Aetiology of stillbirths and neonatal deaths in rural Ghana: implications for health programming in developing countries

In developing countries many stillbirths and neonatal deaths occur at home and cause of death is not recorded by national health information systems. A community-level verbal autopsy tool was used to obtain data on the aetiology of stillbirths and neonatal deaths in rural Ghana. Objectives were to describe the timing and distribution of causes of stillbirths and neonatal deaths according to site of death (health facility or home). Data were collected from 1 January 2003 to 30 June 2004; 20 317 deliveries, 696 stillbirths and 623 neonatal deaths occurred over that time.
Most deaths occurred in the antepartum period (28 weeks gestation to the onset of labour) (33.0%). However, the highest risk periods were during labour and delivery (intrapartum period) and the first day of life. Infections were a major cause of death in the antepartum (10.1%) and neonatal (40.3%) periods. The most important cause of intrapartum death was obstetric complications (59.3%). There were significantly fewer neonatal deaths resulting from birth asphyxia in the home than in the health facilities and more deaths from infection. Only 59 (20.7%) mothers of neonates who died at home reported that they sought care from an appropriate health care provider (doctor, nurse or health facility) during their baby's illness. The results from this study highlight the importance of studying community-level data in developing countries and the high risk of intrapartum stillbirths and infectious diseases in the rural African mother and neonate. Community-level interventions are urgently needed, especially interventions that reduce intrapartum deaths and infection rates in the mother and infant.     

Private health insurance: implications for developing countries

Private health insurance is playing an increasing role in both high- and low-income countries, yet is poorly understood by researchers and policy-makers. This paper shows that the distinction between private and public health insurance is often exaggerated since well regulated private insurance markets share many features with public insurance systems. It notes that private health insurance preceded many modern social insurance systems in western Europe, allowing these countries to develop the mechanisms, institutions and capacities that subsequently made it possible to provide universal access to health care. We also review international experiences with private insurance, demonstrating that its role is not restricted to any particular region or level of national income. The seven countries that finance more than 20% of their health care via private health insurance are Brazil, Chile, Namibia, South Africa, the United States, Uruguay and Zimbabwe. In each case, private health insurance provides primary financial protection for workers and their families while public health-care funds are targeted to programmes covering poor and vulnerable populations. We make recommendations for policy in developing countries, arguing that private health insurance cannot be ignored. Instead, it can be harnessed to serve the public interest if governments implement effective regulations and focus public funds on programmes for those who are poor and vulnerable. It can also be used as a transitional form of health insurance to develop experience with insurance institutions while the public sector increases its own capacity to manage and finance health-care coverage.     

Long-term trends in fetal mortality: implications for developing countries

This paper discusses the problems of defining and measuring late-fetal mortality (stillbirths). It uses evidence from 11 developed countries to trace long-term trends in fetal mortality. Issues associated with varying definitions and registration practices are identified, as well as the range of possible rates, key turning points and recent convergence. The implications for developing countries are spelled out. They emphasize the possible limitations of WHO estimation methods and survey-based data by examining the cross-sectional associations among 187 countries in the year 2000. The important role of skilled birth attendants is emphasized in both data sets, but the different effects on maternal mortality and late-fetal mortality are also noted.     

Sex-specific differences in mortality after high-titre measles immunization in rural Senegal.

Administration of high-titre measles vaccine (Edmonston-Zagreb (EZ) at > 10(5) plaque-forming units (PFU) per dose) before the age of 9 months has been recommended in areas with high measles mortality before the routine age of immunization after 9 months. The study compares the long-term survival after high-titre measles immunization at 5 months of age with that following routine immunization with standard-titre vaccine at 10 months of age. At 5 months of age the high-titre group received Edmonston-Zagreb (EZ-HT, 5 months) or Schwarz (SW-HT, 5 months) at titres > 10(5) PFU per dose, while the standard-titre group received placebo at 5 months of age and < 10(4) PFU per dose of Schwarz vaccine at 10 months (SW-std, 10 months). All the children were followed up to at least 36 months of age. The mortality ratio (MR) for infants in the EZ-HT, 5 months and SW-HT, 5 months groups was 1.32 (P = 0.089) and 1.45 (P = 0.092), respectively, which did not differ significantly from that of recipients of the SW-std, 10 months. The higher MR among recipients of the high-titre vaccines was due to the significantly lower survival among females compared with the females who received SW-std vaccine (EZ-HT, 5 months MR = 1.76, P = 0.013; SW-HT, 5 months MR = 2.14, P = 0.017). For children aged 5-10 months the high-titre measles vaccine did not increase mortality relative to unvaccinated children who had received placebo.     

