Factors influencing maternal healthcare seeking in a highland region of Madagascar: a mixed methods analysis.

BACKGROUND: In Madagascar, maternal mortality remains stable and high (426 deaths per 100,000 live births). This situation is mainly due to a delay or lack of use of maternal healthcare services. Problems related to maternal healthcare services are well documented in Madagascar, but little information related to maternal healthcare seeking is known. Thus, this paper aims to identify and analyze the factors that influence the utilization of maternal services, specifically, the use of antenatal care (ANC) during pregnancy and the use of skilled birth attendants (SBAs) at delivery. METHOD: We used quantitative and qualitative approaches in the study. Two communes of the Vakinankaratra region, which are located in the highlands, were the settings. Data collection occurred from October 2016 to July 2017. A total of 245 pregnant women were included and followed up in the quantitative survey, and among them, 35 participated in in-depth interviews(IDIs). Logistic regressions were applied to explore the influencing factors of antenatal and delivery healthcare seeking practices through thematic qualitative analysis. RESULTS: Among the 245 women surveyed, 13.9% did not attend any ANC visits. School level, occupation and gravidity positively influenced the likelihood of attending one or more ANC visits. The additional use of traditional caregivers remained predominant and was perceived as potentially complementary to medical care. Nine in ten (91%) women expressed a preference for delivery at healthcare facilities (HFs), but 61% of births were assisted by a skilled birth attendant (SBA).The school level; the frequency of ANCs; the origin region; and the preference between modern or traditional care influenced the use of SBAs at delivery. A lack of preparation (financial and logistics problems) and women's low involvement in decision making at delivery were the main barriers to giving birth at HFs. CONCLUSION: The use of maternal healthcare services is starting to gain ground, although many women and their relatives still use traditional caregivers at the same time. Relatives play a crucial role in maternal healthcare seeking. It would be necessary to target women's relatives for awareness-raising messages about ANC and childbirth in healthcare facilities and to support and formalize collaborations between traditional healers and biomedical caregivers.

Zoonotic Semiotics: Plague Narratives and Vanishing Signs in Madagascar.

Zoonosis calls for a multispecies approach to medical semiotics, a method involving the decipherment of outward symptoms and the construction of narrative. In Madagascar, early detection of bubonic plague outbreaks relies on sightings of sick and dead rats. However, people most vulnerable to plague often do not perceive warning signs, and plague symptoms do not always present in rat and human bodies. In August 2015, a plague outbreak killed 10 residents of a rural hamlet in the central highlands. To reconstruct the transmission chain, scientists elicited survivors' memories of dead rats in the vicinity. Not only were these clues imperceptible to most, but residents had also constructed an alternative outbreak narrative based on different evidence. Stark health disparities, a lack of historical memory of the plague, and genetic adaptations of rats and plague bacteria have created a problem of "semiotic cluelessness" that complicates outbreak control measures and increases mortality.

Genomic landscape of human diversity across Madagascar.

Although situated ∼400 km from the east coast of Africa, Madagascar exhibits cultural, linguistic, and genetic traits from both Southeast Asia and Eastern Africa. The settlement history remains contentious; we therefore used a grid-based approach to sample at high resolution the genomic diversity (including maternal lineages, paternal lineages, and genome-wide data) across 257 villages and 2,704 Malagasy individuals. We find a common Bantu and Austronesian descent for all Malagasy individuals with a limited paternal contribution from Europe and the Middle East. Admixture and demographic growth happened recently, suggesting a rapid settlement of Madagascar during the last millennium. However, the distribution of African and Asian ancestry across the island reveals that the admixture was sex biased and happened heterogeneously across Madagascar, suggesting independent colonization of Madagascar from Africa and Asia rather than settlement by an already admixed population. In addition, there are geographic influences on the present genomic diversity, independent of the admixture, showing that a few centuries is sufficient to produce detectable genetic structure in human populations.

Lost in translation: conflicting views of deforestation, land use and identity in western Madagascar.

This paper focuses on the interplay between environmental narratives, identity politics and the management of forest resources in Madagascar. While efforts to conserve the island's biological diversity have centred primarily on the designation of protected areas, policies have increasingly focused on local communities. The experiences of the last 20 years have shown that community-based approaches to conservation offer considerable challenges due to the complex politics of natural resource use, which involve multiple and diverse stakeholders, often with very different and sometimes conflicting values. In this paper, I focus on the environmental perceptions and values of two groups in the Central Menabe region of western Madagascar ­ conservation organisations and rural households ­ revealing a contrasting set of views regarding the region's forest. I show that the conservation discourse has changed over time, increasingly emphasising the biological diversity of the region's tropical dry-deciduous forest and prioritising non-consumptive uses of natural resources. Although policy has changed in response to changing values, I show that it has been underpinned by the notion that hatsake ('slash-and-burn' agriculture) is an irrational practice driven by necessity rather than choice. Policy has thus sought to provide livelihood alternatives, firstly through forestry, then through changes in cultivation and increasingly through tourism. This misunderstands the local view of the forest, which sees hatsake as a way to make the land productive, as long as it is carried out responsibly according to local fady (taboos). As well as facing problems of translating conservation goals into local values and misunderstanding the motives for forest clearance, policy has been based on a narrative that attaches particular land use practices to ethnic identities. I argue that this ignores the history and fluid reality of both identity and land use.

