Estimation of maternal and child mortality one year after user-fee elimination: an impact evaluation and modelling study in Burkina Faso

Objective

To estimate the impact on maternal and child mortality after eliminating user fees for pregnant women and for children less than five years of age in Burkina Faso.

Methods

Two health districts in the Sahel region eliminated user fees for facility deliveries and curative consultations for children in September 2008. To compare health-care coverage before and after this change, we used interrupted time series, propensity scores and three independent data sources. Coverage changes were assessed for four variables: women giving birth at a health facility, and children aged 1 to 59 months receiving oral rehydration salts for diarrhoea, antibiotics for pneumonia and artemesinin for malaria. We modelled the mortality impact of coverage changes in the Lives Saved Tool using several scenarios.

Findings

Coverage increased for all variables, however, the increase was not statistically significant for antibiotics for pneumonia. For estimated mortality impact, the intervention saved approximately 593 (estimate range 168–1060) children’s lives in both districts during the first year. This lowered the estimated under-five mortality rate from 235 deaths per 1000 live births in 2008 to 210 (estimate range 189–228) in 2009. If a similar intervention were to be introduced nationwide, 14 000 to 19 000 (estimate range 4000–28 000) children''s lives could be saved annually. Maternal mortality showed a modest decrease in all scenarios.

Conclusion

In this setting, eliminating user fees increased use of health services and may have contributed to reduced child mortality.     

Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat,India: a difference-in-differences analysis

Objective

To evaluate the effect of the Chiranjeevi Yojana programme, a public–private partnership to improve maternal and neonatal health in Gujarat, India.

Methods

A household survey (n = 5597 households) was conducted in Gujarat to collect retrospective data on births within the preceding 5 years. In an observational study using a difference-in-differences design, the relationship between the Chiranjeevi Yojana programme and the probability of delivery in health-care institutions, the probability of obstetric complications and mean household expenditure for deliveries was subsequently examined. In multivariate regressions, individual and household characteristics as well as district and year fixed effects were controlled for. Data from the most recent District Level Household and Facility Survey (DLHS-3) wave conducted in Gujarat (n = 6484 households) were used in parallel analyses.

Findings

Between 2005 and 2010, the Chiranjeevi Yojana programme was not associated with a statistically significant change in the probability of institutional delivery (2.42 percentage points; 95% confidence interval, CI: −5.90 to 10.74) or of birth-related complications (6.16 percentage points; 95% CI: −2.63 to 14.95). Estimates using DLHS-3 data were similar. Analyses of household expenditures indicated that mean household expenditure for private-sector deliveries had either not fallen or had fallen very little under the Chiranjeevi Yojana programme.

Conclusion

The Chiranjeevi Yojana programme appears to have had no significant impact on institutional delivery rates or maternal health outcomes. The absence of estimated reductions in household spending for private-sector deliveries deserves further study.     

Providing skilled birth attendants and emergency obstetric care to the poor through partnership with private sector obstetricians in Gujarat, India

Problem

India has the world’s largest number of maternal deaths estimated at 117 000 per year. Past efforts to provide skilled birth attendants and emergency obstetric care in rural areas have not succeeded because obstetricians are not willing to be posted in government hospitals at subdistrict level.

Approach

We have documented an innovative public–private partnership scheme between the Government of Gujarat, in India, and private obstetricians practising in rural areas to provide delivery care to poor women.

Local setting

In April 2007, the majority of poor women delivered their babies at home without skilled care.

Relevant changes

More than 800 obstetricians joined the scheme and more than 176 000 poor women delivered in private facilities. We estimate that the coverage of deliveries among poor women under the scheme increased from 27% to 53% between April and October 2007. The programme is considered very successful and shows that these types of social health insurance programmes can be managed by the state health department without help from any insurance company or international donor.

Lessons learned

At least in some areas of India, it is possible to develop large-scale partnerships with the private sector to provide skilled birth attendants and emergency obstetric care to poor women at a relatively small cost. Poor women will take up the benefit of skilled delivery care rapidly, if they do not have to pay for it.     

