Declining maternal mortality ratio in Uganda: priority interventions to achieve the Millennium Development Goal.

PURPOSE: We conducted a survey to determine availability of emergency obstetric care (EmOC) and to provide data for advocating for improved maternal and newborn health in Uganda. METHODS: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions, documented maternal deaths and the related causes. Three levels of health facilities were covered. FINDINGS: Few health units had running water; electricity or a functional operating theater. Yet having these items had a protective effect on maternal deaths as follows: theater (OR 0.56, P<0.0001); electricity (OR 0.39, P<0.0001); laboratory (OR 0.71, P<0.0001) and staffing levels (midwives) OR 0.20, P<0.0001. The availability of midwives had the highest protective effect on maternal deaths, reducing the case fatality rate by 80%. Further, most (97.2%) health facilities expected to offer basic EmOC, were not doing so. This is the likely explanation for the high health facility-based maternal death rate of 671/100,000 live births in Uganda. CONCLUSION: Addressing health system issues, especially human resources, and increasingaccess to EmOC could reduce maternal mortality in Uganda and enable the country to achieve the Millennium Development Goal (MDG).

Emergency obstetric care as the priority intervention to reduce maternal mortality in Uganda.

PURPOSE: We conducted a survey to determine availability of emergency obstetric care (EmOC) to provide baseline data for monitoring provision of obstetric care services in Uganda. METHODS: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions. Following this, performance improvement process was implemented in 20 district hospitals to scale-up EmOC services. FINDINGS: A maternal mortality ratio (MMR) of 671/100,000 live births was recorded. Hemorrhage, 42.2%, was the leading direct cause of maternal deaths, and malaria accounted for 65.5% of the indirect causes. Among the obstetric complications, abortion accounted for 38.9% of direct and malaria 87.4% of indirect causes. Removal of retained products (OR 3.3, P<0.002), assisted vaginal delivery (OR 3.3, P<0.001) and blood transfusion (OR 13.7, P<0.001) were the missing signal functions contributing to maternal deaths. Most health facilities expected to offer basic EmOC, 349 (97.2%) were not offering them. Using the performance improvement process, availability of EmOC in the 20 hospitals improved significantly. CONCLUSION: An integrated programming approach aiming at increasing access to EmOC, malaria treatment and prevention services could reduce maternal mortality in Uganda.

A sector-wide approach to emergency obstetric care in Uganda.

PURPOSE: To establish a baseline for the availability, utilization, and quality of EmOC, and to help develop an operational strategy based on the findings. METHODS: A needs assessment of emergency obstetric care (EmOC) was carried out in 197 health facilities in 19 out of 56 districts in Uganda, covering 38% of the total population. FINDINGS: There were a large number of missing signal functions at health facilities and an urgent need to improve the availability of EmOC. CONCLUSION: By using the data from the assessment, it was possible to influence national policy through the health sector-wide approach (SWAp) and place EmOC high on the national agenda. A national strategy and roll out plan to strengthen EmOC is now in place.

Integrated management of childhood illness: a summary of first experiences.

The strategy of Integrated Management of Childhood Illness (IMCI) aims to reduce child mortality and morbidity in developing countries by combining improved management of common childhood illnesses with proper nutrition and immunization. The strategy includes interventions to improve the skills of health workers, the health system, and family and community practices. This article describes the experience of the first countries to adopt and implement the IMCI interventions, the clinical guidelines dealing with the major causes of morbidity and mortality in children, and the training package on these guidelines for health workers in first-level health facilities. The most relevant lessons learned and how these lessons have served as a basis for developing a broader IMCI strategy are described.

PIP: This article delineates the experience of the first countries to adopt and implement the Integrated Management of Childhood Illness (IMCI) strategy in reducing child mortality and morbidity through the combination of improved management of common childhood illnesses and proper nutrition and immunization. The strategy includes intervention schemes involving improving the skills of health workers, the health systems, and the family and community practices. IMCI implementation proceeds in three phases. The first phase involves activities for the introduction of IMCI, in which clinical guidelines involving the review of child health policies and reorganization of services and interventions are discussed. The second phase is the initial implementation, in which each country adapts the generic IMCI clinical guidelines to suit its own epidemiological and cultural characteristics and begins implementing them in a limited number of districts. The third phase involves expanding of IMCI through increasing access to its programs and broadening the range of its interventions. In this phase, problems identified during the early implementation are addressed, priorities are identified, and strategies for expanding access while maintaining quality are developed. The introduction of the IMCI strategy helped develop and update national policies in the management of sick children. The implementation of IMCI brings together a broader range of programs and national medical expertise relating to child health. The program serves as a catalyst for the identification of substantial weaknesses in public health systems.

Neonatal tetanus mortality in coastal Kenya: a community survey.

In a house-to-house survey in Kilifi District, Kenya, mothers of 2556 liveborn children were interviewed about neonatal mortality, especially from neonatal tetanus (NNT). The crude birth rate was 60.5 per 1000 population, the neonatal mortality rate 21.1 and the NNT mortality rate 3.1 per 1000 livebirths. The neonatal and NNT mortality rates were higher in boys than in girls. Neonatal tetanus was not associated with mother's age, parity, or history of previous child death. The majority of the children (72%) were adequately protected at birth against NNT; in those with documented protection NNT mortality was 0, in those with undocumented protection 1.2 and in other children 8.5 per 1000 livebirths. Other risk factors for NNT included home delivery, untrained assistance during delivery, unhygienic cord cutting and application of potentially infectious substances on the umbilical stump. The survey indicates that over the past decade the surveyed area has greatly reduced neonatal and NNT mortality. Possible strategies for accelerated NNT control have been identified by the survey.

Effect of vitamin A on diarrhoeal and respiratory complications of measles.

A randomized placebo-controlled trial of high dose vitamin A in acute measles was performed in Nairobi, Kenya to determine if it reduced the incidence or severity of diarrhoeal and respiratory complications. On enrollment laryngotracheobronchitis (LTB) pneumonia, diarrhoea and otitis media were each found in 45-80% of children in the treatment and placebo groups. While 4 of 119 cases of LTB in the placebo group progressed to grade III (loud stridor, markedly diminished air entry, chest indrawing, cyanosis), none of 116 in the vitamin A group did. Episodes of diarrhoea, but not pneumonia, resolved faster and were less severe in the vitamin A group. There were no differences in the incidences of pneumonia, LTB or diarrhoea during hospitalization, but children treated with vitamin A had a lower rate of developing otitis media. The overall case fatality rate was 2.7% and did not differ by group. These findings, along with those from three other trials in Africa, suggest that high dose vitamin A reduces the severity of complications during measles.

Escherichia coli associated with acute measles and diarrhoea at Kenyatta National Hospital, Kenya.

Three hundred and three children under 5 years old with acute measles and diarrhoea (cases) and 300 other age-matched children with diarrhoea (controls) were examined for enteroadherent E. coli (EAEC) and other agents including rotavirus and Cryptosporidium. EAEC was determined by tissue culture of HEP-2 cells. Other agents were determined by conventional methods. EAEC was identified from both cases and control accounting for 10.3% (31/303) and 15.2% (46/300) respectively. Other bacterial agents were: 10.3% (31/303) from cases and 12.8% (39/300) from controls. A higher detection rate of enteroparasites was found among cases 15% (45/300) than controls 8.9% (27/300) whereas rotavirus was the reverse, 3% (9/303) in cases and 30.3% (92/300) in controls. To our knowledge characterization of EAEC has not been done before and therefore might be attributing factor to some of our unexplained diarrhoeal cases.