The tip of the iceberg: evidence of seasonality in institutional maternal mortality and implications for health resources management in Burkina Faso

Falciparum but not vivax malaria increases the risk of hypertensive disorders of pregnancy in women followed prospectively from the first trimester

BACKGROUND

Malaria and hypertensive disorders of pregnancy (HDoP) affect millions of pregnancies worldwide, particularly those of young, first-time mothers. Small case-control studies suggest a positive association between falciparum malaria and risk of pre-eclampsia but large prospective analyses are lacking.

METHODS

We characterized the relationship between malaria in pregnancy and the development of HDoP in a large, prospectively followed cohort. Pregnant women living along the Thailand-Myanmar border, an area of low seasonal malaria transmission, were followed at antenatal clinics between 1986 and 2016. The relationships between falciparum and vivax malaria during pregnancy and the odds of gestational hypertension, pre-eclampsia, or eclampsia were examined using logistic regression amongst all women and then stratified by gravidity.

RESULTS

There were 23,262 singleton pregnancies in women who presented during the first trimester and were followed fortnightly. Falciparum malaria was associated with gestational hypertension amongst multigravidae (adjusted odds ratio (AOR) 2.59, 95%CI 1.59-4.23), whereas amongst primigravidae, it was associated with the combined outcome of pre-eclampsia/eclampsia (AOR 2.61, 95%CI 1.01-6.79). In contrast, there was no association between vivax malaria and HDoP.

CONCLUSIONS

Falciparum but not vivax malaria during pregnancy is associated with hypertensive disorders of pregnancy.

Seasonal trends and maternal characteristics as predictors of maternal undernutrition and low birthweight in Eastern Maharashtra, India

Few studies have assessed whether women and infants in rural and peri-urban communities in South Asia experience seasonal fluctuations in nutritional status; however, a handful of studies have documented seasonal variability in risk factors for undernutrition including food availability, physical activity and infections. We used data from the Maternal and Newborn Health (MNH) registry, a population-based pregnancy and birth registry in Eastern Maharashtra, India, to analyse seasonal trends in birthweight and maternal nutritional status-body mass index (BMI) and haemoglobin-in the first trimester of pregnancy. We plotted monthly and seasonal trends in birthweight, and maternal BMI and haemoglobin, and used multivariable regression models to identify seasonal and maternal characteristics that predicted each outcome. Between October 2014 and January 2018, MNH included 29,253 livebirths with recorded birthweight. BMI was assessed in 15,252 women less than 12 weeks of gestation and haemoglobin in 18,278 women less than 13 weeks of gestation. Maternal characteristics (age, education, parity and height) were significantly associated with nutritional status; however, there were minimal seasonal fluctuations in birthweight or maternal nutrition. There were significant secular trends in maternal haemoglobin; between 2014 and 2018, the prevalence of maternal anaemia decreased from 91% to 79% and moderate or severe anaemia from 53% to 37%. The prevalence of maternal underweight (45.3%) and overweight (9.8%) and low birthweight (19.1%) remained relatively constant over the study period. Our findings highlight that in some rural and peri-urban areas in South Asia, tackling systemic drivers of malnutrition may be more effective than targeted interventions based on season.

The impact of reducing and eliminating user fees on facility-based delivery: a controlled interrupted time series in Burkina Faso

User fee reduction and removal policies have been the object of extensive research, but little rigorous evidence exists on their sustained effects in relation to use of delivery care services, and no evidence exists on the effects of partial reduction compared with full removal of user fees. We aimed to fill these knowledge gaps by assessing sustained effects of both partial reduction and complete removal of user fees on utilization of facility-based delivery. Our study took place in four districts in the Sahel region of Burkina Faso, where the national user fee reduction policy (SONU) launched in 2007 (lowering fees at point of use by 80%) co-existed with a user fee removal pilot launched in 2008. We used Health Management Information System data to construct a controlled interrupted time-series analysis and examine both immediate and sustained effects of SONU and the pilot from January 2004 to December 2014. We found that both SONU and the pilot led to a sustained increase in the use of facility-based delivery. SONU produced an accumulative increase of 31.4% (P < 0.01) over 8 years in the four study districts. The pilot further enhanced utilization and produced an additional increase of 23.2% (P < 0.001) over 6 years. These increasing trends did not continue to reach full coverage, i.e. ensuring that all women had a facility-based delivery. Instead, they stabilized 3 years and 4 years after the onset of SONU and the pilot, respectively. Our study provides further evidence that user fee reduction and removal policies are effective in increasing service use in the long term. However, they alone are not sufficient to achieve full coverage. This calls for the need to implement additional measures, targeting for instance geographical barriers and knowledge gaps, to achieve the target of all women delivering in the presence of a skilled attendant.