The impact of rural health system reform on hospitalization rates in the Islamic Republic of Iran: an interrupted time series

Objective

To assess the effects on hospital utilization rates of a major health system reform – a family physician programme and a social protection scheme – undertaken in rural areas of the Islamic Republic of Iran in 2005.

Methods

A “tracer” province that was not a patient referral hub was selected for the collection of monthly hospitalization data over a period of about 10 years, beginning two years before the rural health system reform (the “intervention”) began. An interrupted time series analysis was conducted and segmented regression analysis was used to assess the immediate and gradual effects of the intervention on hospitalization rates in an intervention group composed of rural residents and a comparison group composed of urban residents primarily.

Findings

Before the intervention, the hospitalization rate in the rural population was significantly lower than in the comparison group. Although there was no significant increase or decline in hospitalization rates in the intervention or comparison group before the intervention, after the intervention a significant increase in the hospitalization rate – of 4.6 hospitalizations per 100 000 insured persons per month on average – was noted in the intervention group (P < 0.001). The monthly increase in the hospitalization rate continued for over a year and stabilized thereafter. No increase in the hospitalization rate was observed in the comparison group.

Conclusion

The primary health-care programme instituted as part of the health system reform process has increased access to hospital care in a population that formerly underutilized hospital services. It has not reduced hospitalizations or hospitalization-related expenditure.     

Birth Weight among Singletons Born to Foreign-Born Mothers in Taiwan: A Population-Based Birth Register Study

Background

We compared the birth weight of newborns born to foreign-born mothers (FBMs) and Taiwan-born mothers (TBMs), using data from the 2005–2006 Taiwan Birth Registry of singleton live births.

Methods

The Wilcox–Russell method, data restriction, and multiple linear regression were used to analyze the data. The rates of low birth weight (<2500 g) with 95% confidence intervals were computed for TBMs, and for each of the nationalities of FBMs.

Results

The mean birth weight of newborns of FBMs was 3157 g, which was higher than that of newborns of TBMs (3109 g). On analysis using the Wilcox–Russell method, both the rate and residual proportion of low-birth-weight (LBW) births were lower among newborns of FBMs (4.1% and 1.1%, respectively) than among newborns of TBMs (5.9% and 1.7%, respectively). After adjusting for sex, mode of delivery, maternal age, smoking status, predisposing maternal risk factors, and condition during pregnancy, the newborns of FBMs weighed 72.9 g (95% CI, 68.8 g to 77.0 g) more than the newborns of TBMs. When data were restricted to mothers without any adverse conditions and adjusted for maternal age, the differences in birth weight between the 2 groups remained unchanged. The rates of LBW deliveries among FBMs in Taiwan were significantly lower than those in their respective countries of origin.

Conclusions

In Taiwan, newborns of FBMs had a higher birth weight than those of TBMs, even after accounting for potential confounding factors, and had lower rates of LBW deliveries than did mothers in their respective countries of origin.Key words: birth weight, transnational marriage, foreign-born mothers     

Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia

Objective

To evaluate the effect of vouchers for maternity care in public health-care facilities on the utilization of maternal health-care services in Cambodia.

Methods

The study involved data from the 2010 Cambodian Demographic and Health Survey, which covered births between 2005 and 2010. The effect of voucher schemes, first implemented in 2007, on the utilization of maternal health-care services was quantified using a difference-in-differences method that compared changes in utilization in districts with voucher schemes with changes in districts without them.

Findings

Overall, voucher schemes were associated with an increase of 10.1 percentage points (pp) in the probability of delivery in a public health-care facility; among women from the poorest 40% of households, the increase was 15.6 pp. Vouchers were responsible for about one fifth of the increase observed in institutional deliveries in districts with schemes. Universal voucher schemes had a larger effect on the probability of delivery in a public facility than schemes targeting the poorest women. Both types of schemes increased the probability of receiving postnatal care, but the increase was significant only for non-poor women. Universal, but not targeted, voucher schemes significantly increased the probability of receiving antenatal care.

Conclusion

Voucher schemes increased deliveries in health centres and, to a lesser extent, improved antenatal and postnatal care. However, schemes that targeted poorer women did not appear to be efficient since these women were more likely than less poor women to be encouraged to give birth in a public health-care facility, even with universal voucher schemes.     

