Why women bypass front-line health facility services in pursuit of obstetric care provided elsewhere: a case study in three rural districts of Tanzania.

OBJECTIVES: In the Tanzanian health system, women are expected to first visit their nearest front-line health facility (FLF) for delivery. However, women frequently bypass these FLF. Our study estimates the extent of bypassing for childbirth and assesses factors associated with this behaviour. METHODS: Data describing the experiences of 597 women who recently delivered at a facility and the EmONC service capability at 107 health facilities were collected in 2011. Women who did not deliver at their nearest FLF were considered 'bypassers'. Factors associated with bypassing were assessed using multivariate logistic regression models. Three sets of analyses were conducted: among 597 women who delivered at the first facility they visited, among 521 women with no previous complications, and among 407 women not primigravida and without previous complications. RESULTS: More than 75.4% of women bypassed. In the fully adjusted model of all 597 women those who had experienced complications were more likely to bypass for delivery [OR = 6.31 (2.36, 16.86)]. In the fully adjusted model excluding women with previous complications, primigravida women were more likely to bypass [OR = 3.70 (1.71, 8.01)]. Fully adjusted models for each set of analysis found that, for each additional emergency obstetric and newborn care signal function (EmONC SF) available at the nearest FLF, women's odds of bypassing almost halved. CONCLUSIONS: Bypassing is highly associated with EmONC SF score at nearest FLF, controlling for individual and community-level factors.

Demographic surveillance and health equity in sub-Saharan Africa.

Accurate data are always needed to inform health policy, but are especially critical in tackling health inequities. The growing number of field research stations in sub-Saharan Africa are well-placed to generate relevant data and so support health policy action. Over the past 60 years, demographic surveillance systems have been crucial research tools for the evaluation of health interventions aimed at reducing socioeconomic differentials in mortality and morbidity in sub-Saharan Africa. The bulk of such work has been carried out by field research sites, often operating in remote, resource-constrained settings. The present paper reviews what we have learned since the pioneering work carried out in the field sites of Pholela (South Africa) and Niakhar (Senegal). It then focuses on current efforts to address health equity through INDEPTH, the international network of field sites with continuous demographic evaluation of population and their health in developing countries.

The Household Registration System: computer software for the rapid dissemination of demographic surveillance systems.

Although longitudinal experimental community health research is crucial to testing hypotheses about the demographic impact of health technologies, longitudinal demographic research field stations are rare, owing to the complexity and high cost of developing requisite computer software systems. This paper describes the Household Registration System (HRS), a software package that has been used for the rapid development of eleven surveillance systems in sub-Saharan Africa and Asia. Features of the HRS automate software generation for a family surveillance applications, obviating the need for new and complex computer software systems for each new longitudinal demographic study.

Do managerial efficiency and social responsibility drive long-term financial performance of not-for-profit hospitals before acquisition?

Due to steep declines in charitable support and reduced demand for traditional hospital services, economic goals are increasingly important to not-for-profit hospitals. Effects of efficient management and effective pursuit of not-for-profit status (for example, levels of Medicare, indigent patients, and unprofitable services) on financial viability are explored. While previous research compared hospitals of different ownership status, not-for-profit hospital operations before acquisition by for-profit hospital chains are investigated--"neutral ground" relative to ownership. Results suggest minor links between efficiency and long-term profitability despite effectiveness in pursuit of non taxable status.

Women's fears and men's anxieties: the impact of family planning on gender relations in northern Ghana.

The Navrongo experiment, a family planning and health project in northern Ghana, has demonstrated that an appropriately designed, community-based family planning program can produce a change in contraceptive practice that had been considered unattainable in such a setting. Simultaneously, however, evidence suggests that newly introduced family planning services and contraceptive availability can activate tension in gender relations. In this society, where payment of bridewealth signifies a woman's requirement to bear children, there are deeply ingrained expectations about women's reproductive obligations. Physical abuse and reprisals from the extended family pose substantial threats to women; men are anxious that women who practice contraception might be unfaithful. Data from focus-group discussions with men and women are examined in this report and highlight the strains on gender relations resulting from contraceptive use. The measures taken to address this problem and methods of minimizing the risk of adverse social consequences are discussed.

