Stillbirths and early neonatal mortality in rural Northern Ghana

Objective To calculate perinatal mortality (stillbirth and early neonatal death: END) rates in the Upper East region of Ghana and characterize community‐based stillbirths and END in terms of timing, cause of death, and maternal and infant risk factors. Methods Birth outcomes were obtained from the Navrongo Health and Demographic Surveillance System over a 7‐year period. Results Twenty thousand four hundred and ninty seven pregnant women were registered in the study. The perinatal mortality rate was 39 deaths/1000 deliveries, stillbirth rate 23/1000 deliveries and END rates 16/1000 live births. Most stillbirths were 31 weeks gestation or less. Prematurity, first‐time delivery and multiple gestation all significantly increased the odds of perinatal death. Approximately 70% of END occurred during the first 3 postnatal days, and the most common causes of death were birth asphyxia and injury, infections and prematurity. Conclusion Stillbirths and END remain a significant problem in Navrongo. The main causes of END occur during the first 3 days and may be modifiable with simple targeted perinatal policies.     

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.     

Attachement désorganisé et sémiologie autistique

This paper firstly presents a literature review of the relationships between autistic symptomatology and disorganized attachment. Both have close semiological features but are distinct dimensions, arising within different context and may therefore be associated and be mistaken one for another. Recognition of their difference has important implications for both prognosis and treatment as for working alliance with parents. The discussion is highlighted by the case of Harry, who presented with a picture of autistic-like symptomatology but linked in fact with a disorganized attachment. His favourable evolution and the precisely acknowledged changes with this child during a four years treatment in a day care facility give weight to this hypothesis. An important therapeutic work can be done when early relation troubles exist between a mother and her child. The maternal perinatal depression screening and the child attachment troubles’ prevention are necessary, as it is often the case with migrant and impoverished population as recent meta-analyses show the impact of accumulated psychosocial risk factors on the increase of attachment disorganization.     

Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an under‐resourced setting in Tanzania

Objective To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania, where audit results have been disappointing 2 years after its introduction. Methods Qualitative study involving participative observation of audit sessions, followed by 23 in‐depth interviews with health workers and managers. Knowledge and perceptions of audit were assessed and suggestions for improvement of the audit process explored. Results During the observational period, audit sessions were held irregularly and only when the head of department of obstetrics and gynaecology was available. Cases with evident substandard care factors were audited. In‐depth interviews revealed inadequate knowledge of the purpose of audit, despite the fact that participants regarded obstetric audit as a potentially useful tool. Insufficient staff commitment, managerial support and human and material resources were mentioned as reasons for weak involvement of health workers and poor implementation of recommendations resulting from audit. Suggestions for improvement included enhancing feedback to all staff and managers to attend sessions and assist with the effectuation of audit recommendations. Conclusion Obstetric staff in Ifakara see audit as an important tool for quality improvement. They recognise, however, that in their own situation, insufficient staff commitment and poor managerial support are barriers to successful implementation. They suggested training in concept and principles of audit as well as strengthening feedback of audit outcomes, to achieve structural health care improvements through audit.