252,000 population (1998). Population-based data (deliveries, live births, deaths) were derived from the demographic surveillance system in the surveillance area within the Nouna District, Burkina Faso (population under surveillance: 30,988 in 1998). All births in the period from January 1, 1993 to December 31, 1998 (9457 recorded deliveries with 9,610 live births) were included and followed up until April 30, 2002. The main outcome measures were the prevalence of twin delivery as well as age- and sex-specific mortality risks.Mortality of twins is high, with one out of three dying before reaching the age of five years--2.5 times the mortality risk of singletons. Among twins, mortality is particularly high in the neonatal period (RR 5.16; CI: 3.6-7.5) and in twins born to mothers above the age of 35 (RR 5.12; CI: 3.5-7.6). The overall population-based prevalence of twin delivery is 1.6% (CI: 1.4-1.9) versus a hospital-based prevalence of 2.8% (CI: 2.2-3.1). Despite this moderate trend towards hospital-based obstetric care, most twins (90.5%) are still delivered outside a hospital setting.The high neonatal mortality in twins points to the need for special care in pregnancy, child birth, and postpartum. Maternity services fail to adequately cover the vast majority of multiple pregnancies and deliveries.

Objectives Weight at birth is usually considered as an indicator of the health status of a given society. As a result this study was designed to investigate the association between birth weight and maternal factors such as gestational weight gain, pre—pregnancy BMI and socio—economic status in Northern Ghana. Methods The study was a facility-based cross-sectional survey conducted in two districts in the Northern region of Ghana. These districts were purposively sampled to represent a mix of urban, peri—urban and rural population. The current study included 419 mother-infant pairs who delivered at term (37–42 weeks). Mother’s height, pre-pregnancy weight and weight changes were generated from the antenatal records. Questionnaires were administered to establish socio-economic and demographic information of respondents. Maternal factors associated with birth weight were examined using multiple and univariate regressions. Results The mothers were generally well nourished before conception (Underweight 3.82%, Normal 57.76%, Overweight 25.06% and Obesity 13.37%) but approximately half of them could not gain adequate weight according to Institute of Medicine recommendations (Low weight gain 49.64%, Adequate weight gain 42.96% and Excessive weight gain 7.40%). Infants whose mothers had excess weight gain were 431g (95% CI 18–444) heavier compared to those whose mothers gained normal weight, while those whose mothers gained less were 479g (95% CI -682– (-276) lighter. Infants of mothers who were overweight and obese before conception were 246g (95% CI 87–405) and 595g (95% CI 375–815) respectively heavier than those of normal mothers, whereas those whose mothers were underweight were 305g (95% CI -565 –(-44) lighter. The mean birth weight observed was 2.98 ± 0.68 kg. Conclusion Our findings show that pre-pregnancy body mass index and weight gain during pregnancy influence birth weight. Therefore, emphasis should be placed on counseling and assisting pregnant women to stay within the recommended weight gain ranges.

