Maternity care in rural Nepal: a health service analysis.

This study assesses the performance of maternity care and its specific service components (preventive interventions in antenatal care, antenatal screening, referral, obstetric care) in Banke District, Nepal, using a set of structure, process, and output/outcome indicators. Data sources included health service documents in 14 first level health units and two hospitals, covering 1378 pregnancies and 1323 deliveries, structured observations, antenatal exit interviews (n = 136) and interviews with maternity users (n = 146). Coverage of antenatal care (28%) and skilled delivery care (16%) was low. In antenatal care, preventive interventions were only partially implemented (effective iron supplementation in 17% of users). On average one minute was spent on individual counselling per consultation. 41% of pregnancies were identified as high risk and 15% received referral advice, which was followed in only 32%. Hospital deliveries accounted for 9.8% of all deliveries. Hospital-based maternal mortality was 6.8/1000 births and the stillbirth rate 70/1000. High rates of stillbirth were observed in breech delivery (258/1000 births), caesarean section (143/1000) and twin delivery (133/1000). The risk of stillbirth was higher for rural women (RR 2.3; 95% CI 1.51-3.50) and appeared to be related to low socio-economic status. Emergency admissions were rare and accounted for 3.4% of hospital deliveries or only 0.4% of all expected deliveries. There was hardly any accumulation of high-risk pregnancies at hospital. The population-based rate of caesarean section was 1.1% (urban 2.3%, rural 0.2%). The estimated unmet obstetric need was high (82 cases or 61% of expected live-threatening maternal conditions did not receive appropriate intervention). The limited effectiveness of maternity care is the result of deficiencies of all service components. We propose a two-pronged approach by starting quality improvement of maternity care from both ends of maternity services: preventive interventions for all women and hospital-based obstetric care. Antenatal screening needs to be rationalized by reducing inflated risk catalogues that result in stereotypical and often rejected referral advice.

From diagnosis to drug taking: staff compliance with guidelines and patient compliance to prescriptions in Burkina Faso.

OBJECTIVE: We studied compliance with guidelines and prescriptions for six steps of the health care process to identify the step with the greatest need for improvement. DESIGN: In a cross-sectional study we used hidden observation in health centres and counting of remaining drugs in home visits. We assessed provider compliance with guidelines for medical history, physical examination, drug choice, and explanation of drug dosing, and patient compliance for drug buying and drug taking. SETTING: The study took place in six rural health centres in Burkina Faso. MAIN OUTCOME MEASURES: We measured unconditional (UPC), conditional (CPC) and accumulated proportions of compliant procedures (APC). UPC determined the proportion of compliant procedures independent from earlier steps. CPC was defined as the proportion of compliant procedures among those which were compliant in all previous steps. APC was the proportion of procedures compliant in all steps including the step concerned. RESULTS: Twenty-three per cent UPC medical history, 27% UPC (CPC = 39%) clinical examination, 59% (83%) drug choice, 22% (40%) explanation of dosing, 71% (75%) drug buying, and 63% (67%) drug taking compliance. Two per cent of the patients had compliant procedures for all steps of the process (APC). CONCLUSION: The majority of patients did not get treatment compliant with guidelines. Diagnosis had the largest need for improvement. UPC, CPC and APC were useful to identify steps with the greatest need for improvement and to assess quantitatively aspects of quality of care.

Rationality of drug prescriptions in rural health centres in Burkina Faso.

The objective of this study is to investigate the quality of drug prescriptions in nine health centres of three districts in rural Burkina Faso. 313 outpatient consultations were studied by methods of guided observation. Additionally interviews were held with the health care workers involved in the study. A total of 793 drugs prescribed by 15 health care workers during the observation period and 2815 prescribed drugs copied from the patient register were analyzed. An average of 2.3 drugs were prescribed per visit. 88.0% of the prescribed drugs were on the essential drug list. 88.4% were indicated according to the national treatment guidelines. 79.4% had a correct dosage. The study revealed serious deficiencies in drug prescribing that could not be detected by assessing selected quantitative drug-use indicators as recommended by the WHO. In two-thirds of the cases the patients received no information on how long the drug had to be taken. Errors in dosage occurred significantly more often in children under 5 years. The combined analysis of choice and dosage of drugs showed that 59.3% of all the patients received a correct prescription. Seven out of 21 pregnant women received drugs contraindicated in pregnancy. We conclude that assessment of quantitative drug-use indicators alone does not suffice in identifying specific needs for improvement in treatment quality. We recommend that prescribing for children under 5 and for pregnant women should be targeted in future interventions and that the lay-out, content and distribution of treatment guidelines must be improved.

