Regionalized perinatal care in developing countries.

Neonatal-perinatal ill health and mortality are overwhelmingly a burden of the developing world. As many as 90% of births, 98% of fetal deaths and 98% of neonatal deaths occur in less developed countries. Regionalized perinatal services were introduced in developed countries when most neonatal mortality was confined to very-low-birthweight babies who required intensive perinatal care to survive. A large proportion of newborn morbidity and mortality in developing countries, however, continues to occur among full-term and moderate-sized low-birthweight neonates who can be managed well in the community and at small hospitals. The model of regionalized perinatal care as practiced in developed countries is, at present, neither affordable nor relevant to the needs of many developing countries. It is possible to achieve considerably lower neonatal mortality rates in resource-poor settings by implementing home-based newborn care delivered by community health workers, and by promoting institutional perinatal care at simple facilities provided by trained midwives.     

Standardized diagnosis of pneumonia in developing countries.

The World Health Organization recommends the use of raised respiratory rate and chest wall indrawing to enable health workers in developing countries to diagnose pneumonia. We evaluated the current World Health Organization guidelines for management of the child with cough or difficult breathing in Manila, Philippines and Mbabane, Swaziland using an identical protocol in both countries. Raised respiratory rate was defined as greater than or equal to 50/minute for children ages 2 to 12 months and greater than or equal to 40/minute for children 12 months to 5 years. Chest wall indrawing was defined as inward movement of the bony structures of the lower chest wall with inspiration. In the Philippines raised respiratory rate or chest wall indrawing, when applied by a pediatrician, was found to have a sensitivity of 0.81 and specificity of 0.77 for predicting pneumonia as determined by a pediatrician with the aid of a chest roentgenogram. In Swaziland the sensitivity was 0.77 and the specificity was 0.80. When applied by health workers the sensitivity was similar but the specificity was lower. The current World Health Organization ARI case management guidelines predicted pneumonia with similar sensitivity and specificity in two very different developing countries, the Philippines and Swaziland.