To investigate if the first national insecticide-treated bed-net campaign in Burkina Faso, done in 2010, was followed by a decrease in childhood malaria in a district with high baseline transmission of the disease.We obtained data on the prevalence of Plasmodium falciparum parasitaemia in children aged 2 weeks to 36 months from malaria surveys in 2009 and 2011. We assessed morbidity in children younger than 5 years by comparing data from the Nouna health district's health management information system before and after the campaign in 2010. We analysed mortality data from 2008 to 2012 from Nouna's health and demographic surveillance system.The bed-net campaign was associated with an increase in the reported use of insecticide-treated nets. In 2009, 73% (630/869) of children reportedly slept under nets. In 2011, 92% (449/487) did. The campaign had no effect on the proportion of young children with P. falciparum parasitaemia after the rainy season; 52% (442/858) in 2009 and 53% (263/499) in 2011. Cases of malaria increased markedly after the campaign, as did the number of children presenting with other diseases. The campaign was not associated with any changes in child mortality.The 2010 insecticide-treated net campaign in Burkina Faso was not associated with a decrease in care-seeking for malaria or all-cause mortality in children younger than 5 years. The most likely explanation is the high coverage of nets in the study area before the campaign which could have had an effect on mosquito vectors, limiting the campaign's impact.Étudier si la première campagne nationale visant à utiliser des moustiquaires imprégnées d'insecticide au Burkina Faso, menée en 2010, a été suivie d'une baisse des cas de paludisme infantile dans un district ayant un taux élevé de transmission de la maladie.Nous nous sommes procuré des données sur la prévalence de la parasitémie deLa campagne pour l'utilisation de moustiquaires a été associée à une augmentation de l'utilisation de moustiquaires imprégnées d'insecticide. En 2009, d'après l'enquête menée, 73% des enfants (630/869) dormaient sous une moustiquaire. En 2011, ils étaient 92% (449/487). La campagne n'a pas eu d'effet sur la proportion de jeunes enfants présentant une parasitémie deLa campagne de 2010 pour l'utilisation de moustiquaires imprégnées d'insecticide au Burkina Faso n'a pas été associée à une diminution des consultations pour paludisme ou de la mortalité, toutes causes confondues, chez les enfants de moins de 5 ans. L'explication la plus probable est liée au taux élevé d'utilisation de moustiquaires dans la zone étudiée avant la campagne, qui pourrait avoir eu un effet sur les moustiques vecteurs de la maladie et avoir limité l'impact de la campagne.Investigar si la primera campaña nacional de mosquiteros tratados con insecticida en Burkina Faso, que se llevó a cabo en 2010, tuvo como resultado un descenso del paludismo infantil en un distrito con una referencia elevada de transmisión de la enfermedad.Se obtuvieron datos sobre la prevalencia de parasitemia porLa campaña de distribución de mosquiteros se relacionó con un aparente aumento del uso de redes tratadas con insecticida. En 2009, aparentemente el 73% (630/869) de los niños dormía bajo mosquiteros. En 2011, lo hacía el 92% (449/487). La campaña no tuvo efecto en la proporción de niños pequeños con parasitemia porLa campaña de distribución de mosquiteros tratados con insecticida realizada en 2010 en Burkina Faso no estuvo relacionada con un descenso en la atención médica relacionada con la malaria o la mortalidad a causa de la misma en niños menores de 5 años. La explicación más lógica es la gran cobertura de redes en el área del estudio antes de la campaña, lo que podría haber tenido un efecto en los mosquitos vectores, limitando el impacto de la campaña.استقصاء إذا ما تبع الحملة القومية الأولى لاستخدام الناموسية المعالجة بمبيد حشري في بوركينا فاصو، والتي تم تنفيذها في عام 2010، أي انخفاض في معدل الإصابة بالملاريا عند الأطفال في إحدى المناطق التي تتسم بارتفاع قاعدة انتشار المرض.حصلنا على بيانات عن انتشار التسمم الدموي بطفيلارتبطت حملة استخدام الناموسية بزيادة ما أمكن تسجيله من استخدام الناموسيات المعالجة بالمبيد الحشري. ووفقًا لما تم رصده، فقد بلغت نسبة الأطفال الذين ناموا تحت الناموسية 73% (630/869) في عام 2009، بينما بلغت 92% (449/487) في عام 2011. ولم تؤثر الحملة على نسبة الأطفال الصغار المصابين بالتسمم الدموي بطفيللم ترتبط حملة استخدام الناموسية المعالجة بالمبيد الحشري التي تم تنفيذها في عام 2010 في بوركينا فاصو بانخفاض طلب الرعاية الصحية فيما يتعلق بالملاريا أو بمعدل الوفيات لجميع الأسباب في الأطفال الذين تقل أعمارهم عن خمس سنوات. والتفسير الأرجح لذلك هو ارتفاع مستوى التغطية للناموسيات قبل الحملة في المنطقة التي خضعت للدراسة، مما أثَّر على البعوض الناقل للمرض، وأدى إلى الحد من تأثير الحملة.旨在调查布基纳法索在 2010 年展开的第一次全国经杀虫剂处理的蚊帐运动之后，高基线疾病传播地区的儿童疟疾是否减少。.我们从 2009 和 2011 年的疟疾调查中获取了两周到 36 个月大的儿童感染恶性疟原虫寄生虫血症的患病率数据。我们通过比较 2010 年开展该运动前后努纳卫生地区的卫生管理信息系统中的数据，评估了 5 岁以下儿童的死亡率。我们分析了努纳卫生和人口监测系统中 2008 年到 2012 年间的数据。.蚊帐运动与报道的经杀虫剂处理的蚊帐使用量增长相关。据报道，2009 年，73% (630/869) 的儿童睡在蚊帐中。2011 年，92% (449/487) 的儿童睡在蚊帐中。该运动对雨季后感染恶性疟原虫寄生虫血症的儿童比例没有影响；2009 年该比例为 52% (442/858)，2011 年则为 53% (263/499)。该运动开展后，疟疾病例显著增长，同时感染其它疾病的儿童数量也显著增长。该运动与儿童死亡率的变化毫无关联。.布基纳法索在 2010 年开展的经杀虫剂处理的蚊帐运动与 5 岁以下儿童的疟疾求医行为或全因死亡率的降低不相关。最合理的解释是，在该运动开展前，蚊帐在研究区域的高使用率对蚊虫媒介已产生影响，因此使该运动的影响受到限制。.Выяснить, снизилась ли частота заболевания детей малярией в регионе с высоким базовым уровнем передачи этой инфекции после того, как в 2010 году в Буркина-Фасо была проведена первая национальная кампания по обработке надкроватных сеток инсектицидами.Мы получили данные о частоте случаев паразитемии, вызваннойКампания по обработке сеток сопровождалась ростом числа сообщений об использовании надкроватных сеток, обработанных инсектицидами. По данным отчетов, в 2009 году 73% детей (630 из 869) спали под сетками. В 2011 году их доля составила 92% (449 из 487). Кампания не повлияла на долю малолетних детей, зараженных паразитомПроведенная в Буркина-Фасо в 2010 году кампания по обработке надкроватных сеток инсектицидами не привела к снижению частоты заболевания малярией с обращением родителей за медицинской помощью. Эта кампания также не ассоциировалась со снижением смертности по различным причинам среди детей в возрасте до 5 лет. Наиболее вероятной причиной такого результата может быть тот факт, что в зоне проведения исследования и до начала кампании наблюдался высокий уровень использования надкроватных сеток, что могло повлиять на векторы распространения комаров и ограничить эффект от кампании.