PIP: The perspectives of older and younger men and women and village leaders concerning the impact of family planning on gender relations were distilled from a series of 36 focus group discussions held during 1994-96 in conjunction with the launching of the Navrongo experiment in northern Ghana. The primary aim of the focus groups was to monitor the community's reaction to the introduction of family planning and health services and provide feedback to project managers. Focus group participants made clear that, although contraception can reconcile a husband's sexual desire with the wife's desire to space births, it also generates marital discord, wife beating, and opposition from members of the extended family. Violence against women was considered justified by 51% of female and 43% of male respondents if the wife used a contraceptive method without the husband's knowledge. Women feared that their husband's disapproval of family planning could lead to withholding of affection or sex or even divorce. In the traditional local society, payment of bridewealth in cows and sheep signifies the wife's obligation to bear children. Some men worry that their wives might be unfaithful if they used contraception or that contraceptive use might create conflict among multiple wives. The possibility that women may act independently is regarded as a threat to the strong patriarchal tradition. The Navrongo project has attempted to respond to community concerns by acting through existing local institutions whenever possible while still supporting women and their autonomy.

For-profit chains seek to acquire successful not-for-profit hospitals.

Over the last decade, investor-owned hospital corporations have grown primarily by acquiring other for-profit hospital chains or stand-alone for-profit institutions. Between 1990 and 1995, however, these corporations also acquired nearly 50 not-for-profit hospitals and converted them to for-profit status. An examination of the long-term financial condition of 39 not-for-profit hospitals acquired by various investor-owned hospital corporations between 1992 and 1996 was conducted using free-cash-flow accounting valuation. The results suggest that, initially, only not-for-profit hospitals in dire financial straits were candidates for acquisition and conversion to for-profit status. More recent acquisitions increasingly have involved more successful not-for-profit hospitals.

Serum retinol and HIV-1 RNA viral load in rapid and slow progressors.

Few studies have addressed the relation between serum vitamin A levels and HIV disease progression. Thirty HIV-infected women in Rwanda were studied over a time span of 26 to 99 months. Fourteen subjects seroconverted and died of HIV-related disease at a mean of 44 months (range, 26-69 months) after their first HIV-positive test and were termed "rapid progressors," (RPs). A comparison group of 16 "slow progressors" (SPs) were HIV-positive at the time of their first HIV serology and had asymptomatic HIV infections at a mean of 96 months (range, 93-99 months) after their first HIV serology. Baseline mean serum retinol values were the same in RPs and SPs: 0.65 + 0.08 micromol/L versus 0.67 + 0.09 micromol/L (p = .7). Lower serum retinol levels were observed in RPs compared with SPs for the second and third measurements, obtained at a median of 12 and 24 months past baseline: 0.51 + 0.07 micromol/L versus 0.76 + 0.14 micromol/L (p = .3) and 0.44 + 0.09 micromol/L versus 0.64 + 0.08 micromol/L (p = .08), respectively. Median retinol levels for the third sample measurement were similar in RPs with lower viral load (LVL) and SPs (0.49 micromol/L and 0.52 micromol/L, respectively) compared with only 0.19 micromol/L in RPs with higher viral load (HVL; p = .02). A trend toward decreasing serum retinol levels and increasing HIV-1 RNA viral load was observed at the third sample measurement (p = .04). Subjects with LVL, higher serum retinol levels (> or =0.70 micromol/L), or both had more favorable rates of survival than subjects with HVL, low serum retinol levels (<0.70 micromol/L), or both. Although sample size does not permit definitive conclusions, this study demonstrates an association of high HIV load, rapid progression, and low serum retinol late but not early in disease progression.

Serum retinol and HIV-1 RNA viral load in rapid and slow progressors.

