Quality of antenatal care and obstetrical coverage in rural Burkina Faso.

Improving maternal health is one of the Millennium Development Goals of the United Nations. Despite the efforts to promote maternal and neonatal care to achieve this goal, the use of delivery care remains below expectations in Burkina Faso. This situation raises the question of the quality of care offered in maternity wards. The aim of this study was to identify primary healthcare facility and antenatal care characteristics predictive of an assisted delivery in rural Burkina Faso. A cross-sectional study was carried out in Gnagna province (North-East Burkina Faso) in November 2003. The operational capacities of health facilities were assessed, and a non-participating observation of the antenatal care (ANC) procedure was undertaken to evaluate their quality. Scores were established to summarize the information gathered. The rate of professional childbirth (obstetrical coverage) was derived from the number of childbirths registered in the health facility compared to the size of the population. The established scores were related to the obstetrical coverage using non-parametric tests (Kendall). In total, 17 health facilities were visited, and 81 antenatal consultations were observed. Insufficiencies were observed at all steps of ANC (mean total score for the quality of ANC=10.3 +/- 3.0, ranging from 6 to 16, out of a maximum of 20). Health facilities are poorly equipped, and the availability of qualified staff remained low (mean total score for the provision of care was 22.9 +/- 4.2, ranging from 14 to 33). However, these scores were not significantly related to the rate of professional childbirth (tau Kendall=0.27: p=0.14 and 0.01, p=0.93 respectively). The ability of the primary health centres to provide good antenatal care remains low in rural Burkina Faso. The key factors involved in the limited use of professional childbirth relating to maternal health services may be the quality of ANC.

Association of a summary index of child feeding with diet quality and growth of 6-23 months children in urban Madagascar.

BACKGROUND/OBJECTIVES: The assessment of child feeding practices has received renewed attention through the development of an infant and child feeding index (ICFI). However, the advantages and shortcomings of such a summary index are still not well known. The aim of this study was to assess the usefulness of ICFI as an analytical tool (1) by studying its association with complementary food energy intake and mean micronutrient density adequacy (MMDA) and (2) by testing whether ICFI and its components are associated with length-for-age z-score (LAZ) of 6-23 months children in urban Madagascar. SUBJECTS/METHODS: ICFI was constructed using data from questionnaires on feeding practices and quantitative 24-h recalls (n=1589). Multivariate analysis was used to control for household wealth and other confounding factors. RESULTS: ICFI was positively correlated with complementary food energy intake (P<0.0001) and MMDA (P<0.0001). ICFI was associated with LAZ among 6-8 months children (P=0.02). For all ages combined, there was a tendency towards an association that did not reach statistical significance (P=0.08). Among feeding practices that formed ICFI, breastfeeding was associated with LAZ (P=0.03) but not in the expected direction with +0.16 z-score difference in favour of non-breast-fed children. When breastfeeding was removed and introduced separately into the multivariate model, the relationship between the modified ICFI and LAZ became significant (P=0.02). CONCLUSIONS: Findings suggest that the ICFI could be a useful analytical tool, which needs however to be constructed according to its final use and which should be adapted to each context.

Are dietary diversity scores related to the socio-economic and anthropometric status of women living in an urban area in Burkina Faso?

OBJECTIVES: To study dietary diversity and its relationship with socio-economic and nutritional characteristics of women in an urban Sahelian context. DESIGN: A qualitative dietary recall was performed over a 24-h period. Dietary diversity scores (DDS = number of food groups consumed) were calculated from a list of nine food groups (DDS-9) or from a list of 22 food groups (DDS-22) which detailed both micronutrient- and energy-dense foods more extensively. Body mass index (BMI), mid upper-arm circumference and body fat percentage were used to assess the nutritional status of the women. SETTING AND SUBJECTS: Five hundred and fifty-seven women randomly selected in two districts of Ouagadougou, the capital of Burkina Faso. RESULTS: The mean DDS-9 and DDS-22 were 4.9 +/- 1.0 and 6.5 +/- 1.8 food groups, respectively. In the high tertile of DDS-22, more women consumed fatty and sweetened foods, fresh fish, non-fatty meat and vitamin-A-rich fruits and vegetables. The DDS-9 was not associated with the women's socio-economic characteristics whereas the DDS-22 was higher when the women were younger, richer and had received at least a minimum education. Mean BMI of the women was 24.2 +/- 4.9 kg m-2 and 37% of them were overweight or obese (BMI > or = 25 kg m-2). Neither the DDS-9 nor the DDS-22 was associated with the women's anthropometric status, even though there was a trend towards fewer overweight women in the lowest tertile of DDS-22. CONCLUSION: In this urban area, the qualitative measurement of dietary diversity is not sufficient to identify women at risk of under- or overweight.