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.

Background Maternal mortality is a sensitive indicator for inequity in health. We describe recent trends in overall and cause-specific maternal mortality ratio among women of German and non-German nationality residing in West Germany. Methods Using birth and death register data for 1980‐1996 we related 1067 cases of maternal death (ICD 9: 630‐676) to 11.2 million live births. We assessed the effects of nationality and of marital status, a proxy for socioeconomic status, controlling for year of death and age of the mother in a Poisson regression model. Results Maternal mortality ratio in West Germany decreased from 13 per 100 000 live births in 1980‐1988 to 6.1 in 1989‐1996. The crude relative risk for non-German nationality decreased from 1.9 (95% CI : 1.6‐2.3) to 1.3 (1.0‐1.7); after adjusting for age, year of death and marital status it was 1.7 (95% CI : 1.4‐2.1) and 1.6 (95% CI : 1.2‐2.1). Unmarried women incurred an adjusted relative risk of 1.8 (95% CI : 1.5‐2.3). Non-German women experienced an excess mortality from abortions which largely disappeared in 1989‐1996; concurrently, being unmarried no longer conveyed an additional risk to them. The risk status of German mothers developed unfavourably: increasing proportions are unmarried, which continues to be a marker of elevated relative risk in this group. Conclusions Our findings suggest continuously improving accessibility and quality of obstetric services, in particular for women of non-German nationality. Still, inequity in maternal risk continues to exist. Maternal risk, however, is not determined by the simple distinction ‘German’ versus ‘non-German’; its association with socioeconomic status extends beyond nationality.

