The evolving contribution of non-communicable diseases to maternal mortality in Jamaica, 1998-2015: a population-based study.

OBJECTIVE: To describe trends in indirect cause-specific pregnancy-related mortality from 1998 to 2015. DESIGN: Secondary analysis of annual, national cross-sectional database of maternal and late maternal deaths, identified through active surveillance of deaths among women aged 10-50 years. SETTING: Jamaica, a middle-income Caribbean country. POPULATION: Maternal and late maternal deaths. METHODS: Descriptive trend analyses of demographic and cause-specific maternal and pregnancy-related mortality ratios undertaken comparing the periods 1998-2003, 2004-2009 and 2010-2015. Multivariate logistic regression was used to confirm changes in risk of indirect death. MAIN OUTCOME MEASURES: Maternal, pregnancy-related, direct, indirect and cause-specific mortality ratios (deaths/100 000 live births). RESULTS: Maternal deaths from indirect conditions increased between the first two periods (P = 0.004) and stabilised in the third (P = 0.085). Associated with upward movement in cardiovascular deaths (P[trend] = 0.003), women under 25 years were at elevated risk (odds ratio 1.44, 95% CI 1.00-2.08; P = 0.052). Haematological/immunological conditions (69% sickle cell disease) ranked second but did not vary with time. Health service utilisation was similar across age, parity, health region and major cause categories (non-communicable diseases, non-obstetric infections, direct), however women with indirect conditions spent more time in hospital (median 5 days versus 3 days) and more often died after the puerperium. CONCLUSIONS: Medical conditions, especially cardiovascular disease, are increasingly associated with maternal and late maternal mortality. Middle-income countries need to simultaneously improve management of indirect conditions, while redoubling efforts to reduce direct deaths. Postpuerperal medical services should be integrated into routine infant health services to improve continuity of care during this high-risk period. TWEETABLE ABSTRACT: Maternal survival (SDG 3.1) in LMICs requires better care for women with both non-communicable diseases and obstetric conditions.

The relationship between stimulus intensity and response amplitude for the photopic negative response of the flash electroretinogram.

The aim of this study was to investigate the relationship between stimulus intensity and response amplitude for the photopic negative response (PhNR) of the flash ERG. Specific aims were (i) to determine whether a generalized Naka-Rushton function provided a good fit to the intensity-response data and (ii) to determine the variability of the parameters of the best-fitting Naka-Rushton models. Electroretinograms were recorded in 18 participants, on two occasions, using both DTL fibre and skin active electrodes, in response to Ganzfeld red stimuli (Lee filter "terry red") ranging in stimulus strength from -1.30 to 0.53 log cd.s.m(-2) (0.28-2.11 log phot td.s) presented over a steady blue background (Schott glass filter BG28; 3.9 log scot td). PhNR amplitude was measured from b-wave peak and from pre-stimulus baseline. The Naka-Rushton function was fitted to all intensity-response data, and parameters, 'n', 'Vmax' and 'K' were obtained. Coefficients of variation (CoV), and inter-ocular and inter-session limits of agreement (LoA) were calculated for both Naka-Rushton parameters. A generalized Naka-Rushton function was found to provide a good fit to the intensity-response data, except at the highest stimulus intensity, where a reduction in amplitude occurred in many individuals. The 'Vmax' parameter was less variable than 'K' for all intensity-response data. Variability was lower for DTL than skin electrodes, and for peak-to-trough PhNR measurements, compared to baseline-to-trough. This study has demonstrated for the first time that the Naka-Rushton model provides a useful means of quantifying the intensity-response relationship of the PhNR.

Strategies to prevent eclampsia in a developing country: I. Reorganization of maternity services.

OBJECTIVE: To determine whether changes in primary and secondary care service delivery could prevent antenatal eclampsia. METHOD: One intervention (St. Catherine) and two control (St. Ann, Manchester) parishes were chosen. The health system in St. Catherine was restructured. Primary antenatal clinics had clear instructions for referring patients to a high-risk antenatal clinic or to hospital. Guidelines were provided to high-risk clinics and the antenatal ward for appropriate treatment of hypertension and preeclampsia when induction of labor should occur. Antenatal eclampsia incidence was monitored before and during the intervention and compared with control parishes (no intervention). Each eclampsia case was investigated to identify inadequacies in the system. RESULTS: The process resulted in better identification of women at risk. Antenatal eclampsia incidence dropped dramatically as care improved. Compared with control areas, by completion of the study, the rate was significantly lower than at the start: OR 0.19 (95% CI: 0.13-0.27; p<0.001 trend). Antenatal admissions for hypertensive disorders declined significantly, and the number of bed days halved. CONCLUSION: Reorganization of maternal care can have major public health benefits and cost savings; however, women need to be alerted to recognise and act upon signs of impending eclampsia.