Challenges of Implementing Antenatal Ultrasound Screening in a Rural Study Site: A Case Study From the Democratic Republic of the Congo

In the context of a well-resourced research project on obstetric ultrasound, we encountered major challenges, including security and maintenance of the equipment, electricity requirements, health systems integration, and a variety of other systems issues. We propose future ultrasound interventions have at minimum a functioning health system with skilled and motivated staff, access to a referral hospital capable of providing affordable and higher levels of care, and feasible transportation means.

Persistent global disparities in maternal and neonatal outcomes and the emergence of compact ultrasound technology as an increasingly viable technology for low-resource settings provided the genesis of the First Look Ultrasound study. Initiated in 2014 in 5 low- and middle-income countries and completed in June 2016, the study's intervention included the training of health personnel to perform antenatal ultrasound screening and to refer women identified with high-risk pregnancies to hospitals for appropriate care. This article examines the challenges that arose in implementing the study, with a particular focus on the site in Equateur Province of the Democratic Republic of the Congo (DRC) where the challenges were greatest and the efforts to meet these challenges most illuminating. During the study period, we determined that with resources and dedicated staff, it was possible to leverage the infrastructure and implement ultrasound at antenatal care across a variety of remote sites, including rural DRC. However, numerous technical and logistical challenges had to be addressed including security of the equipment, electricity requirements, and integration of the intervention into the health system. To address security concerns, in most of the countries field sonographers were hired and dispatched each day with the equipment to the health centers. At the end of each day, the equipment was locked in a secure, central location. To obtain the required power source, the DRC health centers installed solar panels bolted on adjacent poles since the thatch roofs of the centers prohibited secure roof-top installation. To realize the full value of the ultrasound intervention, women screened with high-risk pregnancies had to seek a higher level of care at the referral hospital for a definitive diagnosis and appropriate care. While the study did provide guidance on referral and systems management to health center and hospital administration, the extent to which this resulted in the necessary structural changes varied depending on the motivation of the stakeholders. In order for such an intervention to be scaled up and sustained as part of a health system's general services, it would require considerable effort, political will, and financial and human resources. Preliminary results from the study indicate that taking routine antenatal ultrasound screening to scale is not warranted. Lessons learned in implementing the study, however, can help inform future studies or programs that are considering use of ultrasound or other imaging technology for other applications in low-resource settings.

"Children get sick all the time": A qualitative study of socio-cultural and health system factors contributing to recurrent child illnesses in rural Burkina Faso

Background

In Burkina Faso, the government has implemented various health sector reforms in order to overcome financial and geographical barriers to citizens’ access to primary healthcare throughout the country. Despite these efforts, morbidity and mortality rates among children remain high and the utilization of public healthcare services low. This study explores the relationship between mothers’ intentions to use public health services in cases of child sickness, their social strategies and cultural practices to act on these intentions and the actual services provided at the primary health care facilities. Focusing on mothers as the primary caregivers, we follow their pathways from the onset of symptoms through their various attempts of providing treatment for their sick children. The overall objective is to discuss the interconnectedness of various factors, inside and outside of the primary health care services that contribute to the continuing high child morbidity and mortality rates.

Methods

The study is based on ethnographic fieldwork, including in-depth interviews and follow-up interviews with 27 mothers, informal observations of daily-life activities and structured observations of clinical encounters. Data analysis took the form of thematic analysis.

Results and discussion

Focusing on the mothers’ social strategies and cultural practices, three forms of responses/actions have been identified: home-treatment, consultation with a traditional specialist, and consultation at the primary health care services. Due to their accumulated vulnerabilities, mothers shift pragmatically from one treatment to another. However, the sporadic nature of their treatment-seeking hinders them in obtaining long-term solutions and the result is recurrent child illnesses and relapses over long periods of time. The routinization of the clinical encounter at rural dispensaries furthermore fails to address these complexities of children’s illnesses.

