"What is killing me most": chronic pain and the need for palliative care in the Eastern Cape, South Africa.

Palliative care and the provision of pain relief medicine are essential components of health care, yet little research has been conducted on access to pain medicine in rural areas of sub-Saharan Africa. The objective of this study was to examine patient experiences and health care provider attitudes towards chronic pain and palliative care in Eastern Cape Province, South Africa. The study used a mixed-methods approach to evaluate experience of chronic pain in a district hospital and associated clinics. Questionnaires and in-depth interviews were conducted with 45 current and former patients receiving care and 26 health care providers. Forty-six percent (n = 19) of patients rated their pain in the last month as severe. Thirty-nine percent (n = 17) of individuals stated that they had never been provided with an explanation for the cause of their pain. Multiple regression analysis found that being female, not having received a social welfare grant, and not having received an explanation for the cause of pain were associated with higher ratings of pain (P < .10 for each variable). Factors inhibiting the provision of palliative care included insufficient access and availability of pain medication and providers' association of palliative care with end-of-life care. Adequate pain relief is often deprioritized in a busy health care setting. Ensuring patients receive sufficient relief for their pain requires interventions at clinical and policy levels, including the provision of needed pain medication and training in palliative care for all providers.

Are we winning? Improving perinatal outcomes at a deeply rural district hospital in South Africa.

Zithulele Hospital is a deeply rural district hospital in the Eastern Cape province. Beset by staffing, procurement and infrastructure problems, the maternity service in 2005 was poorly organised and offered an inadequate standard of care. By our estimates, nearly 50% of women were still delivering at home. Three years of effort focused on regular auditing to identify problems and improve our service started to bear fruit in 2008, reflected in significantly increased deliveries and a sharp drop in the perinatal mortality rate. We consider some of the successes, which factors have contributed to them, and some remaining challenges.