Strategies to prevent eclampsia in a developing country: II. Use of a maternal pictorial card.

OBJECTIVE: To assess the efficacy and acceptability of a patient-held pictorial card aimed at raising awareness and appropriate health seeking behavior in response to prodromal symptoms of imminent eclampsia. METHOD: Pictorial cards (and posters) were issued to antenatal clinics and used to focus instruction and advice to pregnant women. Mothers were surveyed before and after the cards were introduced to assess maternal likelihood of seeking care if edema was seen, and of attending hospital if so advised. We monitored the eclampsia rate. Health workers were interviewed 6 months after cards and posters were issued to determine the acceptability of using the cards as part of routine antenatal care. RESULTS: The card was seen as widely acceptable by health professionals, and increased their own awareness of the prodromal symptoms of eclampsia and their discussion of these symptoms with antenatal mothers. Mothers' awareness and response to symptoms improved significantly and there was a marked drop in eclampsia incidence. Suggested improvements to the card were made by mothers and health workers. CONCLUSION: The cost of providing a card for every pregnant mother is likely to be offset by health service delivery savings.

Factors determining admission to neonatal units in Jamaica.

In order to identify the factors associated with admission to neonatal care units in a developing country, 1,823 newborns admitted to Jamaica's eight neonatal care units over a 6-month period were compared with 9,563 newborns identified during an island-wide population morbidity study. Maternal sociodemographic characteristics, past obstetric history, infant's growth parameters at birth and mode and place of delivery were investigated. Babies of mothers resident in the two regions of the island where specialist paediatric services were available had increased odds of admission (OR= 1.45, 1.22) compared with those living elsewhere (OR=0.70, 0.80). Maternal history of a previous miscarriage, termination or early neonatal death were associated with subsequent admission, but a previous stillbirth or late neonatal death were not. Very low birthweight infants of gestational age 28-31 weeks were more likely to be admitted than those < 28 weeks with ORs of 1.45 and 0.34 respectively. Factors determining neonatal admission in the developing world may be quite different from those of developed countries. The development of guidelines and support services to ensure wider access to these services for those most in need could contribute to more equitable utilisation of services.

Forty years. An introduction to the development of a Caribbean public health

The development of public health and primary care in Jamaica is examined with particular reference to the historical events which paved the way for their development: notably, the collaborative work undertaken by the Rockefeller Foundation (Commissions on hookworm, tuberculosis, malaria, yaws); recommendations of the Moyne Commission (leading to the establishment of the West Indies School of Public Health); and the Irvine Commission which recommended the establishment of the University College of the West Indies. A confluence of political, social and international activity in the 1970s proved catalytic in the development of the current ethos of primary health care, and the Department of Social and Preventive Medicine was instrumental in the training of the most innovative addition to the primary care health team, the community health aide. Undergraduate and postgraduate training programmes of the Department are highlighted as it celebrates its fortieth anniversary.

Forty years. An introduction to the development of a Caribbean public health.

The development of public health and primary care in Jamaica is examined with particular reference to the historical events which paved the way for their development: notably, the collaborative work undertaken by the Rockefeller Foundation (Commissions on hookworm, tuberculosis, malaria, yaws); recommendations of the Moyne Commission (leading to the establishment of the West Indies School of Public Health); and the Irvine Commission which recommended the establishment of the University College of the West Indies. A confluence of political, social and international activity in the 1970s proved catalytic in the development of the current ethos of primary health care, and the Department of Social and Preventive Medicine was instrumental in the training of the most innovative addition to the primary care health team, the community health aide. Undergraduate and postgraduate training programmes of the Department are highlighted as it celebrates its fortieth anniversary.

Registration of births, stillbirths and infant deaths in Jamaica.

BACKGROUND: Vital statistics underestimate the prevalence of perinatal and infant deaths. This is particularly significant when these parameters affect eligibility for international assistance for newly emerging nations. OBJECTIVE: To determine the level of registration of livebirths, stillbirths and infant deaths in Jamaica. METHODOLOGY: Births, stillbirths and neonatal deaths identified during a cross-sectional study (1986); and infant deaths identified in six parishes (1993) were matched to vital registration documents filed with the Registrar General. RESULTS: While 94% of livebirths were registered by one year of age (1986), only 13% of stillbirths (1986) and 25% of infant deaths (1993) were registered. Post neonatal deaths were more likely to be registered than early neonatal deaths. Frequently the birth was not registered when the infant died. Birth registration rates were highest in parishes with high rates of hospital deliveries (rs = 0.97, P < 0.001) where institutions notify the registrar of each birth. Hospital deaths, however, were less likely to be registered than community deaths as registrars are not automatically notified of these deaths. CONCLUSIONS: To improve vital registration, institutions should become registration centres for all vital events occurring there (births, stillbirths, deaths). Recommendations aimed at modernizing the vital registration system in Jamaica and other developing countries are also made.