Measuring dietary diversity in rural Burkina Faso: comparison of a 1-day and a 3-day dietary recall.

OBJECTIVES: To compare dietary diversity scores measured over a 1-day and a 3-day period, and to assess their relationships with socio-economic characteristics and the nutritional status of rural African women. DESIGN: A qualitative dietary recall allowed calculation of a dietary diversity score (DDS; number of food groups consumed out of a total of nine). Body mass index (BMI) and body fat percentage (BFP) were used to assess the nutritional status of women. SETTING AND SUBJECTS: A representative sample of 550 mothers in north-east Burkina Faso. RESULTS: The DDS increased from 3.5 to 4.4 when calculated from a 1-day or a 3-day recall (P < 0.0001), although for the latter the DDS was affected by memory bias. The DDS calculated from a 1-day recall was higher when a market day occurred during the recall period. Both scores were linked to the sociodemographic and economic characteristics of the women. Women in the lowest DDS tertile calculated from the 1-day recall had a mean BMI of 20.5 kg m-(2) and 17.7% of them were underweight, versus 21.6 kg m (-2) and 3.5% for those in the highest tertile (P = 0.0003 and 0.0007, respectively). The DDS calculated from the 1-day recall was also linked to mean BFP; all these links remained significant after adjustment for confounders. For the 3-day period, no such relationships were found to be significant after adjustment. CONCLUSION: The DDS calculated from a 1-day dietary recall was sufficient to predict the women's nutritional status. In such a context attention should be paid to market days.

Use of variety/diversity scores for diet quality measurement: relation with nutritional status of women in a rural area in Burkina Faso.

OBJECTIVES: To develop scores for food variety and diversity to assess the overall dietary quality in an African rural area; and to study their relationship with the nutritional status of women of childbearing age. DESIGN: Cross-sectional. SETTING: Sahelian rural area in the North-East Burkina Faso (West Africa). SUBJECTS: A total of 691 mothers with children below the age of 5 y, selected at random in 30 villages. METHODS: A qualitative recall of women's food consumption during the previous 24 h made it possible to calculate a food variety score (FVS = count of food items consumed) and a dietary diversity score (DDS = count of food groups, among 14 groups). These scores were then divided into terciles. Body mass index (BMI), mid-upper arm circumference (MUAC) and body fat percentage (BFP) were used to determine the women's nutritional status. RESULTS: The overall dietary quality was poor: mean FVS (s.d.) = 8.3 (2.9) food items; mean DDS = 5.1 (1.7) food groups. A clear relationship was shown between both FVS and DDS (in terciles) and most nutritional indices. Women with a FVS in the lowest tercile had a mean BMI of 20.1, while those in the highest tercile had a BMI of 20.9 (P = 0.009). Those in the lowest tercile of DDS had a 22.8% prevalence of underweight vs 9.8% in the highest tercile (P < 0.0001). The latter relationship remained significant even when the subjects' sociodemographic and economic characteristics were accounted for. CONCLUSION: Dietary scores measured at the individual level are good proxies for overall dietary quality of women living in a poor rural African area. These scores were also shown to be linked with the nutritional status of women. FINANCING: IRD financed the study with the assistance of UNICEF for the purchase of anthropometric equipment. The first author received a research allowance from the French Ministry of Research through the doctoral school 393 of Pierre and Marie Curie University (Paris VI).

Decreased attendance at routine health activities mediates deterioration in nutritional status of young African children under worsening socioeconomic conditions.