Injury control in developing countries

WHERE ARE WE NOW?: Despite the evident overall significance of accidents for publichealth, the number of countries that have established adequatepolicies and programmes based on sound scientific evidence andavailable safety technologies, is still too low. The situationis particularly imbalanced and detrimental to developing countries,where deaths from injuries rank now among the first five causesof general mortality, and where the protection of consumersand communities against hazards is often a reflection of a compromisebetween safety needs and economic pressures. The powerful roleof underdevelopment in determining the extent of the injuryproblem and potential for action in developing countries shouldbe constantly emphasized (WHO 1988).     

The good mother: rural and urban practices related to measles in Haalpulareen women in Senegal

Anthropologists usually describe the village as a place of tradition, and the town as a place of modernity. In order to question this opposition, a study was carried out among 100 Haalpulaaren mothers (Tukulors and Fulas), 50 from a village in the Sahelian area along the Senegal River and 50 from an underprivileged suburb of Dakar. They were asked about their representations and practices related to measles, which is the first cause of mortality under 5 years of age in the urban group, and second in rural group. Although fatality rates were equivalent in both groups and even higher among village children who had been staying in town at the time of the illness, measles seems much more feared in the village where it comes by epidemics than in town where it is endemic. Moreover, causal interpretations seem to be changed by the different environment of the city where the mechanistic explanation by winds has lost its material basis and is changed into the metaphoric and magical interpretation of wind-spirits. As for therapeutic practices, the study reveals a more traditional behaviour (judged on use of local remedies and immunization coverage) in the urban group than in the rural group. This paradoxical result can be explained by the existence of a subgroup of migrant women (seen in town more than in the village) who appear to resist to change and reinforce their traditional behaviours. Finally influence of castes seems to disappear in town, where therapeutic practices vary according to the level of integration into urban society (measured by use of the vehicular language).(ABSTRACT TRUNCATED AT 250 WORDS)     

Animal biotechnology: applications and economic implications in developing countries

In most developing countries, biotechnological applications relating to livestock need to be suitable for animal owners who are resource-poor small-scale operators who own little or no land and few animals. Livestock is becoming increasingly important to economic growth in developing countries and the application of biotechnology is largely dictated by commercial considerations and socio-economic goals. Using technology to support livestock production is an integral part of viable agriculture in multi-enterprise systems. Livestock are part of a fragile ecosystem and a rich source of animal biodiversity, as local species and breeds possess genes and traits of excellence. Molecular markers are increasingly being used to identify and select the particular genes that lead to these desirable traits and it is now possible to select superior germ plasm and disseminate it using artificial insemination, embryo transfer and other assisted reproductive technologies. These technologies have been used in the genetic improvement of livestock, particularly in cattle and buffaloes, and the economic returns are significant. However, morbidity and mortality among animals produced using assisted reproductive technologies lead to high economic losses, so the principal application of animal biotechnology at present is in the production of cheap and dependable diagnostic kits and vaccines. Several obstacles limit the application of biotechnology at present: there is a lack of infrastructure and insufficient manpower, so funding is needed if resource-poor farmers are to benefit from biotechnology.     

Neonatal klebsiella septicaemia in Ibadan: implications for neonatal care in developing countries

The antecedent events, clinical features, prevalence and complications of neonatal Klebsiella septicaemia in 73 infants admitted to a Special Care Baby Unit over an 18 month period during which there was severe national economic depression, are retrospectively reviewed and compared with those of 72 infants who had no risk factors for sepsis and who were not treated for sepsis, admitted to the same unit during the same period. Standard infection control measures were severely compromised in the unit as well as in the delivery unit and a nosocomial acquisition of the infection was evident. Possible implications for neonatal care in developing countries are discussed with suggestions for prevention of a similar trend even in the face of lean resources.     

