The availability of life-saving obstetric services in developing countries: an in-depth look at the signal functions for emergency obstetric care

OBJECTIVE

This paper examines the frequency with which a set of life-saving interventions or signal functions was performed to treat major obstetric complications.

METHODS AND RESULTS

The basic signal functions include parenteral antibiotics, anticonvulsants and oxytocics, and the procedures of manual removal of the placenta, removal of retained uterine products, and assisted vaginal delivery. Comprehensive functions include the six basic functions, cesarean delivery, and blood transfusions. Data from 1906 health facilities in 13 countries indicate that the most likely functions to be reported are oxytocics and antibiotics. The basic function least likely to be reported is assisted vaginal delivery. Many of the facilities surveyed did not have the infrastructure to perform operations or provide blood transfusions.

CONCLUSIONS

These data can help governments allocate their budgets appropriately, help policy makers and planners identify systemic bottlenecks and prioritize solutions. Monitoring the performance of the functions informs us of the capacity of the health system to provide key interventions when obstetric emergencies occur.

Strengthening emergency obstetric care in Ayacucho, Peru

OBJECTIVE

With support from the Averting Maternal Death and Disability (AMDD) Program, CARE began the FEMME Project in 2000 to increase access and utilization of emergency obstetric care (EmOC) services for the approximately 48,000 pregnant women in the northern provinces of Ayacucho.

METHODS

The project targeted 5 facilities with a comprehensive package of interventions designed to improve capacity to provide quality EmOC services and to promote a human rights approach in health care. Key program activities included improvements in infrastructure, human resources capacity development, development of service standards and protocols, quality improvement activities, and promoting a rights-based approach to health.

RESULTS

By the end of the project, northern Ayacucho had 6 functioning EmOC facilities: 3 comprehensive (including a non-FEMME project facility) and 3 basic. This exceeds the UN minimum recommendation of 5 EmOC facilities per 500,000 population. Other changes in the UN process indicators indicate an increase in quality and utilization of EmOC services. Met need for EmOC increased significantly from 30% in 2000 to a high of 84% in 2004. Case fatality rates declined and the number of maternal deaths in the entire region declined.

CONCLUSION

CARE's work in Ayacucho made an impact on policies and programs related to EmOC throughout the region. Within CARE, project experiences have supported maternal health programs particularly in the Latin American/Caribbean region.

Measurement of the tensor structure function b1 of the deuteron

The Hermes experiment has investigated the tensor spin structure of the deuteron using the 27.6 GeV/c positron beam of DESY HERA. The use of a tensor-polarized deuteron gas target with only a negligible residual vector polarization enabled the first measurement of the tensor asymmetry A(d)zz and the tensor structure function b(d)1 for average values of the Bjorken variable 0.01< <x> <0.45 and of the negative of the squared four-momentum transfer 0.5 GeV2 < <Q2> <5 GeV2. The quantities A(d)zz and b(d)1 are found to be nonzero. The rise of b(d)1 for decreasing values of x can be interpreted to originate from the same mechanism that leads to nuclear shadowing in unpolarized scattering.

A tool for assessing 'readiness' in emergency obstetric care: the room-by-room 'walk-through'

This article presents a tool that can be used to assess the readiness of a health facility to provide emergency obstetric care. The 'walk-through' tool is a checklist that follows the physical path that a woman and her caregivers might follow. The items on the checklist are critical to an enabling environment in which skilled providers can save lives. The article explains how the tool can be used and by whom, and it describes several experiences in the field.

Monitoring utilization and need for obstetric care in the highlands of Guatemala

OBJECTIVE

To monitor changes in the utilization and need for obstetric care between 1995 and 1998 at three hospitals in the highlands of Guatemala.

METHODS

We collected data on 5300 obstetric admissions from maternity registries and selected 10 indicators to measure intermediate outcomes.

RESULTS

Utilization of services increased at some or all hospitals as measured by the number of obstetric admissions, proportion of births in facilities, and cesarean deliveries as a proportion of all births. We observed increases in the proportion of women expected to have obstetric complications who were treated at each hospital and in the proportion of women with obstetric complications who were referrals. The changes in patient profile reflect increased service utilization and accessibility among women who traditionally used the health system the least.

CONCLUSIONS

Positive changes in these indicators are likely to be associated with a reduction in maternal mortality. Without a control area, we cannot be sure of a cause and effect relationship between outcomes and interventions, nevertheless, maternity registry data offer an inexpensive source of information for facilities to monitor changes.

Program note: Using UN process indicators to assess needs in emergency obstetric services: Bolivia, El Salvador and Honduras

The UN process indicators are used to assess the availability, utilization and quality of emergency obstetric care (EmOC). Needs assessments for EmOC in Bolivia, El Salvador and Honduras show reasonable availability of comprehensive EmOC facilities for their population sizes, but a scarcity of basic facilities. Utilization rates among women with obstetric complications are high in El Salvador and Honduras. Case fatality rates tend to be below 1% in all three countries, but the more rural areas in each have poorer indicators.