Few studies have addressed the relation between serum vitamin A level and HIV disease progression. Thirty HIV-infected women in Rwanda were studied over a time span of 26 to 99 months. Fourteen subjects seroconverted and died of HIV-related disease at a mean of 44 months (range, 26-69 months) after their first HIV-positive test and were termed "rapid progressors," (RPs). A comparison group of 16 "slow progressors" (SPs) were HIV-positive at the time of their first HIV serology and had asymptomatic HIV infections at a mean of 96 months (range, 93-99 months) after their first HIV serology. Baseline mean serum retinol values were the same in RPs and SPs: 0.65 + 0.08 mmol/L versus 0.67 + 0.09 micromol/L (p = .7). Lower serum retinol levels were observed in RPs compared with SPs for the second and third measurements, obtained at a median of 12 and 24 months past baseline: 0.51 + 0.07 mmol/L versus 0.76 + 0.14 mmol/L (p = .3) and 0.44 + 0.09 mmol/L versus 0.64 + 0.08 mmol/L (p = .08), respectively. Median retinol levels for the third sample measurement were similar in RPs with lower viral load (LVL) and SPs (0.49 mmol/L and 0.52 mmol/L, respectively) compared with only 0.19 mmol/L in RPs with higher viral load (HVL; p = .02). A trend toward decreasing serum retinol levels and increasing HIV-1 RNA viral load was observed at the third sample measurement (p = .04). Subjects with LVL, higher serum retinol levels (> or =0.70 mmol/L), or both had more favorable rates of survival than subjects with HVL, low serum retinol levels (<0.70 mmol/L), or both. Although sample size does not permit definitive conclusions, this study demonstrates an association of high HIV load, rapid progression, and low serum retinol late but not early in disease progression.

The influence of traditional religion on fertility regulation among the Kassena-Nankana of northern Ghana.

This article presents findings from a study of the influence of traditional religion on reproductive preferences of Kassena-Nankana lineage heads in northern Ghana. Seven reproductive preference questions were administered to nine lineage heads who are primary practitioners of the cult of soothsaying. With the assistance of soothsayers, interviews were repeated in conjunction with the invocation of religious rites in order to determine the views of ancestral spirits on the seven questions. Pairs of lineage head and ancestral interviews are compared to determine the role of traditional religion in shaping male reproductive preferences. Interview pairs reflect a shared preference for sons, large compounds, and a growing lineage. Findings nonetheless show that some ancestral spirits want small families, some even wanting fewer children than corresponding lineage heads. Spiritual consultations are nondogmatic and open to external ideas and influences, suggesting that family planning introduction will not encounter systematic religious opposition among the Kassena-Nankana.

PIP: This study examined fertility preferences among male lineage heads (MLHs) among the Kassena-Nankana of Ghana and the role of traditional religion in determining fertility preferences. Data were obtained via semistructured interviews with MLHs and via contacts with ancestral spirits through soothsayers. MLHs were identified in three micropilot villages with family planning (FP) outreach services in the past year. Three heads were selected at random from the listing of lineages in each village. Interviews were conducted first in the privacy of the home and second in the sacred hut of the soothsayer, who was the medium for the ancestral interviews. Soothsayers advised their clients and participated. Paired responses of MLHs and ancestors showed considerable diversity of opinion and inconsistencies. Questions were asked about the benefits of having many children, the achievement of having the desired number of children, changes of preferences after the fact, male or female preferences, hut size preferences, approval of FP, and the benefits of health and FP service availability. Both MLHs and ancestors shared a strong preference for sons, large compounds, and a growing lineage. However, some ancestors wanted small families. Findings suggest that traditional religious practices were not a singular negative force against FP and were flexible and adaptive to social change. Ancestors acknowledged survival strategies. The methodology suggests the usefulness of communicating with men, soothsayers, and spirits about gender issues, reproductive matters, or other health issues.

Serologic and phylogenetic characterization of HIV-1 subtypes in Uganda.

OBJECTIVES: To determine the HIV genetic subtypes present in HIV-1-infected asymptomatic blood donors in Uganda and to evaluate serologic detection of infection by commercial immunoassays; to evaluate samples for HIV-1 group O infections. METHODS: Sixty-four HIV-seropositive plasma samples were collected from the Nakasero Blood Bank, Kampala, Uganda. The plasma were evaluated using commercial HIV enzyme immunoassays (EIA) and a research immunoblot. HIV-1 group M and O infections were identified on the basis of discordant seroreactivity in EIA and reactivity to group M and O antigens on the immunoblot. Regions of gag p24 and env gp41 were amplified using reverse transcriptase polymerase chain reaction, and genetic subtypes were determined by phylogenetic analysis. RESULTS: Serologic testing confirmed that 63 out of 64 plasma units were positive for HIV-1 group M infection and showed no evidence of HIV-1 group O infections. Genetic subtyping determined that 25 samples were subtype A, three subtype C, 22 subtype D, and nine were heterogeneous for subtypes A and D. CONCLUSIONS: Despite the sequence variation observed in Uganda, commercial EIA based on HIV-1 subtype B proteins detected all the infections. In contrast, a peptide-based assay failed to detect three infections by subtype D viruses. This emphasizes the negative impact of HIV genetic variation on assays that rely on peptides to detect HIV infections. The number of infections with heterogeneous subtype (due to mixed infections or recombinant viruses) is high and reflects the growing complexity of the HIV epidemic in endemic regions where multiple subtypes are present in the population.