Performance of village pharmacies and patient compliance after implementation of essential drug programme in rural Burkina Faso.

After implementation of a nation-wide essential drug programme in Burkina Faso a prospective study was undertaken consisting of non-participant observation in the health centre and in the village pharmacy, and of household interviews with the patients. The study covered all general consultations in nine health centres in three districts over a two-week period as well as all client-vendor contacts in the corresponding village pharmacies; comprising 313 patients in consultations and 498 clients in eight village pharmacies with 12 vendors involved in dispensing 908 drugs. Additionally patients were interviewed in their households. Performance and utilization of the village pharmacy: 82.0% of the drugs prescribed in the health centres were actually dispensed at the village pharmacy, 5.9% of the drugs were not available at the village pharmacy. Wrong drugs were dispensed in 2.1% of cases. 41.3% of the drugs dispensed in the village pharmacy were bought without a prescription. Differences are seen between the district and are put in relation to different onset of the essential drug programme. Patient compliance: Patients could recall the correct dosage for 68.3% of the drugs. Drug taking compliance was 63.1%, derived from the pills remaining in the households. 11.5% of the drugs had obviously been taken incorrectly to such an extent that the occurrence of undesired drug effects was likely. The study demonstrates the success of the essential drug programme not only in performance but also in acceptability and utilization by the population.

Diagnostic quality in rural health centres in Burkina Faso.

OBJECTIVE: To study the quality of diagnostic practice in rural Burkina Faso. METHOD: In 9 health centres of 3 districts, 313 outpatient consultations were observed, and 417 diagnoses by 15 nurses were analysed. Criteria for evaluation of patient history and clinical examination were based on the diagnostic guidelines distributed by the Ministry of Health. RESULTS: In only 20% of the diagnoses the nurses took a sufficient history and in only 40% they conducted a sufficient clinical examination. In 21% patients underwent no clinical examination at all. Only 12% of all diagnoses were based on sufficient history-taking and adequate clinical examinations. The individual elements of clinical examination were performed correctly in 82% of cases. The variation between nurses was immense, but no correlation could be found with regard to their basic training. However, nurses who had received the diagnostic guidelines examined patients more carefully than those who had not. Larger numbers of patients per day are not associated with shorter nurse-patient contact, and neither is sufficiency of patient history associated with duration of the consultation. CONCLUSION: The low diagnostic quality of the outpatient consultations in the studied area indicates that this issue has been neglected in national public health initiatives. But examination skills are good and diagnostic guidelines may have had a positive effect on the diagnostic quality.

Utilization of health care in an African urban area: results from a household survey in Ouagadougou, Burkina-Faso.

This study analysed the level of utilization of different kinds of health care providers, and its correlates, by people reporting an illness via a household health survey in a representative sample of 547 households (3667 persons) in the city of Ouagadougou, Burkina-Faso in 1989. More than one-fourth of the sample reported suffering from a health care problem in the 2-week period preceding the interview. Self care was the most frequently reported type of care received (55.6%). Bivariate analysis and logistic regression revealed that the principal determinants of the utilization of modern care givers were age, socio-economic level, illness characteristics (type, length, severity), and cost of care and transportation. In particular, we found that: (1) Even though the family remained the main provider of care in case of minor (mild and short) illnesses, it did not prevent modern health facilities from playing their curative role in case of serious illnesses. (2) Residential zone (central versus peripheral zone) was not significantly associated with health care choice, which was contrary to expectation. (3) On the other hand, socio-economic status strongly affected health-seeking behavior. (4) The travel pattern of the ill persons favored health carde facilities in the central zone. Taken together, the results of this study question the role of community health workers in the urban program of community health care which was in the process of being implemented at the time of the study. They suggest that the family, instead of the community health workers, should be seen as the provider of curative care for minor illnesses. Community health workers may have a more effective role in health education than in curative tasks.