Macrosomic Births in a Tertiary Public Hospital: A Survey of Maternal Characteristics and Fetal Outcome

Background

Macrosomic fetuses are high risk with their delivery process being associated with potential risk to both mother and baby The aim of this study is to determine the incidence of macrosomic births and the associated maternal characteristics and to ascertain the fetal outcome.

Methods

It was a retrospective survey of maternal characteristics and pregnancy outcome of macrosomic births. Comparison was made with the next selected normal birth weight delivery during the study period.

Results

There were 8607 deliveries during the period (3 years) reviewed. Of this, 306 were macrosomic deliveries, a frequency of 3.6%. The mean weight for macrosomic babies was 4.23kg (range 4.01 – 5.62kg). There was a higher mean maternal weight and gestational age of mothers with macrosomic deliveries compared to mothers in the control group, (85.87 ± 19.39kg vs 74.92 ± 19.11kg P<0.01; and 41.51±1.46 vs 39.02±1.29, P<0.001). Caesarean delivery was significantly associated with macrosomic births compared to controls, p<0.0001, odds ratio 3.977. Also, asphyxia and shoulder dystocia occurred more in macrosomic babies, 10.4% vs 2.9% and 2.28% vs 0.65%, P<0.001. The majority of the asphyxiated babies amongst macroomic births were following vagina delivery compared to caesarean delivery, (65.6% vs 34.4%) p= 0.001. There were 3 cases of still birth in the macrosomic deliveries, but no maternal deaths were encountered.

Conclusion

Macrosomic births could be tragic. Although delivery outcome seems better with a caesarean section, good fetal outcome can only be assured on the premise of astute labour and delivery management.     

A prospective study of maternal,fetal and neonatal deaths in low- and middle-income countries

Objective

To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.

Methods

A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum.

Findings

Between 2010 and 2012, 214 070 of 220 235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100 000 live births, ranging from 69 per 100 000 in Argentina to 316 per 100 000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97–11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26–5.67) and 7-day (RR: 3.94; 95% CI: 2.74–5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54–9.77).

Conclusion

Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.     

Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa

Objective

To examine temporal trends in caesarean delivery rates in southern Asia and sub-Saharan Africa, by country and wealth quintile.

Methods

Cross-sectional data were extracted from the results of 80 Demographic and Health Surveys conducted in 26 countries in southern Asia or sub-Saharan Africa. Caesarean delivery rates were evaluated – as percentages of the deliveries that ended in live births – for each wealth quintile in each survey. The annual rates recorded for each country were then compared to see if they had increased over time.

Findings

Caesarean delivery rates had risen over time in all but 6 study countries but were consistently found to be lower than 5% in 18 of the countries and 10% or less in the other eight countries. Among the poorest 20% of the population, caesarean sections accounted for less than 1% and less than 2% of deliveries in 12 and 21 of the study countries, respectively. In each of 11 countries, the caesarean delivery rate in the poorest 40% of the population remained under 1%. In Chad, Ethiopia, Guinea, Madagascar, Mali, Mozambique, Niger and Nigeria, the rate remained under 1% in the poorest 80%. Compared with the 22 African study countries, the four study countries in southern Asia experienced a much greater rise in their caesarean delivery rates over time. However, the rates recorded among the poorest quintile in each of these countries consistently fell below 2%.

Conclusion

Caesarean delivery rates among large sections of the population in sub-Saharan Africa are very low, probably because of poor access to such surgery.     

Introducing rapid diagnostic tests for malaria to drug shops in Uganda: a cluster-randomized controlled trial

Objective

To evaluate the impact – on diagnosis and treatment of malaria – of introducing rapid diagnostic tests to drug shops in eastern Uganda.

Methods

Overall, 2193 households in 79 study villages with at least one licensed drug shop were enrolled and monitored for 12 months. After 3 months of monitoring, drug shop vendors in 67 villages randomly selected for the intervention were offered training in the use of malaria rapid diagnostic tests and – if trained – offered access to such tests at a subsidized price. The remaining 12 study villages served as controls. A difference-in-differences regression model was used to estimate the impact of the intervention.