PIP: Vital statistics indicate only part of the actual prevalence of perinatal and infant mortality. Findings are reported from a study conducted to determine the level of registration of live births, stillbirths, and infant deaths in Jamaica. Births, stillbirths, and neonatal deaths identified during a 1986 cross-sectional study and infant deaths identified in six parishes during 1993 were matched to vital registration documents filed with the Registrar General. While 94% of live births were registered by one year of age, only 13% of stillbirths and 25% of infant deaths were so registered. Post neonatal deaths were more likely to be registered than early neonatal deaths. Frequently the birth was not registered when the infant died. Birth registration rates were highest in parishes with high rates of hospital deliveries where institutions notify the registrar of each birth. Hospital deaths, however, were less likely to be registered than community deaths since registrars are not automatically noticed of such deaths. Institutions should register all vital events occurring there.

Changes in material resource levels in Jamaica's primary health care services between 1984 and 1991/1992.

Jamaica's primary health-care services have been in a process of development since the 1970s. In 1984, a large management study collected data on levels of material resources (basic facilities, utilities, furniture, equipment and supplies items). Since 1984, serious staff shortages have affected the services, and there have been economic constraints, as well as a major hurricane. In order to measure changes over subsequent years, data on material resources were again collected in 1991/1992, using the same sample of 65 types 2 and 3 health centres as in 1984. Data were collected by interview with health centre staff. Results, whilst showing various changes item-by-item, showed constancy or minor improvements overall in levels of resources. Type 2 health centres continued to have lower resource levels than type 3s, even though the methodology allowed for their different needs where appropriate. Staff members' opinions of condition and adequacy of resources had become more positive than before. It was concluded that, in terms of material resources, activities within the primary health-care sector have offset the adverse effects of the macro-environmental conditions affecting the health centres. This method of material resource monitoring has implications for quality assessment of health facilities in primary health-care.

PIP: This follow-up study aimed to compare levels of material resources (facilities, utilities, furniture, equipment and supplies) in type 2 and 3 health centers (HCs) in 1984 with those in 1991/1992, indicating changes which had occurred in the 7-8 year interval between the surveys. In 1984 a sample of type 3 and 2 HCs was selected randomly from the combined parish of Kingston/St. Andrew and four from other urban areas. The sample of HCs actually used was 34 type 3 HCs and 31 type 2 HCs, making 65 in all. In 1991/1992, 34 type 3 HCs and 30 type 2 HCs were used. When comparing the status of items in 1991/1992 with that in 1984 there had been a slight improvement with the general level in type 3 HCs being higher than in type 2 HCs. The items general stores and records offices had shown the highest increases whilst proper security arrangements had become less prevalent. Lunch rooms and laboratory areas were the items least often present. Items in good condition had increased from 49% and 46% in type 2 and 3 HCs to 51% and 67%, respectively. Among the HCs with electricity, water supplies, and telephones in type 2 and 3 HCs their good condition changed from 60% and 58%, respectively, in 1984 to 70% and 77% at the later time. Type 3 HCs were slightly more fully furnished than type 2 HCs were. Results relating to equipment most likely to need maintenance support showed a general decline in levels of equipment in type 2 HCs, and in the later period the type 3 HCs were better equipped. 80% and 79% of the pieces of equipment were fully functional in 1984, compared with 89% and 87% in 1991/1992, in type 2 and 3 HCs, respectively. The equipment was adequate in 52% and 56% of type 2 and 3 HCs, respectively, in 1984, compared with 42% and 56% in 1991/1992. The percentages of HCs with selected supplies improved, being 71% for type 2 and 79% for type 3.

Maternal mortality in Jamaica: health care provision and causes of death.

Details of 62 maternal deaths occurring in 1986/1987 were compared with a control population. The incidence was 11.5 per 10,000 livebirths. The major cause of maternal mortality was hypertension followed by hemorrhage and infection. There were trends with advanced maternal age and high parity. The risk of maternal death varied with hospital facilities available, being lowest in areas with access to a specialist hospital and highest in areas where there were no obstetricians available.

Neonatal mortality determinants in Jamaica.