Behavioral problems in school-going children: implications for medical teachers in developing countries

A large number of children suffer from behavioral problems during their development. Many of these problems are transient and may not even be noticed. At times, however, the extent of these problems and their overall effects on a child's development can be serious (Morita et al., 1993). Further, children may exhibit these behaviors in one setting and not in others (e.g. at home or in school, but not both). In developed countries, parents tend to seek advice for even minor problems, such as persistent thumb sucking, while in developing countries, major problems, even childhood schizophrenia, may go unattended. An awareness of the prevalence of these problems is important so that appropriate mental health services can be planned and provided for affected children, to improve their prospects for leading healthy, productive lives. Such awareness can help enhance the teaching of graduate doctors, equipping them to deal with these problems effectively.     

Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes

This paper synthesizes the rates, barriers, and outcomes of HIV serostatus disclosure among women in developing countries. We identified 17 studies from peer-reviewed journals and international conference abstracts--15 from sub-Saharan Africa and 2 from south-east Asia--that included information on either the rates, barriers or outcomes of HIV serostatus disclosure among women in developing countries. The rates of disclosure reported in these studies ranged from 16.7% to 86%, with women attending free-standing voluntary HIV testing and counselling clinics more likely to disclose their HIV status to their sexual partners than women who were tested in the context of their antenatal care. Barriers to disclosure identified by the women included fear of accusations of infidelity, abandonment, discrimination and violence. Between 3.5% and 14.6% of women reported experiencing a violent reaction from a partner following disclosure. The low rates of HIV serostatus disclosure reported among women in antenatal settings have several implications for prevention of mother-to-child transmission of HIV (pMTCT) programmes as the optimal uptake and adherence to such programmes is difficult for women whose partners are either unaware or not supportive of their participation. This article discusses these implications and offers some strategies for safely increasing the rates of HIV status disclosure among women.     

Tuberculosis in developing countries and methods for its control

Tuberculosis is a major cause of morbidity and mortality in developing countries. It is estimated that one-fifth of the world population is infected, 12-16 million people have the disease, every year 6-8 million develop tuberculosis and 2-3 million die from it. Four methods for the prevention of tuberculosis are available: improvement of socio-economic conditions, case-finding and treatment, chemoprophylaxis, and vaccination. Each of these methods is examined in relation to a model of the chain of transmission and development of disease. Improvement of socio-economic conditions, responsible for the decline of tuberculosis in the developed world, must be seen as a long-term solution. Case-finding and treatment is the only method expected to have an important short-term impact on transmission. A summary of the results of 35 studies shows the estimated efficacy of bacillus Calmette-Guérin (BCG) vaccination ranging from 96% to none. Follow-up results from 10 controlled trials are consistent with waning of BCG protective efficacy with time since vaccination. Chemoprophylaxis and vaccination are expected to protect the individual but not to have a significant short-term impact on transmission.     

Evidence-based policy-making: The implications of globally-applicable research for context-specific problem-solving in developing countries

In the past 15 or so years, the “evidence-based medicine” (EBM) framework has become increasingly institutionalized, facilitating its transfer across the globe. In the late 1990s, the basic principles of EBM began to have a marked influence in a number of non-clinical public policy arenas. Policy-makers working in these areas are now being urged to move away from developing policies according to political ideologies to a more legitimate approach based on “scientific fact,” a process termed “evidence-based policy-making” (EBPM). The conceptual diffusion of EBM to non-clinical arenas has exposed epistemologically destabilizing views regarding the definition of “science,” particularly as it relates to the demands of global versus national/sub-national policy-making. Using the maternal and neonatal subfield as an ethnographic case-study, this paper explores the effects of these divergences on EBPM in 5 developing countries (Bangladesh, Burkina Faso, Ghana, Malawi and Nepal). In doing so, our analysis aims to explain why EBPM has thus far had a limited impact in the area of context-specific programmatic policy-development and implementation at the national and sub-national levels. Results highlight that the political contexts in which EBPM is played out promote uniformity of methodological and policy approaches, despite the fact that disciplinary diversity is being called for repeatedly in the public health literature. Even in situations where national EBPM diverges from international priorities, national evidence-based policies are found to hold little weight in countering global policy interests, which some informants claim are themselves legitimated, rather than informed, by evidence. Informants also highlight the way interpretations of research findings are shaped by the broader political context within which donors set priorities and distribute limited resources – contexts that are driven by the need to provide generalisable research recommendations based on scientifically replicable methods. Added to this are clear rifts between senior and junior-level experts within countries that constrain national and sub-national research agendas from serving as tools for empowered knowledge production and problem-solving. We conclude by arguing for diverse forms of research that can more effectively address context-specific problems. While such diversity may render EBPM more conflict-ridden, debate is by no means an undesirable characteristic in any evolving system of knowledge, for it has the potential to foster critical insight and localized change.     