Purpose: Routine ultrasound screening is a cornerstone of antenatal care in Germany. Screening examinations are carried out decentrally by specialist obstetricians in practice. The effectiveness of this established programme can no longer be assessed in a randomised trial. We investigated the reliability of ultrasound-based antepartal diagnoses in an observational study. Material and Methods: We established the presence or absence of an antepartal diagnosis of multiple pregnancy, breech presentation, placenta praevia, post maturity, malformation or intrauterine growth retardation (IUGR) in a birth cohort of 2499 consecutive life births. We then compared antepartal diagnosis and actual birth outcome. Results: The mean number of ultrasound examinations per woman was 4.7. High antepartal detection rates were achieved for multiple pregnancy (100%) and breech presentation (97%). Detection rates were low for placenta praevia (57%), post maturity (46%), malformation (41%) and IUGR (30%). Data from the Hessian Perinatal Registry show equally low detection rates for IUGR and post maturity, and no improvement with time. Conclusion: Detection rates of important target conditions of antenatal ultrasound screening are considerably lower in clinical routine than in controlled trials. Important objectives of routine screening like detecting IUGR and malformation and decreasing the frequency of induced labour are not achieved. Where routine screening has already been established, randomised controlled trials are no longer possible. Therefore, the routine screening programme in Germany should be continually evaluated using observational studies. For this purpose, process and output indicators must be developed.

To assess whether antenatal care achieves identification and timely referral of high-risk pregnancies in southern Tanzania.We compared the risk profiles of pregnant women in general with those attending obstetric care and investigated the reasons for seeking care. The risk profile of inpatients was drawn up through interviews with maternity cases and analysis of their antenatal records at the regional referral hospital (n = 415); population-based data on the prevalence of specific risk factors were obtained from entries in antenatal care registers (n = 1630) and from literature.A significant risk selection towards obstetric referral level care was observed only for previous caesarean section (prevalence hospital 6.7%, all pregnancies 1.5%, P0.005) and for nulliparity (hospital 42.8%, all pregnancies 25.0%, P0.005). No significant differences were observed for other risk factors such as previous perinatal death, height150 cm, multiple gestation and breech presentation. Prevalence of the risk factors age34 years and grand multiparity was significantly lower among hospital users. Coverage of obstetric care was below 50% for all risk factors except previous caesarean section (91.5%).Despite pursuing the risk approach and very good coverage, antenatal care in Tanzania has only limited effect on extending obstetric care to high-risk mothers. A critical review of the present screening and counselling practices, including a more focused and client-centred application of risk assessment, is warranted.

Insecticide-treated mosquito nets (ITNs) are an essential tool of the Roll Back Malaria strategy. An increasing number of African countries have embarked on mass distribution campaigns of long-lasting insecticide-treated nets (LLINs) with the ultimate goal of universal coverage. Such a national campaign with the goal of one ITN for every two people has been conducted in Burkina Faso in 2010. Our aim was to assess the coverage and equity effect of the universal distribution campaign of LLINs in Burkina Faso and to identify determinants of ITN ownership across households after the campaign. We evaluated its effects through comparison of data from two household surveys conducted in early 2010 (before the campaign) and early 2011 (after the campaign) on a representative rural district in north-western Burkina Faso. Data were collected on household characteristics (including socio-economic status) and ITN ownership. We used concentration curves and indices to compare ITN coverage indicators before and after the campaign and multilevel multivariate logistic regression to estimate factors associated with achievement of the universal coverage target in 2011. The survey included 1106 households in 2010 and 1094 in 2011. We found that the proportion of households with at least one ITN increased from 59% before the campaign to 99% afterwards, whereas the concentration index dropped from 0.087 (standard error (SE): 0.014) to 0.002 (SE: 0.002). Fifty-two per cent of households reached the target of one ITN for every two people per household, with the relevant concentration index at -0.031 (SE: 0.016). Eighty-six per cent of households owned at least one ITN for every three people. The main characteristics significantly associated with the targeted intra-household coverage were family size and distance to the health centre but not socio-economic status. In conclusion, despite not having fully met its target, the national LLIN campaign achieved a high level of coverage and fostered equity.