Atmospheric concentrations and dry and wet deposits of some herbicides currently used on the Canadian Prairies

High volume air sampling in the Canadian Prairies was used to characterize atmospheric concentrations for 10 herbicides (alachlor, atrazine, ethalfluralin, metolachlor, 2,4-D, dicamba, bromoxynil, MCPA, trifluralin, and triallate) along a 500-km north-south transect. Atmospheric concentration measurements at various altitudes identified that of the six herbicides present in the highest concentrations, triallate was strongly influenced by local sources, while 2,4-D, dicamba, bromoxynil, MCPA and trifluralin were dominated by regional atmospheric transport. Concentrations of the herbicides measured at various altitudes were compared with dry deposition rates measured using a dry/wet deposition sampler and used to calculate deposition velocities V(d). The primary atmospheric transport mechanism for MCPA and bromoxynil was shown to be adsorption to particles dispersed in the atmosphere, with the same mechanism also confirmed for 2,4-D and dicamba, while trifluralin was shown to be transported mainly in the gas phase. This method of calculation indicated that transportation of triallate was influenced by particle adsorption. Weekly maximum atmospheric loadings of the major herbicides present in the Prairies were estimated to range from 73 kg for trifluralin to 541 kg for 2,4-D.

Single-spin asymmetries in semi-inclusive deep-inelastic scattering on a transversely polarized hydrogen target

Single-spin asymmetries for semi-inclusive electroproduction of charged pions in deep-inelastic scattering of positrons are measured for the first time with transverse target polarization. The asymmetry depends on the azimuthal angles of both the pion (phi) and the target spin axis (phi(S)) about the virtual-photon direction and relative to the lepton scattering plane. The extracted Fourier component sin((phi+phi(S))(pi)(UT) is a signal of the previously unmeasured quark transversity distribution, in conjunction with the Collins fragmentation function, also unknown. The component sin((phi-phi(S)(pi)(UT) arises from a correlation between the transverse polarization of the target nucleon and the intrinsic transverse momentum of quarks, as represented by the previously unmeasured Sivers distribution function. Evidence for both signals is observed, but the Sivers asymmetry may be affected by exclusive vector meson production.

Flavor decomposition of the sea-quark helicity distributions in the nucleon from semiinclusive deep inelastic scattering

Double-spin asymmetries of semiinclusive cross sections for the production of identified pions and kaons have been measured in deep inelastic scattering of polarized positrons on a polarized deuterium target. Five helicity distributions including those for three sea quark flavors were extracted from these data together with reanalyzed previous data for identified pions from a hydrogen target. These distributions are consistent with zero for all three sea flavors. A recently predicted flavor asymmetry in the polarization of the light quark sea appears to be disfavored by the data.

Evidence for quark-hadron duality in the proton spin asymmetry A1

Spin-dependent lepton-nucleon scattering data have been used to investigate the validity of the concept of quark-hadron duality for the spin asymmetry A1. Longitudinally polarized positrons were scattered off a longitudinally polarized hydrogen target for values of Q2 between 1.2 and 12 GeV2 and values of W2 between 1 and 4 GeV2. The average double-spin asymmetry in the nucleon resonance region is found to agree with that measured in deep-inelastic scattering at the same values of the Bjorken scaling variable x. This finding implies that the description of A1 in terms of quark degrees of freedom is valid also in the nucleon resonance region for values of Q2 above 1.6 GeV2.

Q2 dependence of nuclear transparency for exclusive rho0 production

Exclusive coherent and incoherent electroproduction of the rho(0) meson from 1H and 14N targets has been studied at the HERMES experiment as a function of coherence length (l(c)), corresponding to the lifetime of hadronic fluctuations of the virtual photon, and squared four-momentum of the virtual photon (-Q2). The ratio of 14N to 1H cross sections per nucleon, called nuclear transparency, was found to increase (decrease) with increasing l(c) for coherent (incoherent) rho(0) electroproduction. For fixed l(c), a rise of nuclear transparency with Q2 is observed for both coherent and incoherent rho(0) production, which is in agreement with theoretical calculations of color transparency.

An intervention to increase coping and reduce health care utilization for school-age children and adolescents with sickle cell disease

The purpose of this study was to examine whether coping with pain changed immediately and one year after a self-care intervention for school-age children and adolescents with sickle cell disease (SCD). Sixty-five children and 32 adolescents attended an educational program for living with SCD. They were then randomly assigned to relaxation, art therapy or attention-control groups. Coping was measured before, after the intervention, and 12 months later. Thirty-three children and 14 adolescents completed the one year follow-up. Although there was no significant increase in the overall number of coping strategies school-age children and adolescents used from baseline to 12 months, there was a significant increase in those strategies specifically targeted by the intervention. For adolescents, there was a significant increase in the total number of coping scores used before the intervention and one year later. When compared to well African-American adolescents, overall coping scores in this sample were significantly lower. Health care utilization related to clinic visits, emergency department visits and hospitalizations decreased significantly for all participants in the study.

