Disabled women's attendance at community women's groups in rural Nepal.

There is strong evidence that participatory approaches to health and participatory women's groups hold great potential to improve the health of women and children in resource poor settings. It is important to consider if interventions are reaching the most marginalized, and therefore we examined disabled women's participation in women's groups and other community groups in rural Nepal. People with disabilities constitute 15% of the world's population and face high levels of poverty, stigma, social marginalization and unequal access to health resources, and therefore their access to women's groups is particularly important. We used a mixed methods approach to describe attendance in groups among disabled and non-disabled women, considering different types and severities of disability. We found no significant differences in the percentage of women that had ever attended at least one of our women's groups, between non-disabled and disabled women. This was true for women with all severities and types of disability, except physically disabled women who were slightly less likely to have attended. Barriers such as poverty, lack of family support, lack of self-confidence and attendance in many groups prevented women from attending groups. Our findings are particularly significant because disabled people's participation in broader community groups, not focused on disability, has been little studied. We conclude that women's groups are an important way to reach disabled women in resource poor communities. We recommend that disabled persons organizations help to increase awareness of disability issues among organizations running community groups to further increase their effectiveness in reaching disabled women.

Non-invasive ventilation with bubble CPAP is feasible and improves respiratory physiology in hospitalised Malawian children with acute respiratory failure.

BACKGROUND: In low-income countries and those with a high prevalence of HIV, respiratory failure is a common cause of death in children. However, the role of non-invasive ventilation with bubble continuous positive airway pressure (bCPAP) in these patients is not well established. METHODS: A prospective observational study of bCPAP was undertaken between July and September 2012 in 77 Malawian children aged 1 week to 14 years with progressive acute respiratory failure despite oxygen and antimicrobial therapy. RESULTS: Forty-one (53%) patients survived following bCPAP treatment, and an HIV-uninfected single-organ disease subgroup demonstrated bCPAP success in 14 of 17 (82%). Compared with children aged ≧60 months, infants of 0-2 months had a 93% lower odds of bCPAP failure (odds ratio 0·07, 95% confidence interval 0·004-1·02, P  =  0·05). Following commencement of bCPAP, respiratory physiology improved, the average respiratory rate decreased from 61 to 49 breaths/minute (P  =  0·0006), and mean oxygen saturation increased from 92·1% to 96·1% (P  =  0·02). CONCLUSIONS: bCPAP was well accepted by caregivers and patients and can be feasibly implemented into a tertiary African hospital with high-risk patients and limited resources.

Knowledge and perceptions of quality of obstetric and newborn care of local health providers: a cross-sectional study in three districts in Malawi.

AIM: Quality of service delivery for maternal and newborn health in Malawi is influenced by human resource shortages and knowledge and care practices of the existing service providers. We assessed Malawian healthcare providers' knowledge of management of routine labour, emergency obstetric care and emergency newborn care; correlated knowledge with reported confidence and previous study or training; and measured perception of the care they provided. METHODS: This study formed part of a large-scale quality of care assessment in three districts (Kasungu, Lilongwe and Salima) of Malawi. Subjects were selected purposively by their role as providers of obstetric and newborn care during routine visits to health facilities by a research assistant. Research assistants introduced and supervised the self-completed questionnaire by the service providers. Respondents included 42 nurse midwives, 1 clinical officer, 4 medical assistants and 5 other staff. Of these, 37 were staff working in facilities providing Basic Emergency Obstetric Care (BEMoC) and 15 were from staff working in facilities providing Comprehensive Emergency Obstetric Care (CEMoC). RESULTS: Knowledge regarding management of routine labour was good (80% correct responses), but knowledge of correct monitoring during routine labour (35% correct) was not in keeping with internationally recognized good practice. Questions regarding emergency obstetric care were answered correctly by 70% of respondents with significant variation depending on clinicians' place of work. Knowledge of emergency newborn care was poor across all groups surveyed with 58% correct responses and high rates of potentially life-threatening responses from BEmOC facilities. Reported confidence and training had little impact on levels of knowledge. Staff in general reported perception of poor quality of care. CONCLUSION: Serious deficiencies in providers' knowledge regarding monitoring during routine labour and management of emergency newborn care were documented. These may contribute to maternal and neonatal deaths in Malawi. The knowledge gap cannot be overcome by simply providing more training.

Prenatal screening and treatment strategies to prevent group B streptococcal and other bacterial infections in early infancy: cost-effectiveness and expected value of information analyses.

OBJECTIVES: To determine the cost-effectiveness of prenatal strategies for preventing group B streptococci (GBS) and other serious bacterial infections in early infancy and to establish the expected value of further information. DATA SOURCES: Electronic databases were searched up to March 2006. Expert opinion was also sought. REVIEW METHODS: Twelve mutually exclusive maternal risk groups were defined at presentation in labour and the consequences considered of early-onset GBS and non-GBS bacterial infections and late onset GBS infection, measured in terms of lifetime NHS costs and quality-adjusted life-years (QALYs). These were for preterm delivery (<37 weeks): (1) planned Caesarean section, (2) previous baby with GBS disease, (3) positive urine or vaginal swab for GBS in current pregnancy, (4) fever >or=38 degrees C during labour, (5) membrane rupture >or=2 hours before labour onset, (6) membrane rupture <2 hours before labour onset. For term delivery (>or=37 weeks): (7) planned Caesarean section, (8) previous baby with GBS disease, (9) positive urine or vaginal swab for GBS in current pregnancy, (10) fever >or=38 degrees C during labour, (11) membrane rupture >or=18 hours, and (12) none of the above risk factors. Fourteen intervention strategies were applied to each maternal risk group. Data inputs were obtained from systematic reviews, primary data and expert opinion. The model parameters were simultaneously estimated from the data inputs using Bayesian evidence synthesis. The expected net benefit was calculated relative to no intervention for each intervention within each risk group for two scenarios, with and without vaccination. Interventions with more than a 1% probability of being cost-effective (i.e. maximising net benefit at a threshold of 25,000 pounds per QALY gained) in a specific risk group were combined to form strategies. To limit antibiotic exposure, women who were low risk at presentation could not be treated without a positive culture or polymerase chain reaction result. RESULTS: Current best practice, comprising intravenous treatment for pyrexia, previous GBS baby and previous GBS swab or urine culture, and oral treatment for preterm pre-labour membrane rupture (groups 2-5 and 8-10) was not cost-effective. All cost-effective options involved treatment of all preterm groups and high-risk term groups (groups 8-10). Testing high-risk women for maternal GBS colonisation would not be cost-effective, as even those with negative results would be better off treated to reduce the risk of early-onset non-GBS infection. In the absence of vaccination, culture-based testing of women in groups 11 and 12, combined with treatment for the rest, would be the most cost-effective strategy. If vaccination was available, vaccination for all and treatment for groups 1-10 would be marginally more cost-effective than treatment for groups 1-10 and culture for groups 11 and 12, but this is uncertain and is based on expert opinion on vaccine efficacy. The expected value of perfect information results suggest that moderate investment in research would be worthwhile. CONCLUSIONS: Based on our findings, immediate extension of current practice to treat all preterm and high-risk term groups would be beneficial. Further research aimed at the realisation of a GBS vaccine should be prioritized.