Monitoring obstetric services: putting the 'UN Guidelines' into practice in Malawi: 3 years on.

The maternal mortality ratio is difficult to use for monitoring short-term progress in safe motherhood programs. UNICEF/WHO/UNFPA have proposed alternative process indicators monitoring the availability, utilization and quality of obstetric services. There is little experience in the large-scale use of these indicators as part of routine health information systems in developing countries. The Malawi Safe Motherhood Project, which covers a population of over 5 million, was one of the first large projects to implement the new process indicators. At the end of 2000 data were available from the new monitoring system for 3 consecutive years. In 1998, availability of comprehensive emergency obstetric care was adequate but availability of basic emergency obstetric care was very poor. Although institutional delivery rates were over 30%, the met need for obstetric care was only 19.8% and the cesarean section rate was only 1.6%. The mean case fatality rate in District hospitals was nearly 5%. By the end of 2000, improvements in availability, utilization and quality of obstetric care were observed. Participation in developing the monitoring system had also created a strong sense of ownership and interest in analyzing and using the data. Several issues have emerged from routine use of the process indicators. In particular, it has been difficult to be certain that obstetric complications have been recorded correctly. The results confirm that a focus on improving emergency obstetric care in Malawi was justified and that process indicators for obstetric care can be successfully introduced in developing countries. The monitoring system has provided data that are of immediate relevance to service providers, managers, and policy makers and provide many lessons useful for similar programs in other settings.

Monitoring obstetric services: putting the UN guidelines into practice in Malawi. I: developing the system.

The UNICEF/WHO/ UNFPA "Guidelines for Monitoring the Availability and Use of Obstetric Services" was published in 1997 as a guide for implementing process indicators. The Malawi Safe Motherhood Project covers 5 million people and was the first large project to introduce the new indicators as part of a routine monitoring system. A rigorous process of needs assessment, tools development, operations research, field testing and training was conducted. It was necessary to reach agreement on locally appropriate standard definitions of obstetric emergencies, reporting formats and catchment populations. Underreporting of emergencies, misreporting of maternal deaths and double counting of referrals were minimized by improving recording tools. Time, cost, political and technical inputs are important considerations--in Malawi, the system took 1 year to set up at a cost of $100 000. Developing a routine monitoring system to obtain data for the process indicators is feasible, but requires adaptation of the cross-sectional evaluation methods described in the UN Guidelines.

Young people's health in developing countries: a neglected problem and opportunity.

Although the number of young people in developing countries is increasing, their health has not been considered a priority. This is partly because of their lower mortality relative to other age groups, but also because of a lack of appropriate data collection and analysis. However, the burden of disease in young people is not trivial, and most importantly, it is during adolescence that long-term health-related behaviours are formed. Most research investigating health problems in young people has tended to concentrate on a narrow conception of problem areas, such as those relating to reproduction and substance abuse. However, in many developing countries diseases such as schistosomiasis and intestinal parasites may also have a disproportionate impact on young people's health. Young people often have radically different perceptions and priorities in terms of health and disease to those of health planners. Successful programmes will need to incorporate the views of young people themselves. Interventions targeted at young people have enormous potential for primary and secondary prevention of a huge range of health problems and present an opportunity that should not be ignored.

Training traditional birth attendants in clean delivery does not prevent postpartum infection.

OBJECTIVE: To compare the maternal outcome, in terms of postpartum infection, of deliveries conducted by trained traditional birth attendants (TBAs) with those conducted by untrained birth attendants. METHODS: The study took place in a rural area of Bangladesh where a local NGO (BRAC) had previously undertaken TBA training. Demographic surveillance in the study site allowed the systematic identification of pregnant women. Pregnant women were recruited continuously over a period of 18 months. Data on the delivery circumstances were collected shortly after delivery while data on postpartum morbidity were collected prospectively at 2 and 6 weeks. All women with complete records who had delivered at home with a non-formal birth attendant (800) were included in the analysis. The intervention investigated was TBA training in hygienic delivery comprising the 'three cleans' (hand-washing with soap, clean cord care, clean surface). The key outcome measure was maternal postpartum genital tract infection diagnosed by a symptom complex of any two out of three symptoms: foul discharge, fever, lower abdominal pain. RESULTS: Trained TBAs were significantly more likely to practice hygienic delivery than untrained TBAs (45.0 vs. 19.3%, p < 0.0001). However, no significant difference in levels of postpartum infection was found when deliveries by trained TBAs and untrained TBAs were compared. The practice of hygienic delivery itself also had no significant effect on postpartum infection. Logistic regression models confirmed that TBA training and hygienic delivery had no independent effect on postpartum outcome. Other factors, such as pre-existing infection, long labour and insertion of hands into the vagina were found to be highly significant. CONCLUSIONS: Trained TBAs are more likely to practice hygienic delivery than those that are untrained. However, hygienic delivery practices do not prevent postpartum infection in this community. Training TBAs to wash their hands is not an effective strategy to prevent maternal postpartum infection. More rigorous evaluation is needed, not only of TBA training programmes as a whole, but also of the effectiveness of the individual components of the training.