The Jamaican Perinatal Survey included among its objectives the quantification of the island's neonatal mortality rate, the identification of the causes of these deaths (Wigglesworth Classification), and the determination of characteristics of both mother and infant that are associated with increased mortality. A death questionnaire was completed on babies who were born between September 1986 and August 1987, and who died in the neonatal period throughout the island of Jamaica. The neonatal mortality rate was 17.9 per 1000 live births with early and late rates of 16.0 and 1.9 per 1000, respectively. The major contributors to neonatal demise were prematurity and intrapartum asphyxia (74 per cent). Twins had a seven-fold greater risk of dying than singletons. Babies born to mothers under 15 years had a four-fold greater risk of dying than those of mothers 25-29 years. The neonatal mortality rate for Jamaica is high, with room for improvement, particularly in the prevention of perinatal asphyxia.

Deletion mutation as a means of isolating avirulence genes in flax rust.

The interaction between flax rust,Melampsora lini, and its host, flax,Linum usitatissimum, has been extensively studied, and certain genetic features make the system an appropriate choice to utilize in isolating genes conferring avirulence in rust. A mutant that was selected for virulence on Lx plants was isolated, after treatment with gamma rays, from a strain that is genotypicallyA-L5,A-L6,A-L7,A-Lx/A-L5,A-L6,a-L7,a-Lx. These four specificities are tightly linked. Breeding tests showed that this mutant was genotypicallyA-L5,A-L6,a-L7,a-Lx/a-L5,a-L6,a-L7,a-Lx and, when made homozygous for the mutant chromosome, was virulent onL5,L6,L7, andLx. This result excludes somatic recombination as a source of the mutation and indicates deletion as a likely cause. A 250 bp genomic sequence from a strain of rust homozygous for these four linked avirulence genes (A-L5,A-L6,A-L7,A-Lx) was isolated, using a method that allows the differential cloning of the specific DNA sequences located within a deletion in the mutant genome. This clone hybridized to two EcoRI bands in genomic DNA from the strain homozygous for the four linked avirulence genes and from the strain homozygousA-L5 andA-L6 and heterozygousA-L7 andA-Lx, but showed no homology to DNA from the strain carrying the putative chromosomal deletion. The correlation between the genetically characterized deletion mutation and the isolation of a sequence from within a region of chromosome missing from this strain of rust suggests that this 250 bp tract may be part of, or closely linked to, the defined set of avirulence genes.

Patient-flow and waiting times in general medical and dental clinics in Jamaica's primary health care services.

Jamaica has implemented primary health care services closely in accordance with the philosophy of the Declaration of Alma Ata. However, resources are scarce and need to be well managed. Ideal patient-flow in health centres (HCs) would achieve both high efficiency in use of staff time and minimum waiting times for patients. This study of 465 patients in 44 general medical clinics served by 34 doctors and 25 nurse practitioners, and 167 patients served by dentists in each of 15 clinics, showed that mean contact time of patients with doctors was 7 minutes, with nurse practitioners 11 minutes, and dentists 4 minutes. Medical patients waited an average of 3 hours 53 minutes, whilst dental patients waited an average of 2 hours 23 minutes. Doctors', nurse practitioners' and dentists' median times for starting to see patients were 10.00 a.m., 9.35 a.m. and 9.48 a.m. respectively. They were able to work without experiencing any delays in patient-flow since many patients were waiting at the HC by 8 a.m., and preliminary processing was short. It is suggested that if they started seeing patients earlier, patients' waiting times would be shorter. The shortage of pharmacists to dispense drugs after medical consultations added to patients' waiting time. The results were a natural outcome of the low supply of personnel and high demand for services situation being experienced in the medical and dental services.

Patient-flow and waiting times in General Medical and Dental Clinics in Jamaica's primary health care services

Jamaica has implemented primary health care services closely in accordance with the philosophy of the Declaration of Alma Ata. However, resources are scarce and need to be well managed. Ideal patient-flow in health centres (HCs) would achieve both high efficiency in use of staff time and minimum waiting times for patients. this study of 465 patients in 44 general medical clinics served by 34 doctors and 25 nurse practitioners, and 167 patients served by dentists in each of 15 clinics, showed that mean contact time of patients with doctors was 7 minutes, with nurse practitioners 11 minutes, and dentists 4 minutes. Medical patients waited an average of 3 hours 53 minutes, whilst dental patients waited an average of 2 hours 23 minutes. Doctor's, nurse practitioners' and dentists' median times for starting to see patients were 10.00 a.m., 9.35 and 9.48 a.m. respectively. They were able to work without experiencing any delays in patient-flow since many patients were waiting at the HC by 8 a.m., and preliminary processing was short. It is suggested that if they started seeing patients earlier, patients' waiting times would be shorter. The shortage of pharmacists to dispense drugs after medical consultations added to patients' waiting time. The results were a natural outcome of the low supply of personnel and high demand for services situation being experienced in the medical and dental services