Findings

Vendors from 92 drug shops successfully completed training and 50 actively stocked and performed the rapid tests. Over 9 months, trained vendors did an average of 146 tests per shop. Households reported 22 697 episodes of febrile illness. The availability of rapid tests at local drug shops significantly increased the probability of any febrile illness being tested for malaria by 23.15% (P = 0.015) and being treated with an antimalarial drug by 8.84% (P = 0.056). The probability that artemisinin combination therapy was bought increased by a statistically insignificant 5.48% (P = 0.574).

Conclusion

In our study area, testing for malaria was increased by training drug shop vendors in the use of rapid tests and providing them access to such tests at a subsidized price. Additional interventions may be needed to achieve a higher coverage of testing and a higher rate of appropriate responses to test results.     

Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: national cohort study in Denmark

Objective

Based on converging observations in animal, clinical and ecological studies, we hypothesised a possible impact of ritual circumcision on the subsequent risk of autism spectrum disorder (ASD) in young boys.

Design

National, register-based cohort study.

Setting

Denmark.

Participants

A total of 342,877 boys born between 1994 and 2003 and followed in the age span 0–9 years between 1994 and 2013.

Main outcome measures

Information about cohort members’ ritual circumcisions, confounders and ASD outcomes, as well as two supplementary outcomes, hyperkinetic disorder and asthma, was obtained from national registers. Hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status were obtained using Cox proportional hazards regression analyses.

Results

With a total of 4986 ASD cases, our study showed that regardless of cultural background circumcised boys were more likely than intact boys to develop ASD before age 10 years (HR = 1.46; 95% CI: 1.11–1.93). Risk was particularly high for infantile autism before age five years (HR = 2.06; 95% CI: 1.36–3.13). Circumcised boys in non-Muslim families were also more likely to develop hyperkinetic disorder (HR = 1.81; 95% CI: 1.11–2.96). Associations with asthma were consistently inconspicuous (HR = 0.96; 95% CI: 0.84–1.10).

Conclusions

We confirmed our hypothesis that boys who undergo ritual circumcision may run a greater risk of developing ASD. This finding, and the unexpected observation of an increased risk of hyperactivity disorder among circumcised boys in non-Muslim families, need attention, particularly because data limitations most likely rendered our HR estimates conservative. Considering the widespread practice of non-therapeutic circumcision in infancy and childhood around the world, confirmatory studies should be given priority.     

Drinking water and sanitation: progress in 73 countries in relation to socioeconomic indicators

Objective

To assess progress in the provision of drinking water and sanitation in relation to national socioeconomic indicators.

Methods

We used household survey data for 73 countries – collected between 2000 and 2012 – to calculate linear rates of change in population access to improved drinking water (n = 67) and/or sanitation (n = 61). To enable comparison of progress between countries with different initial levels of access, the calculated rates of change were normalized to fall between –1 and 1. In regression analyses, we investigated associations between the normalized rates of change in population access and national socioeconomic indicators: gross national income per capita, government effectiveness, official development assistance, freshwater resources, education, poverty, Gini coefficient, child mortality and the human development index.

Findings

The normalized rates of change indicated that most of the investigated countries were making progress towards achieving universal access to improved drinking water and sanitation. However, only about a third showed a level of progress that was at least half the maximum achievable level. The normalized rates of change did not appear to be correlated with any of the national indicators that we investigated.

Conclusion

In many countries, the progress being made towards universal access to improved drinking water and sanitation is falling well short of the maximum achievable level. Progress does not appear to be correlated with a country’s social and economic characteristics. The between-country variations observed in such progress may be linked to variations in government policies and in the institutional commitment and capacity needed to execute such policies effectively.     

Maternal Low-Level Lead Exposure and Fetal Growth

Background

Limited epidemiologic studies have examined the association between maternal low-level lead exposure [blood lead (PbB) < 10 μg/dL] and fetal growth.

Objective

We examined whether maternal low-level lead exposure is associated with decreased fetal growth.

Methods

We linked New York State Heavy Metals Registry records of women who had PbB measurements with birth certificates to identify 43,288 mother–infant pairs in upstate New York in a retrospective cohort study from 2003 through 2005. We used multiple linear regression with fractional polynomials and logistic regression to relate birth weight, preterm delivery, and small for gestational age to PbB levels, adjusting for potential confounders. We used a closed-test procedure to identify the best fractional polynomials for PbB among 44 combinations.