BACKGROUND: Economic crisis and sociopolitical instability are generally associated with worsening health and nutrition in developing countries. This study examines the role played by the attendance rate of young children at routine health activities in the deterioration of their nutritional status under adverse social and economic conditions. METHODS: Two nutritional cross-sectional surveys were carried out in two districts of Brazzaville, capital city of The Congo, in 1993 and 1996. They included respectively 2807 and 1695 randomly selected children 4--23 months old. The children's nutritional status was assessed by height-for-age in z-scores. Using embedded general linear regression models, explanatory variables (routine health activities index, socio-demographic context, household economic level, prenatal factors) were tested as potential mediators for the effect of the year of survey on child mean height-for-age. RESULTS: The routine health activities index declined sharply from 1993 to 1996. Its introduction in the regression model including all other explanatory variables led to a sharp decrease in the effect of the year on children's nutritional status, showing the important mediating effect of routine health activities. This result was encountered across all economic categories of households. Other explanatory variables showed more limited mediating effect. CONCLUSIONS: Attendance at preventive health activities should be fostered in African urban communities facing harsh socioeconomic situations to prevent further deterioration in the nutritional status of children.

[Nutrition, urbanization and poverty in subsaharan Africa]. / Nutrition, urbanisation et pauvreté en Afrique subsaharienne.

Africa is currently the continent with the highest urbanization rate in the world. This demographic upheaval has sometimes been considered as an opportunity for modernization but as early as the 1980s experts called attention to its potential impact on nutrition. In recent decades, economic problems and structural reforms have had dire effects on urban populations. Today increasing poverty and the effects of globalization have revived concerns about urban nutrition. Retarded growth and emaciation are less common than in urban areas than in rural areas, but disparities between the rich and poor are much greater. However, in some cities, the incidence of emaciation progressed the more during the 1990s, and now equals that in rural areas. In cities the level of obesity in adult women is a sign of nutritional transition but emaciation has also increased. Despite the wide variety of urban conditions, analysis of the underlying factors reveals several constants. For most of these factors, the characteristic feature of the urban environment is a further increase of social inequality.

Dietary changes in African urban households in response to currency devaluation: foreseeable risks for health and nutrition.

OBJECTIVE: To investigate the effects of currency devaluation on dietary change and nutritional vulnerability of poor households in two African capital cities. DESIGN: A qualitative study based on 120 semistructured individual interviews and four focus group discussions in each city. SETTING: Dakar, Senegal (western Africa) and Brazzaville, Congo (central Africa). SUBJECTS: All of the subjects were randomly selected women from modest or poor households, who spoke the local common language and were responsible for household meal preparation. Only those likely to restrict the dynamic of focus group discussions (because of language, age or education) were excluded. RESULTS: Changes were found in meal preparation characteristics (frequency, sharing pattern) and meal composition. There was frequent depletion of fat and vegetable contents in meals, frequent elimination of desserts and even the elimination of one daily meal. These changes specifically affected economically disadvantaged and socially isolated households, and those headed by women. Other changes were the reduction in the size of consumption units and the development of neighbourhood-specific street food - which has been a growing trend in Brazzaville since the outset of the economic crisis but is more recent in Dakar. CONCLUSIONS: If lasting, these changes pose a dual health risk, i.e. reducing dietary diversity and altering the bacteriological quality of prepared meals. In addition, attempts to reduce the consumption units were found to upset community ties that bind these societies.

Economic crisis and malnutrition: socioeconomic determinants of anthropometric status of preschool children and their mothers in an African urban area.

OBJECTIVE: To assess the relative importance of socioeconomic and maternal/prenatal determinants of the nutritional situation of children < 6 years old in an urban African area after several years of economic crisis. DESIGN: Cross-sectional cluster sample survey. SETTING: Brazzaville, capital city of the Congo. SUBJECTS: Information on socioeconomic characteristics was gathered from a random sample of 1368 households by house visits and anthropometric measurements were performed using standardized procedures on preschool children (n = 2373) and their mothers (n = 1512). RESULTS: The influence of socioeconomic factors on the nutritional status of children, taking into account adjustment variables such as mother's age and child's age and sex was assessed. For stunting, as well as for the mean height-for-age index among children, the main determinants were economic level of the household (P = 0.048 and P = 0.004, respectively), schooling of the mother (P = 0.004 and P < 10(-3)) and living in the peripheral district (P = 0.005 and P < 10(-3)). The influence of socioeconomic determinants on weight-for-age and wasting was less straightforward. When adjusting, in addition, for maternal and prenatal factors (mother's height and body mass index (BMI) and birth weight), most of the effects of the socioeconomic determinants on the nutritional status of children persisted somewhat, but the effect of the economic level on the stunting became not significant (P = 0.11). The mean BMI of mothers appeared to be related to the economic level of the household (P < 10(-4)), to the marital status (P = 0.01) and to the occupation of the mother (P < 10(-4)). CONCLUSIONS: Among the socioeconomic determinants of malnutrition in children, some, such as economic level of the household or schooling of the mother, seem to act mainly through prenatal factors, whereas others, mainly dwelling district characteristics, seem to influence more directly the children's nutritional status.

