Reproductive health in rural Malawi: a population-based survey.

OBJECTIVES: To assess pregnancy outcome, maternal mortality and health-seeking behaviour in a rural African population and to assess the effects on these of women's education, distance from a health centre and household type. DESIGN: Descriptive population-based study. SETTING: A rural community in southern Malawi. POPULATION: All women living in the catchment area of a rural health centre. METHODS: Interviews with women in 20,649 households using structured questionnaires. MAIN OUTCOME MEASURES: Pregnancy outcome, the effect of women's education, distance from a health centre and household type on pregnancy outcome, maternal morbidity and estimates of maternal and perinatal mortality. RESULTS: Educational level was lower for women than for men. A significant association was found between educational level and fertility. Women aged 45-49 reported an average of six pregnancies with four resulting in currently living children. Successful pregnancy outcome was more likely with increased education and if the woman lived closer to the health centre. Despite living an average of 5 km from the health centre, over 90% of women attended antenatal clinic with a mean of five visits. Assistance at delivery by a trained health care worker was more likely as education increased and was less likely as distance from the health centre increased. Maternal mortality was reported at 413 per 100,000 deliveries (95% CI 144-682). The perinatal mortality rate in this population was estimated at 30 per 1000. An increased perinatal mortality was noted for women who were delivered by a female relative. Perinatal mortality rates were similar for delivery by a traditional birth attendant or a trained nurse-midwife. Education and proximity to the health centre were both associated with improved outcome. CONCLUSIONS: Many women in this rural community suffer the consequences of high pregnancy loss. Maternal and perinatal mortality are high. Improved education and skilled assistance at delivery can result in improved pregnancy outcome. Proximity of any household to a health centre has an effect on outcomes.

Diagnosing anaemia in pregnancy in rural clinics: assessing the potential of the Haemoglobin Colour Scale.

Anaemia in pregnancy is a common and severe problem in many developing countries. Because of lack of resources and staff motivation, screening for anaemia is often solely by clinical examination of the conjunctiva or is not carried out at all. A new colour scale for the estimation of haemoglobin concentration has been developed by WHO. The present study compares the results obtained using the new colour scale on 729 women visiting rural antenatal clinics in Malawi with those obtained by HemoCue haemoglobinometer and electronic Coulter Counter and with the assessment of anaemia by clinical examination of the conjunctiva. Sensitivity using the colour scale was consistently better than for conjunctival inspection alone and interobserver agreement and agreement with Coulter Counter measurements was good. The Haemoglobin Colour Scale is simple to use, well accepted, cheap and gives immediate results. It shows considerable potential for use in screening for anaemia in antenatal clinics in settings where resources are limited.

PIP: In developing country settings, screening of pregnant women for anemia may be limited to inspection of the conjunctiva for the presence of pallor. The potential for anemia diagnosis of a new color scale for the estimation of hemoglobin (Hb) was assessed in a study conducted at three rural hospitals and two health centers in southern Malawi. The Hemoglobin Color Scale, recently developed by the World Health Organization, is simple to use, inexpensive, and gives an immediate result. A total of 729 pregnant women underwent conjunctiva examination, HemoCue hemoglobinometer reading, electronic Coulter Counter analysis, and at least one Hemoglobin Color Scale reading (n = 1066 observations). Each of these tests was performed by a different trained nurse-midwife to reduce the potential for bias. According to the Coulter Counter measurements, 58.1% of participants had Hb levels of 11 g/dl or less, 32.0% were 10 g/dl or less, and 4.0% were 8 g/dl or less. Sensitivity was 80.0-96.6% for HemoCue, 33.2-62.1% for conjunctiva examination, and 50.0-81.6% for the Hemoglobin Color Scale. Positive predictive values were 46.8-68.1% for HemoCue, 1.2-75.0% for conjunctival examination, and 11.0-66.2% for the color scale. The highest sensitivity for the color scale was obtained at a cut-off point of 10 g/dl and the highest positive predictive value at 11 g/dl. Agreement of the Hemoglobin Color Scale readings to within +or- 1 g/dl of the Coulter Counter measurement was obtained in 40% of cases; agreement to within 2 g/dl occurred in 67% of cases. The positive predictive value of the Hemoglobin Color Scale increases with increases in the prevalence of severe anemia.