Results

We found a statistically significant association between PbB (square root transformed) and birth weight. Relative to 0 μg/dL, PbBs of 5 and 10 μg/dL were associated with an average of 61-g and 87-g decrease in birth weight, respectively. The adjusted odds ratio for PbBs between 3.1 and 9.9 μg/dL (highest quartile) was 1.04 [95% confidence interval (CI), 0.89–1.22] for preterm delivery and 1.07 (95% CI, 0.93–1.23) for small for gestational age, relative to PbBs ≤ 1 μg/dL (lowest quartile). No clear dose–response trends were evident when all of the quartiles were assessed.

Conclusions

Low-level PbB was associated with a small risk of decreased birth weight with a supralinear dose–response relationship, but was not related to preterm birth or small for gestational age. The results have important implications regarding maternal PbB.     

Community-based surveillance of maternal deaths in rural Ghana

Objective

To examine the feasibility and effectiveness of community-based maternal mortality surveillance in rural Ghana, where most information on maternal deaths usually comes from retrospective surveys and hospital records.

Methods

In 2013, community-based surveillance volunteers used a modified reproductive age mortality survey (RAMOS 4+2) to interview family members of women of reproductive age (13–49 years) who died in Bosomtwe district in the previous five years. The survey comprised four yes–no questions and two supplementary questions. Verbal autopsies were done if there was a positive answer to at least one yes–no question. A mortality review committee established the cause of death.

Findings

Survey results were available for 357 women of reproductive age who died in the district. A positive response to at least one yes–no question was recorded for respondents reporting on the deaths of 132 women. These women had either a maternal death or died within one year of termination of pregnancy. Review of 108 available verbal autopsies found that 64 women had a maternal or late maternal death and 36 died of causes unrelated to childbearing. The most common causes of death were haemorrhage (15) and abortion (14). The resulting maternal mortality ratio was 357 per 100 000 live births, compared with 128 per 100 000 live births derived from hospital records.

Conclusion

The community-based mortality survey was effective for ascertaining maternal deaths and identified many deaths not included in hospital records. National surveys could provide the information needed to end preventable maternal mortality by 2030.     

Inequities in postnatal care in low- and middle-income countries: a systematic review and meta-analysis

Objective

To assess the socioeconomic, geographical and demographic inequities in the use of postnatal health-care services in low- and middle-income countries.

Methods

We searched Medline, Embase and Cochrane Central databases and grey literature for experimental, quasi-experimental and observational studies that had been conducted in low- and middle-income countries. We summarized the relevant studies qualitatively and performed meta-analyses of the use of postnatal care services according to selected indicators of socioeconomic status and residence in an urban or rural setting.

Findings

A total of 36 studies were included in the narrative synthesis and 10 of them were used for the meta-analyses. Compared with women in the lowest quintile of socioeconomic status, the pooled odds ratios for use of postnatal care by women in the second, third, fourth and fifth quintiles were: 1.14 (95% confidence interval, CI : 0.96–1.34), 1.32 (95% CI: 1.12–1.55), 1.60 (95% CI: 1.30–1.98) and 2.27 (95% CI: 1.75–2.93) respectively. Compared to women living in rural settings, the pooled odds ratio for the use of postnatal care by women living in urban settings was 1.36 (95% CI: 1.01–1.81). A qualitative assessment of the relevant published data also indicated that use of postnatal care services increased with increasing level of education.

Conclusion

In low- and middle-income countries, use of postnatal care services remains highly inequitable and varies markedly with socioeconomic status and between urban and rural residents.     

Severe acute maternal morbidity and associated deaths in conflict and post-conflict settings in Africa

Setting:

 Five hospitals in four conflict and post-conflict countries (Democratic Republic of Congo, Somaliland, Sierra Leone and Burundi).

Objectives:

 To report among hospital deliveries: 1) the proportion of severe acute maternal morbidity (SAMM), 2) the pattern of SAMM, and 3) maternal deaths according to type of SAMM.