User fee removal policies have been extensively evaluated in relation to their impact on access to care, but rarely, and mostly poorly, in relation to their impact on household out-of-pocket (OOP) spending. This paucity of evidence is surprising given that reduction in household economic burden is an explicit aim for such policies. Our study assessed the equity impact on household OOP spending for facility-based delivery of the user fee reduction policy implemented in Burkina Faso since 2007 (i.e. subsidised price set at 900 Communaute Financiere Africaine francs (CFA) for all, but free for the poorest). Taking into account the challenges linked to implementing exemption policies, we aimed to test the hypothesis that the user fee reduction policy had favoured the least poor more than the poor. We used data from six consecutive rounds (2006–2011) of a household survey conducted in the Nouna Health District. Primary outcomes are the proportion of households being fully exempted (the poorest 20 % according to the policy) and the actual level of household OOP spending on facility-based delivery. The estimation of the effects relied on a Heckman selection model. This allowed us to estimate changes in OOP spending across socio-economic strata given changes in service utilisation produced by the policy. A total of 2,316 women reported a delivery between 2006 and 2011. Average household OOP spending decreased from 3,827 CFA in 2006 to 1,523 in 2011, without significant differences across socio-economic strata, neither in terms of households being fully exempted from payment nor in terms of the amount paid. Payment remained regressive and substantially higher than the stipulated 900 CFA. The Burkinabe policy led to a significant and sustained reduction in household OOP health spending across all socio-economic groups, but failed to properly target the poorest by ensuring a progressive payment system.

In the Federal State of Hesse, Germany, pregnancy and delivery related data are collected in a central perinatal registry called "Hessische Perinatalerhebung" (HEPE) since 1981, the objective being to enforce quality assurance and to contribute to a reduction in perinatal mortality and morbidity. The delivery unit compiles these data based on the antenatal record called "Mother Passport" and the actual delivery. In order to check on the quality of data, information on risk factors obtained from the perinatal register was compared to information from antenatal records and from a questionnaire administered to pregnant women prior to delivery. The study population comprised 1978 women who delivered at the maternity unit of the Municipal Hospital of Wiesbaden, the Dr. Horst Schmidt Kliniken, in 1990 and 1991. Comparison of the three data sources revealed substantial differences: Almost all risk factors were most frequently mentioned by the mothers themselves, less by the antenatal record and even less by the perinatal register. These differences were less pronounced for data on previous pregnancies and pre-existing disease and on abnormal positioning. Considerable differences were found in relation to pregnancy induced hypertension, intra-uterine growth retardation, incapacity of the cervix, preterm labour and bleeding. Risk factors related to the social environment and personal habits like psycho-social stress and smoking were found to be extremely under-reported in the antenatal records as well as in the perinatal register. The following factors could be identified as major reasons for the different risk profiles obtained from the various data sources: [1] Data loss through the transfer of data from the antenatal record to the record form of the perinatal register or to the computer, [2] selective recording of those risk factors considered by doctors to be particularly relevant, [3] missing definition of some risk factors and [4] recording of antenatal data for the perinatal register by the delivery unit after knowing the pregnancy outcome. Antenatal data in the perinatal register of Hessen are doubtful and should not be used uncritically for comparative studies and the assessment of relative risks. The extreme under-reporting of some risk factors may even lead to giving some interventions undue priority. In future, regular validity studies should become routine. A reduction of the data losses as well as a clear separation of antenatal data and delivery data could be achieved if antenatal data would be transferred from the doctor providing antenatal care direct to the perinatal register.

A kind of courtship is going on between proponents of universal health coverage (UHC) and proponents of global health security (GHS). In our opinion, efforts to make progress on the path to UHC and efforts to improve GHS can be synergistic, but are not self-evidently so. Making this partnership work will require careful thinking and planning. Several comments on ‘lessons from Ebola’ highlight the potential of UHC as a way to improve GHS.1 Simon Rushton, Louis Lillywhite and Bhimsen Devkota argue that the “[p]romotion of health security therefore entails ensuring that effective health systems exist before a crisis, are sustained during and after conflict and disaster, and are at all times accessible to the population.”1 Rob Yates, Ranu Dhillon and Ravi Rannan-Eliya remind us that several epidemics of global concern ‘occurred in settings without universal health coverage where health systems were unable to perform effective public health functions’.1 In a reaction to these ‘lessons from Ebola’, and a preview to the G7 summit in Ise-Shima of May 2016, Gavin Yamey argued that a way to make the case for UHC more compelling ‘could be to link UHC to the worldwide concern about pandemics in the wake of the Ebola crisis’,2 and he encouraged Japan—a longstanding proponent of UHC and GHS—to ‘rouse the G7 nations into action on universal health coverage’.2 Japan indeed promoted UHC and GHS, as an ‘inseparable couple’,3 and the ‘G7 Ise-Shima Vision for Global Health’ outcome document highlights both.4 ### Not a new attempt to create an alliance The present courtship is not new. The 2007 World Health Report, on ‘A safer future: global public health security in the 21st century’,5 highlighted the importance of strong health systems to enhance GHS. Without using the expression UHC, this report tried to tie efforts to make progress towards UHC into …