Seasonal variations of household costs of illness in Burkina Faso.

This paper assesses the seasonal variations of the time and financial costs of illness for rural households in Burkina Faso. It is based on a multiple round survey of 566 households, which included a time allocation study. The economic parameters of households which influence health seeking behavior changed substantially between the dry and rainy seasons: revenues fell in the rainy season and were exceeded by expenditures. Household production was at its peak in the rainy season resulting in significantly higher opportunity costs of time. At the same time illness perception changed: in the rainy season, significantly fewer illness episodes were perceived, and of those, the proportion perceived as severe decreased over-proportionally. Households shifted their healer choice in the rainy season away from high cost treatment, such as the hospital and dispensary, to low cost home treatment. For all these reasons, households incurred significantly fewer costs of illness in the rainy season (27% of dry season costs). Household health care expenditures were reduced to 1/6 of dry season levels, the time costs incurred by healthy household members to tend to the sick was reduced to 1/5 and the time costs of work incapacity due to sickness fell to about 1/2 of dry season levels. The authors stress the need to carry out research in all relevant seasons when studying health seeking behavior and the household costs of illness in order to avoid serious seasonal bias. They suggest policy options to increase health care utilization in the rainy season by reducing the financial and time costs of access to health care. Finally, the authors put forward a hypothesis to be tested by future research: They argue that the cognitive (changes in illness perception) and behavioral changes (different health care seeking) reflect the high opportunity costs of time and the low availability of cash households face during the rainy season. The paper discusses the negative implication that untreated illness has on the health status of household members.

The economic costs of illness for rural households in Burkina Faso.

Analyses of the health costs in developing countries have mainly dealt with provider costs. This is in spite of the fact that the bulk of illness related costs is borne by households. Where studied, household time and financial costs have not been treated in a comprehensive way. However, an incomplete cost assessment will lead to an underestimation of household costs. Using data from a household interview survey in a rural area of Burkina Faso, the authors carried out an exhaustive assessment of the economic cost of illness that households incur. Financial costs included out-of-pocket expenditures for drugs, fees, transport to the treatment site, lodging and food for accompanying household members. Time costs, in turn, were comprised of production foregone both by the sick person and by healthy household members, who tended to the sick. Time costs amounted to by far the largest proportion (73%) of total household costs. Of the total amount of illness related time loss of the average household, 45% was due to the fact that healthy household members tended to or accompanied their sick kin. Of the financial cost items, expenditures for drugs or traditional products represented 62%. When Western type services were sought, expenditures for transport, food etc., exceeded those for treatment fees. Total cost of illness was 4,002 F CFA/month for the average household. This amounted to 3.7% of household income and to 6.2% of household expenditures in the reference month. The authors discuss policy measures aimed to reduce household time costs.(ABSTRACT TRUNCATED AT 250 WORDS)

Schistosomiasis in the southern region of Oman: vector snails and serological identification of patients in several locations.

The snail Biomphalaria arabica is apparently ubiquitous in the south of Oman (Dhofar province). Snails bred in the laboratory were susceptible to infection with miracidia of Schistosoma mansoni (Puerto Rican strain). The snail Bulinus wrighti, a potential intermediate host of S. haematobium, was found for the first time in Dhofar. Human sera from five localities had antibodies against adult worm antigens and in particular against Sm31/32. The prevalence of seropositive patients was 28% of 47 farm workers, 12% of 99 out-patients from a clinic and 1% of 389 children from four localities. Autochthonous transmission of schistosomiasis in Dhofar is discussed.

Evidence of sex variations in microfilaraemia and fluorescent antibody titre level at puberty in a bancroftian filariasis endemic area.

1101 children and young adults between 2 and 17 years age, residing in Bancroftian filariasis endemic area of the Jharia Coalfields in Bihar, were examined by Indirect Immunofluorescent Test (IIFT) against Dipetalonema Vitae. The results, along with those of two night blood surveys conducted in the same area, covering 2148 and 2246 persons respectively, are reported. In the prepubertal age groups there was no statistically significant variation in the percentage of children showing positive antibody titre in either sex, but a sudden fall of more than 50 per cent in the antibody level was observed in females at the onset of puberty. This did not occur in males. Analysis of the night blood results also indicated a remarkable fall in microfilaria rate and density in females at the onset of puberty and a low level was then maintained over the whole of the child bearing age. No such change was observable in males. Sex differences in the susceptibility of the host to helminthic infections is well-known and in animal experiments the effect of sex hormones in modifying such susceptibility has been established. In human filariasis the probable part played by the male and female sex hormones in bringing about abrupt changes in immunoresponse and infection rate at the onset of puberty is discussed.