Methods:

 An audit of data from a standardised database implemented in all the sites in the study.

Results:

 Of the 18 675 deliveries, there were 6314 (34%) known SAMM cases with 63 associated deaths, implying that for every 100 SAMM cases there was one maternal death. In descending order, the death-to-SAMM ratios per 1000 deliveries were: 1:7 for sepsis, 6 for haemorrhage 1:70 for hypertensive disorder and 1:398 for obstructed labour. A substantial proportion of deaths (38%) that occurred in hospitals could not be categorised into the standardised SAMM conditions available in the database.

Conclusion:

 As this is the first study using multi-centre data from conflict and post-conflict countries, these findings are relevant to improving maternal health in such settings. Findings, implications and possible ways forward in addressing various challenges are discussed.     

The Effect of an Increase in the Rate of Multiple Births on Low-Birth-Weight and Preterm Deliveries during 1975–2008

Background

Despite the rapid increase in the rate of multiple births due to the growth of reproductive medicine, there have been no epidemiologic studies of the secular trends in the impact of multiple births on the rates of low-birth-weight and preterm deliveries in Japan.

Methods

Japanese vital statistics for multiple live births were obtained from the Ministry of Health, Labour and Welfare and reanalyzed. With singletons as the reference group, an analysis was performed of secular trends in relative risk and population attributable risk percent of low-birth-weight (<2500 grams), very-low-birth-weight (<1500 grams), and extremely-low-birth-weight (<1000 grams) deliveries, using 1975–2008 vital statistics, and of preterm deliveries (ie, before 37, 32, and 28 weeks), using 1979–2008 vital statistics.

Results

The rate of multiple births doubled during the past 2 decades, and about 2% of all neonates are now multiples. The population attributable risk percent tended to increase during the same period for all variables, and was approximately 20% in 2008.

Conclusions

The public health impact of the rapid increase in multiple births remains high in Japan.Key words: multiple births, low birth weight, preterm delivery, relative risk, population attributable risk percent     

Public sector services for the prevention of mother-to-child transmission of HIV infection: a micro-costing survey in Namibia and Rwanda

Objective

To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries.

Methods

In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$).

Findings

The estimated costs to the providers of PMTCT, for each mother–infant pair, were US$ 202.75–1029.55 in Namibia and US$ 94.14–342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$ 3.15 million in Namibia and US$ 7.04 million in Rwanda (or < US$ 0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries.

Conclusion

The costs involved in the PMTCT of HIV varied widely between study countries and in accordance with the protocols used. However, since per-capita costs were relatively low, the scaling up of PMTCT services in Namibia and Rwanda should be possible.     

Rapid monitoring in vaccination campaigns during emergencies: the post-earthquake campaign in Haiti

Problem

The earthquake that struck Haiti in January 2010 caused 1.5 million people to be displaced to temporary camps. The Haitian Ministry of Public Health and Population and global immunization partners developed a plan to deliver vaccines to those residing in these camps. A strategy was needed to determine whether the immunization targets set for the campaign were achieved.

Approach

Following the vaccination campaign, staff from the Ministry of Public Health and Population interviewed convenience samples of households – in specific predetermined locations in each of the camps – regarding receipt of the emergency vaccinations. A camp was targeted for “mop-up vaccination” – i.e. repeat mass vaccination – if more than 25% of the children aged 9 months to 7 years in the sample were found not to have received the emergency vaccinations.

Local setting

Rapid monitoring was implemented in camps located in the Port-au-Prince metropolitan area. Camps that housed more than 5000 people were monitored first.

Relevant changes

By the end of March 2010, 72 (23%) of the 310 vaccinated camps had been monitored. Although 32 (44%) of the monitored camps were targeted for mop-up vaccination, only six of them had received such repeat mass vaccination when checked several weeks after monitoring.

Lessons learnt

Rapid monitoring was only marginally beneficial in achieving immunization targets in the temporary camps in Port-au-Prince. More research is needed to evaluate the utility of conventional rapid monitoring, as well as other strategies, during post-disaster vaccination campaigns that involve mobile populations, particularly when there is little capacity to conduct repeat mass vaccination.