This editorial was published in the Bulletin of the World Health Organization [© 2013 Bulletin of the World Health Organization] and the definite version is available at: http://www.who.int/bulletin/volumes/91/1/12-115808/en/

We conducted the first population-based impact assessment of a financing policy introduced in Burkina Faso in 2007 on women's access to delivery services. The policy offers an 80 per cent subsidy for facility-based delivery. We collected information on delivery in five repeated cross-sectional surveys carried out from 2006 to 2010 on a representative sample of 1050 households in rural Nouna Health District. Over the 5 years, the proportion of facility-based deliveries increased from 49 to 84 per cent (P

The objective is to investigate the effect of malaria control with insecticide-treated mosquito nets (ITNs) regarding possible higher mortality in children protected during early infancy, due to interference with immunity development, and to assess long-term effects on malaria prevalence and morbidity.Between 2000 and 2002, a birth cohort was enrolled in 41 villages of a malaria holoendemic area in north-western Burkina Faso. All neonates (n = 3387) were individually randomised to ITN protection from birth (group A) vs. ITN protection from age 6 months (group B). Primary outcome was all-cause mortality. In 2009, a survey took place in six sentinel villages, and in 2010, a census was conducted in all study villages.After a median follow-up time of 8.3 years, 443/3387 (13.1%) children had migrated out of the area and 484/2944 (16.4%) had died, mostly at home. Long-term compliance with ITN protection was good. There were no differences in mortality between study groups (248 deaths in group A, 236 deaths in group B; rate ratio 1.05, 95% CI: 0.889-1.237, P = 0.574). The survey conducted briefly after the rainy season in 2009 showed that more than 80% of study children carried asexual malaria parasites and up to 20% had clinical malaria.Insecticide-treated mosquito net protection in early infancy is not a risk factor for mortality. Individual ITN protection does not sufficiently reduce malaria prevalence in high-transmission areas. Achieving universal ITN coverage remains a major challenge for malaria prevention in Africa.

This paper reports on a study, which assessed coverage with malaria control interventions in rural Burkina Faso, namely insecticide-treated mosquito nets (ITN) ownership, intermittent preventive treatment (IPTp) for pregnant women and artemisinin-based combination therapy (ACT) for under-five children. The study also addressed the distributional impact of such interventions, with specific reference to equity. The study used data from a representative household survey conducted on 1106 households in the Nouna Health District in 2010. Findings indicated that 59% of all households owned at least one ITN, 66% of all pregnant women received IPT at least once and 34% of under-five children reporting a malaria case were treated with ACT. Multivariate logistic regression revealed that higher socio-economic status, ownership of at least one radio and living in a village within a Health and Demographic Surveillance System were significantly positively associated with ITN, IPTp and ACT coverage. ITN coverage was higher among households in villages, which had previously hosted an ITN trial and/or the most favourable arm of a trial. Comparing current findings with previous estimates suggests that the country has made substantial progress towards scaling up malaria control interventions but that current coverage rates are still far from achieving the universal coverage targets set by the Roll Back Malaria Partnership. In addition, current coverage patterns reveal the existence of multiple inequities across groups, suggesting that current policies are inadequate to achieve equitable scaling up. Future planning of malaria control interventions ought to take into consideration current inadequacies and lead to programmes better designed to overcome them.

Copyright © 2011 The European Society of Contraception and Reproductive Health. All rights reserved., The article focuses on the of the sexual and reproductive heath (SRH) report analyzing SRH policies within the European Union (EU) member states. It states that the report identifies disparities in five areas of SRH in EU member states including contraception use and its policies, teenage sexual behavior, and assisted reproductive technologies (ART) and induced abortions. The report's general and specific SRH recommendations are also discussed.