Deterioration in the nutritional status of young children and their mothers in Brazzaville, Congo, following the 1994 devaluation of the CFA franc.

The effects of the January 1994 devaluation of the African Financial Community (CFA) franc on the nutritional situation of the populations concerned has been little documented. We report in this article on two nutritional cross-sectional surveys that were conducted before and after this devaluation (1993 and 1996) in two districts of Brazzaville, Congo. The surveys involved a representative sample of 4206 households with a child aged 4-23 months. Complementary feeding practices and the anthropometric indices of the children and their mothers were compared, adjusting for changes in household socioeconomic characteristics. The results show a decline in the quality of the first complementary foods offered to the infants, i.e. less frequent use of special transitional foods and imported complementary flours (of higher nutritional quality), and preparation of less nutritious local gruels. Overall, the nutritional situation had deteriorated, with greater levels of stunting and wasting among children, mothers with lower body mass index, and infants with reduced birth weights. Increased food prices would appear to be the direct cause of the decreased quality in complementary feeding, but factors other than the devaluation have also had an impact on household welfare. The influence of these factors on nutritional-status is discussed.

[Logistic regression vs other generalized linear models to estimate prevalence rate ratios]. / Régression logistique vs autres modèles linéaires généralisés pour l'estimation de rapports de prévalences.

In cross-sectional studies, to quantify the association between a risk factor and a disease (possibly adjusted for confounders), in the framework of the multiplicative model, the more obvious effect measure is a prevalence rate ratio with an associated confidence interval. The validity of this confidence interval requires an unbiased estimator and an appropriate estimate of the variance. In numerous epidemiological studies however, routine use is made of odds ratios and logistic regression. As the odds ratio per se is difficult to understand, prevalence odds ratios are often interpreted as prevalence rate ratios. But this latter approximation is valid only under the rare disease assumption. Moreover, in the logistic regression model, the variance of the estimates is based on the assumption of binomial variability, which is not always supported by the data; in the frequent case of overdispersion, this leads to under-estimation of the type I error rate. Yet, within the generalized linear model, it is easy to choose a link function other than the logit. For example, the log link (log-binomial model) is appropriate to directly estimate adjusted prevalence rate ratios. In case of overdispersion, it is also possible to achieve a better fit of the model, either by choosing another distribution in the exponential family or by estimating a dispersion parameter for the binomial distribution. Thus, there are no valid reasons for the systematic choice of odds ratio and of the logistic regression model to estimate prevalence rate ratios, unless the type of study imperatively requires their use.

Lipid content and essential fatty acid (EFA) composition of mature Congolese breast milk are influenced by mothers' nutritional status: impact on infants' EFA supply.

OBJECTIVE: To measure the lipid content and the fatty acid (FA) composition of breast milk as part of a nutritional survey of the essential fatty acid (EFA) status of 5 months old Congolese infants. DESIGN: Cross sectional nutrition survey. SETTING: A suburban district of Brazzaville (capital of the Congo). SUBJECTS: A random sample of nursing mothers and their 5 months old infants (n = 102). Data collection procedures: The mothers were questioned on their socio-economic status, dietary habits, and their body mass index (BMI) was measured. Breast milk samples were collected from each mother. Milk lipid content and fatty acid composition were determined. RESULTS: Compared with milk from various countries, Congolese women's mature breast milk was low in lipid (28.70+/-11.33 g/L) but rich in 8:0-14:0 FAs (25.97+/-8.17% of total FAs) and in polyunsaturated FAs (PUFAs), particularly n-3 PUFAs (2.39+/-0.68% of total FAs, mainly 18:3 and 22:6). This was associated with the frequent consumption of high-carbohydrate foods (processed cassava roots, wheat bread, doughnuts) known to enhance 8:0-14:0 FA biosynthesis, and with that of foods providing n-6 and n-3 EFAs such as freshwater and saltwater fish, vegetable oil, green leafy vegetables, and high-fat fruit (peanuts, avocado, bushbutter). These foods were traditionally and locally produced. Milk lipid content was negatively related with mothers' BMI (P < 0.01) and varied with the frequency of consumption of certain foods corresponding to distinct dietary patterns. CONCLUSIONS: Lipid content and FA composition of Congolese breast milk were dependent on mother's nutritional status. However, despite an adequate EFA composition of breast milk, partially breast-fed 5 months old Congolese infants probably did not get enough n-6 and n-3 EFAs from breast milk to meet their EFA requirements.

