Access to a health facility and care‐seeking for danger signs in children: before and after a community‐based intervention in Lusaka,Zambia

Objective To assess the association of accessibility to a health facility with caregivers’ care‐seeking practices for children with danger signs before and after community‐based intervention in Lusaka, Zambia. Method Health education on childhood danger signs was started in September 2003 at the monthly Growth Monitoring Program Plus (GMP+) service through various channels of health talk and one‐on‐one communication in a peri‐urban area of Lusaka. Two repeated surveys were conducted: in 2003 to collect baseline data before the intervention and in 2006 for 3‐year follow‐up data. Caregivers who had perceived one or more danger signs in their children within 2 months of the surveys were eligible for the analysis. The association between appropriate and timely care‐seeking practices and socio‐demographic and socio‐economic factors, attendance at community‐based intervention and the distance to a health facility was examined with logistic regression analysis. Results The percentage of caregivers immediately seeking care from health professionals increased from 56.1% (106/189) at baseline to 65.8% (148/225) at follow‐up 3 years later (OR = 1.51, P < 0.05). Long distance to the health facility and low‐household income negatively influenced caregivers’ appropriate and timely care‐seeking practices at baseline, but 3 years later, after the implementation of a community‐based intervention, distance and household income were not significantly related to caregivers’ care‐seeking practices. Conclusion Poor accessibility to health facilities was a significant barrier to care‐seeking in a peri‐urban area. However, when caregivers are properly educated about danger signs and appropriate responses through community‐based intervention, this barrier can be overcome through behavioural change in caregivers.     

Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn

The huge majority of the annual 6.3 million perinatal deaths and half a million maternal deaths take place in developing countries and are avoidable. However, most of the interventions aiming at reducing perinatal and maternal deaths need a health care system offering appropriate antenatal care and quality delivery care, including basic and comprehensive emergency obstetric care facilities. To promote the uptake of quality care, there are two possible approaches: influencing the demand and/or the supply of care. Five lessons emerged from experiences. First, it is difficult to obtain robust evidence of the effects of a particular intervention in a context, where they are always associated with other interventions. Second, the interventions tend to have relatively modest short‐term impacts, when they address only part of the health system. Third, the long‐term effects of an intervention on the whole health system are uncertain. Fourth, because newborn health is intimately linked with maternal health, it is of paramount importance to organise the continuum of care between mother and newborn. Finally, the transfer of experiences is delicate, and an intervention package that has proved to have a positive effect in one setting may have very different effects in other settings.     

Public health services,an essential determinant of health during crisis. Lessons from Cuba, 1989–2000

During the 1990s, Cuba was able to overcome a severe crisis, almost without negative health impacts. This national retrospective study covering the years 1989–2000 analyses the country’s strategy through essential social, demographic, health process and health outcome indicators. Gross domestic product (GDP) diminished by 34.76% between 1989 and 1993. In 1994 slow recuperation started. During the crisis, public health expenses increased. The number of family doctors rose from 9.22 to 27.03 per 104 inhabitants between 1989 and 2000. Infant mortality rate and life expectancy exemplify a series of health indicators that continued to improve during the crisis years, whereas low birth weight and tuberculosis incidence are among the few indicators that suffered deterioration. GDP is inversely related to tuberculosis incidence, whereas the average salary is inversely related to low birth weight. Infant mortality rate has a strong negative correlation with the health expenses per inhabitant, the number of maternal homes, the number of family doctors and the proportion of pregnant women receiving care in maternal homes. Life expectancy has a strong positive correlation with health expenses, the number of nursing personnel and the number of medical contacts per inhabitant. The Cuban strategy effectively resolved health risks during the crisis. In times of serious socio‐economic constraints, a well conceptualized public health policy can play an important role in maintaining the overall well‐being of a population.     

Causes of stillbirth, neonatal death and early childhood death in rural Zambia by verbal autopsy assessments

Objectives To describe specific causes of the high rates of stillbirth, neonatal death and early child childhood death in Zambia. Methods We conducted a household‐based survey in rural Zambia. Socio‐demographic and delivery characteristics were recorded, alongside a maternal HIV test. Verbal autopsy questionnaires were administered to elicit mortality‐related information and independently reviewed by three experienced paediatricians who assigned a cause and contributing factor to death. For this secondary analysis, deaths were categorized into: stillbirths (foetal death ≥28 weeks of gestation), neonatal deaths (≤28 days) and early childhood deaths (>28 days to <2 years). Results Among 1679 households, information was collected on 148 deaths: 34% stillbirths, 26% neonatal and 40% early childhood deaths. Leading identifiable causes of stillbirth were intrauterine infection (26%) and birth asphyxia (18%). Of 32 neonatal deaths, 38 (84%) occurred within the first week of life, primarily because of infections (37%) and prematurity (34%). The majority of early childhood deaths were caused by suspected bacterial infections (82%). HIV prevalence was significantly higher in mothers who reported an early childhood death (44%) than mothers who did not (17%; P < 0.01). Factors significantly associated with mortality were lower socio‐economic status (P < 0.01), inadequate water or sanitation facilities (P < 0.01), home delivery (P = 0.04) and absence of a trained delivery attendant (P < 0.01). Conclusion We provide community‐level data about the causes of death among children under 2 years of age. Infectious etiologies for mortality ranked highest. At a public health level, such information may have an important role in guiding prevention and treatment strategies to address perinatal and early childhood mortality.     

Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co‐operative Medical System)

Objective To investigate factors influencing maternal health care utilisation in western rural China and its relation to income before (2002) and after (2007) introducing a new rural health insurance system (NCMS). Methods Data from cross‐sectional household‐based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log‐linear model. Results Between 2002 and 2007, having no any pre‐natal visit decreased from 25% to 12% (difference 13%, 95% CI 10–17%); facility‐based delivery increased from 45% to 80% (difference 35%, 95% CI 29–37%); and differences in using pre‐natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre‐natal and delivery care in 2007. The expenditure for facility‐based delivery increased over the period, but the out‐of‐pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low‐income group. NCMS participation was found positively correlated with lower out‐of‐pocket expenditure for facility‐based delivery (coefficient ?1.14 P < 0.05) in 2007. Conclusions Facility‐based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility‐based delivery, although NCMS participation reduced the out‐of‐pocket expenditure on average.