An outbreak of meningitis with 85 secondary cases and an unusually high attack rate of 16% occurred in a rural village in southern Tanzania. We investigated risk factors for clinical illness in a community-based case-control study. Attending a commercial mobile video show carried an age- and sex-adjusted odds ratio of 8.0 (95% confidence interval: 3.8-16.8). The videos had been shown in a windowless and overcrowded storeroom and had been attended by the primary case, a visitor from neighbouring Mozambique who died from meningitis on the following day. We conclude that mobile video shows, which have become popular in many developing countries, constitute a potential health hazard in areas prone to meningitis epidemics.

Background Insecticide-treated nets (ITNs) have been confirmed to be a very effective tool in malaria control. Two different delivery strategies for roll-out of ITN programmes have been the focus of debate in the last years: free distribution and distribution through commercial marketing systems. They are now seen as complementary rather than opponent. Acceptance of these programmes by the community and involved providers is an important aspect influencing their sustainability. This paper looks at how providers perceived, understood and accepted two interventions involving two different delivery strategies (subsidized sales supported by social marketing and free distribution to pregnant women attending antenatal care services). Methods The interventions took place in one province of north-western Burkina Faso in 2006 in the frame of a large randomized controlled ITN intervention study. For this descriptive qualitative study data were collected through focus group discussions and individual interviews. A total of four focus group discussions and eleven individual interviews have been conducted with the providers of the study interventions. Results The free distribution intervention was well accepted and perceived as running well. The health care staff had a positive and beneficial view of the intervention and did not feel overwhelmed by the additional workload. The social marketing intervention was also seen as positive by the rural shopkeepers. However, working in market economy, shopkeepers feared the risk of unsold ITNs, due to the low demand and capacity to pay for the product in the community. Conclusion The combination of ITN free distribution and social marketing was in general well accepted by the different providers. However, low purchasing power of clients and the resulting financial insecurities of shopkeepers remain a challenge to ITN social marketing in rural SSA.

Background In Tanzania, maternal mortality ratio remains unacceptably high at 578/100,000 live births. Despite a high coverage of antenatal care (96%), only 44% of deliveries take place within the formal health services. Still, "Ensure skilled attendant at birth" is acknowledged as one of the most effective interventions to reduce maternal deaths. Exploring the potential of community-based interventions in increasing the utilization of obstetric care, the study aimed at developing, testing and assessing a community-based safe motherhood intervention in Mtwara rural District of Tanzania. Method This community-based intervention was designed as a pre-post comparison study, covering 4 villages with a total population of 8300. Intervention activities were implemented by 50 trained safe motherhood promoters (SMPs). Their tasks focused on promoting early and complete antenatal care visits and delivery with a skilled attendant. Data on all 512 deliveries taking place from October 2004 to November 2006 were collected by the SMPs and cross-checked with health service records. In addition 242 respondents were interviewed with respect to knowledge on safe motherhood issues and their perception of the SMP's performance. Skilled delivery attendance was our primary outcome; secondary outcomes included antenatal care attendance and knowledge on Safe Motherhood issues. Results Deliveries with skilled attendant significantly increased from 34.1% to 51.4% (ρ < 0.05). Early ANC booking (4 to 16 weeks) rose significantly from 18.7% at baseline to 37.7% in 2005 and 56.9% (ρ < 0.001) at final assessment. After two years 44 (88%) of the SMPs were still active, 79% of pregnant women were visited. Further benefits included the enhancement of male involvement in safe motherhood issues. Conclusion The study has demonstrated the effectiveness of community-based safe motherhood intervention in promoting the utilization of obstetric care and a skilled attendant at delivery. This improvement is attributed to the SMPs' home visits and the close collaboration with existing community structures as well as health services.