PIP: Extensive sequence heterogeneity between HIV-1 isolates has led to the classification of HIV-1 into group M (major) subtypes A-J, and group O (outlier). Some isolates have also been found to be the result of recombination between different group M subtypes. Findings are reported from a study conducted to determine the various HIV genetic subtypes in HIV-1-infected asymptomatic blood donors in Uganda and to evaluate the serologic detection of infection by commercial immunoassays. 64 HIV-seropositive plasma samples were collected from the Nakasero Blood Bank in Kampala and evaluated using commercial HIV enzyme immunoassays (EIA) and a research immunoblot. 63 of 64 plasma units were positive for HIV-1 group M infection and showed no evidence of group O infections. According to phylogenetic analysis, 25 samples were subtype A, 3 subtype C, 22 subtype D, and 9 heterogenous for subtypes A and D. Despite the sequence variation observed in this study population, commercial EIA based upon HIV-1 subtype B proteins detected all of the infections. A peptide-based assay failed to detect 3 infections by subtype D viruses.

Cultural factors constraining the introduction of family planning among the Kassena-Nankana of northern Ghana.

This study presents a focus group investigation of reasons why women in a rural, Sahelian community are reluctant to adopt family planning even when convenient services are made freely available. First, women opting to practice contraception must do so at considerable risk of social ostracism or familial conflict. Implementing individual preference is something that must be done without the support of others. Second, few women view personal decisions about contraceptives as theirs to make. Women and children are the property of the corporate family-kin and community militate against reproductive control. Third, although children are highly valued for a variety of economic, social, and cultural reasons, mortality risks remain extremely high. Low fertility imposes the unacceptable risk that a woman will have no surviving children at the end of her reproductive life. Taken together, these findings attest to the inadequacy of service strategies focused on the contribution of distribution, individual agency, or personal choice. Outreach should also build a sense of community legitimacy for the program, collective health action, and traditional leadership support for family planning behavior.

The long-term demographic role of community-based family planning in rural Bangladesh.

Experimental studies demonstrating the effectiveness of nonclinical distribution of contraceptives are typically conducted in settings where contraceptive use is low and unmet need is extensive. Determining the long-term role of active outreach programs after initial demand is met represents an increasingly important policy issue in Asia, where contraceptive prevalence is high and fixed service points are conveniently available. This article examines the long-term rationale for household family planning in Bangladesh-where growing use of contraceptives, rapid fertility decline, and normative change in reproductive preferences are in progress, bringing into question the rationale for large-scale deployment of paid outreach workers. Longitudinal data are analyzed that record outreach encounters and contraceptive use dynamics in a large rural population. Findings demonstrate that outreach has a continuing impact on program effectiveness, even after a decade of household visitation. The policy implications of this finding are reviewed.

PIP: Longitudinal data were analyzed to determine the long-term impact of community-based distribution of contraception in rural Bangladesh. Since 1978, the Family Welfare Assistant initiative has grown to involve more than 40,000 nonclinical outreach workers and supervisors. Debate has focused on the sheer scope of this undertaking and on its potential, permanent impact on demographic transition, especially with the advent of less expensive supply depots, satellite clinics, and social marketing outlets that now blanket the country. This study provides an analytical framework for interpreting the long-term role of service outreach as a determinant of contraceptive use. The framework has pathways that connect to demographic, socioeconomic, and programmatic factors. A typology is also developed to explain the interface of the costs of fertility regulation and the demand for contraception. The Maternal and Child Health-Family Planning Extension Project monitoring activities provided data for this analysis through a Sample Registration System covering a 10-year period. A statistical model was developed to analyze changes in the reproductive behavior and motives of 4236 respondents arising from exposure to outreach activities. Results of the analysis indicate that 1) outreach generates incremental contraceptive use that would not arise if underlying demand were the sole determinant of use; 2) the outreach activities of male workers have no role in maintaining use; 3) outreach continues to foster contraceptive use because of the high frequency of encounters; 4) the outreach program is the single most important component of program exposure in the study population; 5) outreach generates a small but significant demand for contraception; and 6) sex preferences for offspring are weakened, but not eliminated, by outreach. These results suggest that the outreach program should be continued and that the male health assistant role should be revised or phased-out. Without outreach, contraceptive prevalence would be 15 points lower than the observed level of 40%. Even though outreach has a continuing demographic role, this role should be reevaluated periodically, especially to determine how to employ supporting communication strategies. These findings may also be extrapolated to similar settings in other countries.