Problems related to schoolgirl pregnancies in Burkina Faso.

A qualitative study of pregnancy among schoolgirls in a small town in Burkina Faso was conducted that described the situation of pregnant students and their motherhood, their social environment, and the situation of their children. The analysis of findings revealed four main factors that influenced students' pregnancies: lack of contraceptive knowledge, ambiguous feelings about pregnancy and contraception, conflicting messages concerning the reproductive role of young women, and the girls' low self-esteem in their interaction with older, experienced male partners. The study revealed that existing family planning programs fail to address the needs of the sexually active school-age population. Recommendations are made concerning sex education and service delivery.

Estimating the direct and indirect economic costs of malaria in a rural district of Burkina Faso.

Comprehensive estimates of the direct economic costs of malaria should include not only the costs of care at established health facilities, but also other expenditures, such as travel and out-of-pocket costs of drugs. They should include all episodes of illness, whether or not the patient attended a health facility. Also, the indirect economic costs, which are based on the value of time lost due to illness, consider seasonal variations in the marginal product of labor according to the agricultural season. A 1985 representative survey of 626 households in Solenzo medical district, Burkina Faso, provided household data on health service utilization, expenditures, and agricultural production with which to implement these refinements. Numbers of malaria deaths and cases were estimated by adjusting survey totals according to monthly patterns of reported malaria deaths. The marginal product of labor was valued according to typical activities in each of three agricultural seasons: brewing millet beer during the maintenance period (January-February), growing cotton during the cash crop season (March-April), and growing millet and sorghum during the food crop season (May-December). The resulting values were $0.28, $1.09, and $0.55 per day, respectively. Cost per case averaged $5.96 and cost per capita $1.15. Indirect cost due to mortality was the largest cost component ($0.79 per capita), followed by direct costs incurred by the user (e.g. transportation costs and drug purchases, $0.22 per capita). Direct costs paid by providers were small, only $0.04 per capita. A household survey provides the necessary data for more comprehensive population-based estimates of costs of malaria.

Assessment of MCH services in the district of Solenzo, Burkina Faso. II. Acceptability.

Acceptability of professional MCH services in the district of Solenzo was assessed using the techniques of time and motion study combined with a user survey of attending mothers. A large proportion of mothers said to have difficulty in using the services. Three types of problems were identified and their relevance discussed: (i) wasting mothers' time through inappropriate opening hours, long waiting time in contrast with short contact time; (ii) organizational features, i.e. fragmentation of clinics offering single MCH components at different times; and (iii) staff behaviour, i.e. poor communication with users. While services do little to help mothers to utilize them, mothers were shown to receive little support in their work at home from their families while attending the clinic. Possible ways to increase acceptability of MCH care are outlined.

Assessment of MCH services offered by professional and community health workers in the district of Solenzo, Burkina Faso. I. Utilization of MCH services.

A representative household survey of a district of Burkina Faso was carried out in order to study the utilization of trained birth attendants (TBA) versus professional health workers as providers of under fives' (UFC), antenatal (ANC), and maternity care (MC). Overall utilization by the target groups varied between 13 per cent (UFC), 31 per cent (ANC), and 32 per cent (MC). The presence of a village health post did not increase utilization of MCH care. Furthermore, those who did utilize, preferred to choose another source of care: the professional midwife for ANC, the traditional 'old woman' for delivery. Sick infants were generally not taken to the village health worker (VHW), but rather treated by the family itself. The determinants of utilization were assessed by means of multivariate analysis. The level of care offered in the village (health post, dispensary, and medical centre), educational level of both the mother and the husband, and ethnic group were identified as major factors influencing health seeking behaviour in MCH. A strong case is made for improvement of quality of care before extension of geographical coverage. The importance of involving husbands in sensitization for the utilization of MCH-care is stressed and the implications are discussed for the role of the community health workers in caring for mothers and children.