Beliefs and practices regarding delivery and postpartum maternal morbidity in rural Bangladesh.

Most maternal deaths occur in the puerperium and most maternal morbidities probably also arise at that time. Maternal morbidities occur much more frequently than maternal deaths, but very little is known about their magnitude or causes. This study uses focus-group discussions to explore the experiences of childbirth and postpartum illness among rural Bangladeshi women. The women's beliefs about disease causation, and their use of traditional health care, are explored. The significance of the findings for the training of traditional birth attendants and for programs of postpartum care is discussed.

PIP: In August 1991 in rural central Bangladesh, researchers conducted focus group discussions with mothers of all ages and trained and untrained traditional birth attendants (TBAs) to examine the experiences of childbirth, postpartum morbidity, local beliefs, and practices. They intended to use the information to design a prospective study of postpartum morbidity and its relation to delivery practices. Postpartum morbidity was common. Most frequently described postpartum conditions were breast problems, perineal problems, infections, and prolapse. Participants mentioned a wide range of local treatments, but few mentioned antibiotics as a treatment for infections. They believed in supernatural causes of disease. Training did not substantially change the belief systems or practices of TBAs. Harmful traditional practices included internal manipulations and massage, introduction of oils into the vagina, use of fundal pressure or tight abdominal bands during labor, pulling on the umbilical cord, choking or inducing vomiting in the mother to facilitate placental delivery, and not using uterine massage to prevent and treat postpartum hemorrhage. Beneficial practices were adopting an upright position and walking during labor, squatting for delivery, noninterferring with the membranes, having psychological support from attendants, and being in familiar surroundings. The custom of seclusion was a key obstacle to health-care seeking after delivery. Thus, home visits during the first two weeks after delivery are needed. Relatives rather than TBAs performed many deliveries. Food taboos were not as significant as earlier believed. These discussions revealed that the preventive aspect of modern prenatal care has not been incorporated into the women's belief system. They also suggest that the need for health care is not being addressed.

Is preoperative localisation of insulinomas necessary?

During the past 20 years 33 patients suspected of harbouring an insulinoma have been investigated. 29 had laparotomy, and tumours were removed from 27.2 of the 29 and 1 other proved not to have an insulinoma, although preoperative imaging had suggested a tumour. Four different localisation procedures were used, and in some patients more than one technique was applied. Selective arteriography of branches of the coeliac axis showed the position of the insulinoma correctly in 9 out of 18 cases, but in all of these the tumour was felt at operation, so that the information provided was unnecessary. Arteriography gave false localisation in 4 patients and missed the tumour completely in 4 but was also negative in 1 patient not harbouring a tumour. Ultrasonic examination provided correct localisation in only 2 out of 11 instances and computer-assisted tomography in 1 out of 8. Insulin estimation in blood obtained at percutaneous transhepatic portal-venous sampling (THPVS) provided correct localisation in 2 out of 8 cases, but in only 1 of these was it needed to guide pancreatic resection. Localisation was spurious in 5 patients, and in 1 there was no evidence of a tumour at all. In 23 patients the surgeon felt and removed the insulinoma at the first operation. In 3 tumour was palpable at a second laparotomy some years later. In only 1 was no tumour felt at operation. The false-positive findings in the THPVS were caused by misinterpretation of data. For a peak of insulin concentration in the portal vein to be meaningful, it should exceed 200 mU/l and to be fully diagnostic it should be greater than 500 mU/l. Present imaging techniques are not precise enough to localise an insulinoma. An experienced surgeon has a very high probability of being able to palpate the tumour at operation, and preliminary localisation is therefore not needed in most cases.