PIP: Optimum infant growth and development, especially neurodevelopment and visual acuity, require sufficient n-6 and n-3 essential fatty acid supplies from the placenta or breast milk. The lipid content and fatty acid composition of mature breast milk were measured in samples from 102 randomly selected Congolese mothers of 5-month-old infants, residing in a suburban district of Brazzaville. Mean body mass index (BMI) was 22.3; 14% of mothers were energy-deficient and 22% were overweight. Breast milk samples from these mothers were low in lipids (mean, 28.70 g/l), and 75% had a lipid content below reference values. Adequate lipid content was associated with a maternal diet high in carbohydrates and low in fats. Breast milk was rich in 8:0-14:0 fatty acids (25.97% of total fatty acids) and in polyunsaturated fatty acids, especially n-3. These findings appear related to Congolese mothers' frequent consumption of high-carbohydrate foods such as processed cassava roots, wheat bread, and doughnuts known to enhance 8:0-14:0 fatty acid biosynthesis, as well as locally produced foods such as fish, vegetable oil, leafy green vegetables, and high-fat fruit that provide n-6 and n-3 essential fatty acids. Milk lipid content was inversely associated with the maternal BMI, but was unrelated to maternal age or socioeconomic status. Since the essential fatty acid content of traditional complementary foods is lower than that present in breast milk, Congolese mothers should be encouraged to postpone the introduction of such foods until their infant is 4-6 months old.

[Complementary nutrition for the young child following the devaluation of the CFA franc (African Financial Community): 2 case studies in the Congo and Senegal urban environment]. / L'alimentation de complément du jeune enfant après la dévaluation du franc CFA: deux études de cas en milieu urbain, au Congo et au Sénégal.

Developing countries frequently see their currency depreciated to varying degrees. The consequences of such monetary disturbances on the nutrition of young children are not well known, though children are the most vulnerable in nutritional terms. One year after the 50% devaluation of the CFA Franc (communauté financière africaine, "African Financial Community"), which took place on 12 January 1994 simultaneously in fourteen countries, nine of which are on the UNDP list of least developed countries, we wanted to find out the long-term effects of the devaluation, and the strategies that families had adopted to cope with it. In Brazzaville, Congo, in December 1994, an epidemiological survey was conducted on a representative sample of 893 children between the ages of 4 and 12 months in two districts, and indicators of child nutrition were established. A comparable survey had been conducted in December 1993, before the devaluation. In Senegal, in the absence of a previous survey which could be used in comparison, a qualitative survey using RAP methodology, was conducted in January 1995 in two towns near the capital. In three districts in each of these towns, a cluster of ten plots was chosen at random and surveyed, with a combination of semi-structured individual interviews with mothers (n = 60) and group interviews with all the women together (n = 6). The information was put together with interviews of 25 local traders selling food. In the Congo, comparison of the two surveys shows that the practice of breast-feeding had hardly changed, nor had the age at which baby food was introduced (90% of children of 4-5 months take semi-solid and solid foods); on the other hand, more children are being given the ordinary family meal earlier, at 6-9 months. The proportion of baby foods based on commercially imported flour has fallen (from 32% in 1993 to 18% in 1994), and has been replaced with local products based on maize; this change is more marked among poorer families. The low nutritional value of such preparations is in part compensated by the addition of sugar, though less milk is added (28% in 1994 as opposed to 43% in 1993). In Senegal, mothers do not seem to have changed their breast-feeding practices either, the age at which baby foods are introduced, or the number of times they are provided daily. The most important change is the drop in quality of food given to children, and the poorer family food for the older children. The partial switch from imported products to local produce was an expected consequence of devaluation; it is clearly confirmed here for nutrition of young children, with the consequent loss of nutritional quality (a reduction in energy density and in nutrients). The first thing needed is, therefore, an improvement in local manufacture of food supplements of good nutritional quality, for young children. Mothers also complain of the increased difficulty in managing a family diet so as to take account of economic needs, cultural values and nutrition. They therefore criticize a number of nutritional education messages that are clearly no longer appropriate to the new economic context. Finally the fact that young children are getting poorer quality nutrition is worrying for the future: if it lasts, the nutritional status of children will deteriorate; whenever possible, monitoring must be established so that measures can be taken when necessary to forestall any dramatic deterioration that would endanger the health of the children.