The impact of outreach on the continuity of contraceptive use in rural Bangladesh.

In 1978, the Bangladesh family planning program launched a national program of outreach services that continues to the present. Young married women were hired and trained to visit women in their homes, offer contraceptive services, provide information, and support sustained use over time. This report uses data from two rural districts to assess the effect of the household visitation program on the continuity of contraceptive use. Results of a multivariate analysis show that household outreach has had a pronounced net effect on the continuity of contraceptive use throughout the study period and that the magnitude of this effect has increased with time. This finding suggests that sustained contraceptive use continues to benefit from home-based outreach even after a decade of service encounters. Policy implications of this finding are discussed.

Developing a culturally appropriate family planning program for the Navrongo experiment.

This article describes the first six months of the strategic planning process to develop a culturally appropriate community health and family planning program for a traditional community in a district of northern Ghana, served by the Navrongo Health Research Centre. To explain the context within which fertility decisions are made, this article describes the district's severe ecological, social, economic, and health constraints to family planning. It discusses related programmatic obstacles and presents the strategies developed to respond to them. A system of care has been developed that is closely coordinated with traditional leaders and communication networks. Management systems support outreach workers by emphasizing the importance of peer leadership, supervisory support, and community liaison in the implementation of village-based services. A large-scale experiment will be fielded to test the demographic impact of this approach.

Natural history of HIV-1 cell-free viremia.

OBJECTIVE: To characterize the natural history of viremia with human immunodeficiency virus type 1 (HIV-1) and its association with disease progression from infection to acquired immunodeficiency syndrome (AIDS). DESIGN: Prospective cohort study. Annual specimens were tested for quantitative virion-associated HIV-1 RNA, p24 antigen, and CD4+ lymphocyte levels. PARTICIPANTS: A total of 42 homosexual men who seroconverted to HIV-1 between 1982 and 1985. MAIN OUTCOME MEASURES: Trends over time in serum HIV-1 RNA level, correlations between serum HIV-1 RNA and other markers, and prediction of AIDS using these markers. RESULTS: HIV-1 RNA levels were stable over time, increasing by 10-fold or more in only six (14%) of the 42 subjects during 3 to 11 years of follow-up. Mean HIV-1 RNA levels were 10(3.8) copies/mL if AIDS occurred in less than 4 years, 10(3.07) copies/mL if AIDS developed within 4 through 9 years, and 10(2.27) copies/mL if AIDS did not develop within 6 through 11 years. In both univariate and multivariate models, initial and subsequent HIV-1 RNA levels, p24 antigenemia, and percentage of CD4+ lymphocytes were independently predictive of AIDS. CONCLUSIONS: The stability of virion-associated HIV-1 RNA levels suggests that an equilibrium between HIV-1 replication rate and efficacy of immunologic response is established shortly after infection and persists throughout the asymptomatic period of the disease. Thus, defective immunologic control of HIV-1 infection may be as important as the viral replication rate for determining AIDS-free survival. Because individual steady-state levels of viremia were established soon after infection, HIV-1 RNA levels may be useful markers for predicting clinical outcome.

The Navrongo Community Health and Family Planning Project.

In 1994, an experiment was launched by the Navrongo Health Research Centre that will test the demographic impact of community health and family planning services in a rural, traditional area of northern Ghana. While exhaustive social research has been directed to clarifying societal constraints to reproductive change, relatively little is known about how African cultural characteristics can be a resource to family planning programs. This study will clarify ways in which cultural resources of a traditional African society can be used in efforts to foster reproductive change. This article reviews characteristics of the study population, the design of the Navrongo experiment, and the research plan. The Navrongo Project will be the first African experimental trial of the demographic impact of family planning.