The origin of skeletal muscle stem cells in the embryo and the adult

Skeletal muscle progenitors are specified during embryogenesis and in addition have recently been found to be generated from either mesenchymal or neural stem cells in the adult. We review recent progress in identifying the signals and transcription factors that control skeletal muscle formation during embryogenesis and in the adult.

Computerised dynamic posturography to assess recovery comparing general anaesthesia with sedation and local anaesthesia for day case nasal surgery

Computerised dynamic posturography (CDP) can be used as an early marker of recovery to street fitness in patients undergoing ambulatory surgery. We studied three groups of patients undergoing nasal surgery. The goal of this study was to determine whether recovery, as assessed by CDP, is more rapid in patients having nasal surgery under sedation coupled with local anaesthesia or those having surgery under general anaesthesia. We further assessed the acceptability of sedation accompanied by local anaesthesia. A control group was included to determine if there is a learning curve to posturography. There was no difference between the two study groups in terms of balance. Balance was not significantly impaired at 3 h postoperative testing.

Childrens' and adolescents' use of diaries for sickle cell pain

ISSUES AND PURPOSE

To evaluate the characteristics of vaso-occlusive episodes, home management of pain and its impact on the daily activities, and a diary as a method of data collection.

DESIGN AND METHODS

Forty-six adolescents and 75 children were asked to complete daily diaries during the intervention period of a larger study.

RESULTS

Mild pain was recorded 95% of the time; moderate pain, 3%; and severe pain, 1%. The pattern and location of pain varied greatly. Adolescents used more interventions than did children. When pain intensity was mild, 80% of the children/adolescents maintained school, social, and home activities, but decreased play/sport activities. When pain intensity was high, they decreased their participation in all activities.

PRACTICE IMPLICATIONS

Sickle cell pain episodes are unpredictable and highly variable. Diaries can enhance children's and adolescents' documentation and communication about their pain experiences.

Lack of effect of HPA axis hyperactivity on hormonal responses to d-fenfluramine in major depressed patients: implications for pathogenesis of suicidal behaviour

There is evidence for inhibitory effects of adrenocorticosteroids on serotonergic (5-HT) activity. However, in depression the relationship between altered cortisol levels and brain 5-HT function remains to be clarified. The aim of this study was to investigate whether hypothalamic-pituitary-adrenal (HPA) axis hyperactivity is associated with 5-HT dysfunction in depressed patients, especially in those with suicidal behaviour. Cortisol levels following the dexamethasone suppression test (DST, 1 mg PO) and prolactin, corticotropin and cortisol responses to the d-fenfluramine test (d-FEN, 45 mg PO) - a specific 5-HT releaser/uptake inhibitor - were measured in 71 drug-free DSM-IV major depressed inpatients (40 with a history of suicide attempt, 31 without) and 34 hospitalized healthy control subjects. Depressed patients showed higher post-DST cortisol levels but similar responses to d-FEN compared with control subjects. Hormonal responses to d-FEN were not correlated with cortisol levels (basal or post-DST). Among the depressed patients, DST suppressors and DST nonsuppressors exhibited no significant difference in endocrine responses to d-FEN. However, patients with a history of suicide attempt, when compared with patients without such a history, showed lower hormonal responses to d-FEN but comparable basal and post-DST cortisol levels. Taken together these results suggest that, in depression, HPA axis hyperactivity is not responsible for the reduced 5-HT activity found in patients with a history of suicidal behavior.

Comparison of two dosages of tolcapone added to levodopa in nonfluctuating patients with PD

The efficacy and safety of two dosages of tolcapone were compared in a 12-week crossover trial involving 118 nonfluctuating patients with PD on a stable dose of levodopa (L-Dopa). At trial onset, all patients received open-label tolcapone 100 mg three times daily for 4 weeks. At week 4, 116 eligible patients entered an 8-week double-blind treatment period and were randomized to receive tolcapone three times daily at either 100 mg (group 1; n = 58) or 200 mg (group 2; n = 58) until week 8, followed by the alternative tolcapone dosage until week 12. Ratings included Unified Parkinson's Disease Rating Scale (UPDRS), Schwab & England, and patient diaries, assessed at baseline and at 4, 8, and 12 weeks. At week 4, the investigator's global assessment (IGA) of efficacy showed improvement in 76% of patients. The mean total daily L-Dopa dose and mean UPDRS scores for subscales II and III decreased significantly (p < 0.001). During the double-blind treatment period, IGA showed improvements at either or both dosages in 61% of patients; further changes in other efficacy variables were minimal and were similar with both tolcapone dosages. The most frequent adverse events were dopaminergic (nausea and dyskinesia); the most frequent nondopaminergic adverse event was diarrhea. The incidence of adverse events during double-blind treatment was slightly higher with tolcapone 200 mg three times daily (33%) than with tolcapone 100 mg three times daily (24%). The authors conclude that tolcapone dosages of 100 mg three times daily and 200 mg three times daily are well tolerated and equally effective in improving function in L-Dopa-treated nonfluctuating patients with PD.