[Vertical transmission of the human T-cell leukemia virus in an endemic area. An epidemiological study in children from 0 to 5 years in Gabon]. / Etude de la transmission verticale du human T-cell leukemia virus en zone d'endémie. A travers une enquête épidémiologique chez les enfants de 0 à 5 ans au Gabon.

A seroepidemiological survey was conducted in a representative population of children aged 0-5 in Gabon. Breast-feeding appears to an important mode of HTLV vertical transmission. Owing to other epidemiological data in population of gabonese adults allow us to think that breast-feeding related transmission and sexual transmission seem to occur in equal proportion in the global HTLV transmission in that area of endemicity.

Tolerance and efficacy of single high-dose ivermectin for the treatment of loiasis.

A study was carried out in southeastern Gabon to evaluate the tolerance and efficacy of single high doses of ivermectin in 31 Loa loa-infected subjects with low-to-moderate parasitemia (7-7,700 microfilaria/ml). The first group of 16 subjects received 300 micrograms/kg of ivermectin and, seven days later, a second group of 15 received 400 micrograms/kg. Complete clinical and biological monitoring was carried out during the first 10 days post-treatment and again after one and three months. All subjects continued with their usual activities during the study. The clinical tolerance of treatment was very good, and except in one case, only mild adverse reactions were observed, with pruritus being the most common symptom. There were no significant changes in blood or urine function test results or in hematologic results, except for a pronounced eosinophil reaction. The 400 micrograms/kg dose of ivermectin equaled or surpassed in tolerance that of 300 micrograms/kg dose. After treatment, L. loa microfilaremia decreased rapidly to less than 9% of the pretreatment value by day 10. This decrease was enhanced with the 400 micrograms/kg dose, although differences between the two groups diminished slightly with time. At 100 days post-treatment, the microfilaremia was still at less than 10% of the initial values in the two groups, which may indicate an effect of ivermectin on the adult worms.

Non-Hodgkin lymphoma in Gabon and its relation to HTLV-I.

A case-control study was performed in Libreville, Gabon, to determine whether a relationship can be established between the relatively high proportion of non-Hodgkin lymphoma (NHL) among all cancer cases and the high seroprevalence rate of HTLV-I observed, and to discover whether cases of adult T-leukemia/lymphoma (ATLL) related to HTLV-I exist in Gabon. From November 1987 to April 1989, a total of 32 patients with NHL were recruited; 6 were infants with Burkitt's lymphoma and 26 were adults with NHL. Each patient was matched with 2 asymptomatic controls for age, sex and ethnic group. HTLV-I serology was done by ELISA and Western blot. Comparison of the groups was done by chi-square analysis. None of the 6 infants with Burkitt's lymphoma and none of their controls had antibodies to HTLV-I. Of the 26 patients with NHL, 7 (26.9%) had HTLV-I antibodies. Among the 52 controls, the HTLV-I rate was 13.4% (n = 7). There was no difference between cases and controls (Fisher's exact test, p = 0.16). Among the 26 NHL, 4 cases fitted the criteria of ATLL and were HTLV-I-positive; 3 others who were positive for HTLV-I were a woman with lymphoblastic gastric NHL and 2 old men with an unclassified lymphoma. From the results of this limited series it is not possible to state that there is an association between NHL and HTLV-I infection. Nevertheless, cases of ATLL related to HTLV-I are reported from this area. Based on the HTLV-I seroprevalence rates reported in Gabon, the estimated incidence rate of ATL among seropositive people in Gabon appears much lower than in Japan. Different explanations can be proposed, but under-diagnosis of ATLL is probably one of the main factors.