Conclusions

The analysis of case studies, interviews and observations shows how mothers in a rural area struggle and often fail to receive care at public healthcare facilities. Health service delivery could be organized in a manner that responds better to the needs of these mothers in terms of both access and retention.

Towards elimination of maternal deaths: maternal deaths surveillance and response

Current methods for estimating maternal mortality lack precision, and are not suitable for monitoring progress in the short run. In addition, national maternal mortality ratios (MMRs) alone do not provide useful information on where the greatest burden of mortality is located, who is concerned, what are the causes, and more importantly what sub-national variations occur. This paper discusses a maternal death surveillance and response (MDSR) system. MDSR systems are not yet established in most countries and have potential added value for policy making and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. Accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organizations but on routine counting, investigation, sub national data analysis, long term investments in vital registration and national health information systems. Establishing effective maternal death surveillance and response will help achieve MDG 5, improve quality of maternity care and eliminate maternal mortality (MMR ≤ 30 per 100,000 by 2030).

Estimating obstetric mortality from pregnancy-related deaths recorded in demographic censuses and surveys

Demographic surveys and censuses often record pregnancy-related deaths, defined as those occurring during the maternal risk period (pregnancy, delivery, and six weeks postpartum), but do not include cause of death. This study presents a method for estimating obstetric mortality from pregnancy-related deaths data. Calculations are based on multiple-decrement life tables, and data needed are simply age-specific fertility and mortality rates that are commonly available in Demographic and Health Survey (DHS) or census data, and an estimate of the relative risk of death from nonobstetric causes during the maternal risk period. The method is tested on 59 DHS surveys from Africa. Results show that, on average, less than half of the pregnancy-related deaths are attributable to obstetric causes. This proportion varies with the level of mortality and fertility, and in particular with the prevalence of HIV in the population.

Difficulties leaving home: a cross-sectional study of delays in seeking emergency obstetric care in Herat, Afghanistan

This study used an analytical cross-sectional design to identify risk factors associated with delays in care-seeking among women admitted in life-threatening conditions to a maternity hospital in Herat, Afghanistan, from February 2007 to January 2008. Disease-specific criteria of 'near-miss' were used to identify women in life-threatening conditions. Among 472 eligible women and their husbands, 411 paired interviews were conducted, and information on socio-demographic factors; the woman's status and social resources; the husband's social networks; health care accessibility and utilisation; care-seeking costs; and community characteristics were obtained. Decision and departure delays were assessed quantitatively from reported timings of symptom recognition, care-seeking decision, and departure for health facilities. Censored normal regression analyses suggest that although determinants of decision delay were influenced by the nature and symptoms of complications, uptake of antenatal care (ANC) and the birth plan reduced decision delay at the time of the obstetric emergency. Access to care and social networks reduced departure delay. Programmatic efforts may be directed towards exploiting the roles of ANC and social resources in facilitating access to emergency obstetric care.

Bottlenecks for high coverage of intermittent preventive treatment in pregnancy: the case of adolescent pregnancies in rural Burkina Faso

BACKGROUND

While IPTp-SP is currently being scaled up in sub-Saharan Africa (SSA), the coverage with the required>or=2 doses of SP remains considerably short of the Roll Back Malaria (RBM) goal of 80%, not to mention of the recently advocated universal coverage.

METHODS

The study triangulates quantitative data from a health center randomized community-based trial on IPTp-SP effectiveness and the additional benefit of a promotional campaign with qualitative data from focused ethnography.

FINDINGS

In rural Burkina Faso, despite the significantly higher risk of malaria infection among adolescent primigravidae (PG) (OR 2.44 95%CI 1.81-3.28, p<0.001), making them primary target beneficiaries of IPTp-SP, adolescents adhered to the required three or more ANC visits significantly less (PG: 46.6%; SG 43.7%) than adults (PG: 61.9%; SG 54.9%) and had lower SP uptake during the malaria transmission season, further showing the difficulty of reaching this age group. Adolescents' structural constraints (such as their social position and household labor requirements) and needs (such as anonymity in the health encounter) leave them highly vulnerable during their pregnancies and, especially, during the high malaria transmission season.

CONCLUSION

Our study shows that adolescents need to be targeted specifically, prior to their first pregnancy and with measures adapted to their social context, addressing their structural constraints and needs and going beyond standard health promotion campaigns. Unless such specific measures are taken, adolescents' social vulnerability will present a serious bottleneck for the effectiveness of IPTi-SP.