PIP: The persistence of high fertility in sub-Saharan Africa has been investigated extensively over the past decade. While the social forces which sustain high fertility and impede family planning programs are well understood, appropriate policy responses to the circumstances, however, continue to be debated. Relatively little is known about how African cultural characteristics can be a resource to family planning programs. An experiment was launched in 1994 by the Navrongo Health Research Center to test the demographic impact of community health and family planning services in a rural, traditional area of northern Ghana. The study will clarify ways in which cultural resources of a traditional African society can be used to foster reproductive change. A field station has been established where a partnership was developed between health professionals and traditional village groups for designing culturally sensitive approaches to family planning services. The experiment, to be conducted by the Navrongo Health Research Center (NHRC), a research station of the Ghanaian Ministry of Health, will appraise the demographic impact of the program and foster policy based upon the lessons learned. The population monitored by the NHRC research system receives all of its allopathic health care and contraceptive services from primary health care programs of the Ministry of Health. The Ministry has established close collaboration between the District Health Management Team which directs the program and the research team of the NHRC. This collaborative arrangement permits flexibility in designing field operations so that varying work routines, staffing patterns, or the intensity of services can be tailored to the requirements of research protocols. Collaboration between service providers and researchers makes the Navrongo project uniquely suited for a study of the demographic role of family planning. This article reviews characteristics of the study population, the design of the Navrongo experiment, and the research plan. The Navrongo project will be the first African experimental trial of the demographic impact of family planning.

Worker-client exchanges and contraceptive use in rural Bangladesh.

In this article, longitudinal data from rural Bangladesh are used to assess the impact of household visits from family planning workers on contraceptive use. A panel of women was interviewed in a demographic survey and reinterviewed every 90 days for six successive rounds. Regression methods are used to estimate the effect of these encounters on the odds that a woman will use contraceptives. Statistical controls adjust for the potentially confounding effects of underlying demand for contraception. Findings suggest that both male and female worker-initiated exchanges have an effect, although the impact of outreach is more pronounced if the worker is female. Estimated effects are consistent with the hypothesis that the predominant impact of outreach is to crystallize existing latent demand for contraception. Results also suggest, however, that female worker outreach generates new demand by fostering ideational change.

Reduction of self-injurious hand mouthing using response blocking.

We evaluated a response-blocking procedure for reducing the self-injurious hand mouthing of 2 adults with profound disabilities. The procedure reduced mouthing in both cases. The results suggest research is warranted to delineate the behavioral process responsible for the effect of response blocking and to determine the procedure's long-term utility.

Contraceptive use in Matlab, Bangladesh: the role of gender preference.

Research in several Asian societies has suggested that sons are generally preferred over daughters. The implications of gender preferences for actual fertility behavior have not been adequately investigated, however. This analysis examines the effect of the sex composition of surviving children on the acceptance and discontinuation of contraception in a sample of 3,145 women in Matlab, Bangladesh, who were observed for 60 months. Hazards regression analyses are employed in the analysis. Strong and highly significant effects of gender preference on contraceptive use are observed. The preference is not monotonically son-biased but is moderated toward a balanced composition, because parents desire to have several sons and at least one daughter. These findings suggest that gender preferences, particularly a preference for sons, represent a significant barrier to fertility regulation in rural Bangladesh.

PIP: Research in several Asian societies has shown that sons are preferred over daughters. This paper explores the effect of sex composition of surviving children on the acceptance and discontinuation of contraception in a sample of 3145 women in Matlab, Bangladesh, observed over a period of 60 months. Data were analyzed via hazards regression. Strong and significant effects of gender preference were found on contraceptive use. Specifically, parents have a strong preference for sons and a moderate preference for daughters. This conclusion is based upon bivariate analysis which revealed contraceptive acceptance and continuation rates to be higher among couples who have at least 1 surviving son than among couples who have no son; rates steadily increased with the number of surviving sons. Acceptance and continuation are lower, however, among couples who have only sons than among those who have children of both sexes. Parental sex preference is therefore moderated toward a balanced composition of several sons and at least 1 daughter. These preferences pose a significant barrier to fertility regulation in rural Bangladesh. Related literature is reviewed and the study are described.