Background Effective and timely treatment is an essential aspect of malaria control, but remains a challenge in many parts of sub-Saharan Africa. The objective of this study was to describe young children's access to malaria treatment in Nouna Health District, Burkina Faso. Methods In February/March 2006, a survey was conducted in a representative sample of 1,052 households. Results Overall 149/1052 (14%) households reported the current possession of anti-malarial medicine, which was significantly associated with urban area, literacy of household head, having young children, and high socio-economic status. Out of a total of 802 children under five years, at least one malaria episode was reported for 239 (30%) within the last month. Overall 95% of children received treatment, either modern (72%), traditional (18%) or mixed (5%). Most of the medicines were provided as home treatment by the caregiver and half of children received some type of modern treatment within 24 hours of the occurrence of first symptoms. Despite a recent policy change to artemisinin-based combination therapy, modern anti-malarials consisted mainly of chloroquine (93%). Modern drugs were obtained more often from a health facility in localities with a health facility compared to those without (60% vs. 25.6%, p < 0.001). In contrast, beside informal providers, volunteer community health workers (CHW) were the main source of modern medicine in localities without a health centre (28% vs. 3%, p < 0.001). Conclusion Access to modern health services providing quality controlled effective combination therapies against malaria needs to be strengthened in rural Africa, which should include a re-investigation of the role of CHW 30 years after Alma Ata.

Insecticide-treated nets (ITNs) are effective in substantially reducing malaria transmission. Still, ITN coverage in sub-Saharan Africa (SSA) remains extremely low. Policy makers are concerned with identifying the most suitable delivery mechanism to achieve rapid yet sustainable increases in ITN coverage. Little is known, however, on the comparative costs of alternative ITN distribution strategies. This paper aimed to fill this gap in knowledge by developing such a comparative cost analysis, looking at the cost per ITN distributed for two alternative interventions: subsidized sales supported by social marketing and free distribution to pregnant women through antenatal care (ANC). The study was conducted in rural Burkina Faso, where the two interventions were carried out alongside one another in 2006/07. Cost information was collected prospectively to derive both a financial analysis adopting a provider's perspective and an economic analysis adopting a societal perspective. The average financial cost per ITN distributed was US$8.08 and US$7.21 for sales supported by social marketing and free distribution through ANC, respectively. The average economic cost per ITN distributed was US$4.81 for both interventions. Contrary to common belief, costs did not differ substantially between the two interventions. Due to the district's ability to rely fully on the use of existing resources, financial costs associated with free ITN distribution through ANC were in fact even lower than those associated with the social marketing campaign. This represents an encouraging finding for SSA governments and points to the possibility to invest in programmes to favour free ITN distribution through existing health facilities. Given restricted budgets, however, free distribution programmes are unlikely to be feasible.

After reading this chapter and answering the questions that follow, you should be able to Identify the various manifestations of undernutrition (hunger, undernourishment, stunting, wasting, underweight, protein-energy malnutrition, and micronutrient deficiency) and describe their management and control. Identify the global magnitude of obesity among women and children. Identify and discuss the various biological, environmental, sociocultural, and behavioral factors that underlie malnutrition (overnutrition and undernutrition) among women and children. Appraise the evidence base of interventions to prevent malnutrition among women and children and assess the feasibility of achieving the Millennium Development Goal target of reducing by half of 1990 figures, the proportion of people who suffer from hunger.

BackgroundInsecticide-impregnated bed nets (ITNs) have been shown to be a highly effective tool against malaria in the endemic regions of sub-Saharan Africa (SSA). There are however different opinions about the role of ITN social marketing and ITN free distribution in the roll-out of ITN programmes. The objective of this study was to evaluate the effects of free ITN distribution through antenatal care services in addition to an ITN social marketing programme in an area typical for rural SSA.MethodsA cluster-randomised controlled ITN trial took place in the whole Kossi Province in north-western Burkina Faso, an area highly endemic for malaria. Twelve clusters were assigned to long-term ITN (Serena brand) social marketing plus free ITN (Serena brand) distribution to all pregnant women attending governmental antenatal care services (group A), and 13 clusters to ITN social marketing only (group B). The intervention took place during the rainy season of 2006 and thereafter. The trial was evaluated through a representative household survey at baseline and after one year. Serena ITN household ownership was the primary outcome measure.FindingsA total of 1052 households were visited at baseline in February 2006 and 1050 at follow-up in February 2007. Overall Serena ITN household ownership increased from 16% to 28% over the study period, with a significantly higher increase in group A (13% to 35%) than in group B (18% to 23%) (pInterpretationThe free distribution of ITNs to pregnant women through governmental antenatal care services in addition to ITN social marketing substantially improved ITN household ownership in rural Burkina Faso.Trial registrationControlled-Trials.com ISRCTN07985309.