Diagnosis of measles by clinical case definition in dengue-endemic areas: implications for measles surveillance and control.

In many countries, measles surveillance relies heavily on the use of a standard clinical case definition; however, the clinical signs and symptoms of measles are similar to those of dengue. For example, during 1985, in Puerto Rico, 22 (23%) of 94 cases of illnesses with rashes that met the measles clinical case definition were serologically confirmed as measles, but 32 (34%) others were serologically confirmed as dengue. Retrospective analysis at the San Juan Laboratories of the Centers for Disease Control showed also that at least 28% of all laboratory-confirmed cases of dengue in Puerto Rico in 1985 met the measles clinical case definition. If the true measles vaccine efficacy (VE) is assumed to be 90%, the occurrence of laboratory-confirmed dengue cases that meet the measles clinical case definition results in a reduction of the apparent measles VE to only 64% (a 29% relative reduction from the true VE). The results of the study demonstrate the importance of a laboratory-based surveillance system in measles control or elimination efforts in dengue-endemic areas.     

Challenges for improving surveillance for pesticide poisoning: policy implications for developing countries.

BACKGROUND: Surveillance is a critical public health tool for the control of pesticide poisoning. However, surveillance activities in developing countries are bedevilled by multiple problems, and inferences made from review of flawed data may lead to mistaken policy decisions. METHODS: Results of intensified surveillance from an intervention project in the Western Cape Province of South Africa were compared to the pattern of poisonings reported in routine notifications to the health authorities for a control farming district and in the study district over a 5-year period preceding the study. Intensified surveillance data results were also contrasted with policy approaches based on routine notifications and on Regional Poison Centre reports. RESULTS: Poisoning rates reported in the study area increased almost 10-fold during the intervention period. Compared to intensified surveillance, hospital and health authority sources greatly underestimate the proportion of cases due to occupational poisoning, and overestimate suicide as a proportional cause. In addition, the risks for women appear underestimated from routine notifications. Assumptions that a lack of awareness is responsible for most poisonings are not borne out by the empirical data when reporting is intensified. CONCLUSIONS: Current policy assumptions are faulty, may result in inappropriate blame being attributed to victims and, by relying on information as the main element of education, may shift responsibility onto the individual. Improvements in the surveillance system should aim to restructure the types of data collected, and facilitate intra-governmental and inter-sector collaboration. The culture of monitoring based on report writing must change to one of surveillance that leads to intervention.     

Strategies for risk assessment and control in welding: challenges for developing countries

Metal arc welding ranges from primitive (manual) to increasingly complex automated welding processes. Welding occupies 1% of the labour force in some industrialised countries and increasing knowledge of health risks, necessitating improved assessment strategies and controls have been identified by the International Institute of Welding (IIW), ILO, WHO and other authoritative bodies. Challenges for developing countries need to be addressed. For small scale production and repair work, predominantly by manual metal arc on mild steel, the focus in developing economies has correctly been on control of obvious physical and acute health affects. Development introduces more sophisticated processes and hazards. Work pieces of stainless steel and consumables with chromium, nickel and manganese constituents are used with increasingly complex semi-manual or automated systems involving variety of fluxes or gasses. Uncritical adoption of new welding technologies by developing countries potentiates future health problems. Control should be integral at the design stage, otherwise substantive detriments and later costs can ensue. Developing countries need particular guidance on selection of the optimised welding consumables and processes to minimise such detriments. The role of the IIW and the MFRU are described. Applications of occupational hygiene principals of prevention and control of welding fume at source by process modification are presented.