Malagasy dialects and the peopling of Madagascar.

The origin of Malagasy DNA is half African and half Indonesian, nevertheless the Malagasy language, spoken by the entire population, belongs to the Austronesian family. The language most closely related to Malagasy is Maanyan (Greater Barito East group of the Austronesian family), but related languages are also in Sulawesi, Malaysia and Sumatra. For this reason, and because Maanyan is spoken by a population which lives along the Barito river in Kalimantan and which does not possess the necessary skill for long maritime navigation, the ethnic composition of the Indonesian colonizers is still unclear. There is a general consensus that Indonesian sailors reached Madagascar by a maritime trek, but the time, the path and the landing area of the first colonization are all disputed. In this research, we try to answer these problems together with other ones, such as the historical configuration of Malagasy dialects, by types of analysis related to lexicostatistics and glottochronology that draw upon the automated method recently proposed by the authors. The data were collected by the first author at the beginning of 2010 with the invaluable help of Joselinà Soafara Néré and consist of Swadesh lists of 200 items for 23 dialects covering all areas of the island.

The Arabo-Islamic migrations in Madagascar: first genetic study of the GM system in three Malagasy populations.

The Antemoro are an ethnic group from the southeast coast of Madagascar who claims an Arab origin. Cultural signatures of an Arabo-Islamic influence have been found in this region. Nevertheless, their origins are very contentious. Through this study, we want to determine whether this ethnic group had a particular GM profile that differentiated it from other Malagasy populations, and whether there were detectable genetic traces of the Arabo-Islamic migration. The Gm polymorphisms of IgG immunoglobulins was analysed in a population of Antemoro (N = 85), two other Malagasy populations from northern Fiherena (N = 82) and southern Fiherena (N = 50) and in a Comorian population (N = 171). This last group was used to enlarge the database for genetic comparisons. Results revealed significant contributions from Africa (60%, 0.092 ≤F(ST) ≤ 0.280) and Southeast Asia (40%, 0.043 ≤ F(ST) ≤ 0.590) to the Antemoro genetic pool. No direct genetic relationships with the Middle East. These results bring new insights into the population history of Madagascar.

[Dengue fever in the Reunion Island and in South Western islands of the Indian Ocean]. / Dengue à la Réunion et dans les îles du sud-ouest de l'océan Indien.

South Western islands of the Indian Ocean are permanently threatened by dengue fever outbreaks. On the Reunion Island, two dengue outbreaks were biologically documented (1977-1978 and 2004). And since July 2004 there has been an inter-epidemic period for the island with sporadic cases and clusters. Between January 1, 2007 and October 5, 2009, the epidemiologic surveillance system detected five confirmed autochthonous cases, five confirmed imported cases (South-East Asia), and 71 probable cases. All the five autochthonous confirmed cases occurred in Saint-Louis during two consecutive clusters. In other South Western islands of the Indian Ocean, several dengue fever outbreaks have been reported. Importation of dengue virus from South-East Asia is a major risk for a new outbreak on the island. The introduction of a new serotype could lead to the emergence of new and severe clinical forms, including dengue hemorrhagic fever.

[Tuberculous pericarditis: still a relevant disease]. / La péricardite tuberculeuse: un diagnostic qui reste d'actualité

Vaccination against tuberculosis is not an obligation anymore in France, except for children at risk, but this disease remains not so rare, including its extrapulmonary forms. The authors report the case of a 27-year-old Madagascan HIV seronegative patient, who developed a pericardial effusion when coming back from a long stay in Madagascar. An anti-inflammatory treatment and then a probabilistic antibiotic treatment were ineffective, and at the same time echocardiographic signs of tamponade appeared. As a consequence, it was decided to perform a surgical pericardial drainage and a biopsy, and to introduce an antituberculosis chemotherapy, given the epidemiologic status. The course was then quickly favorable. The presence of granulomatous inflammation on the biopsy and an elevated pericardial adenosine deaminase activity level retrospectively supported the diagnosis of tuberculous pericarditis.

"... But then he became my sipa": the implications of relationship fluidity for condom use among women sex workers in Antananarivo, Madagascar.

Increasing evidence indicates that sex workers use condoms less consistently with regular (i.e., nonpaying) partners than with clients. Few studies have examined the extent to which these 2 categories are mutually exclusive. In an ethnographic study of women's sex work in Antananarivo, Madagascar, we examined how the meaning of women sex workers' sexual relationships could shift among 3 different forms of sex work. Condom use was less likely in forms in which the distinction between client and lover (sipa in Malagasy) was fluid. For many sex workers, therefore, relationships they understood to be intimate imparted the greatest health vulnerability. It is important to examine the influence of the meaning of sexual relationships on condom use for HIV prevention. Policy implications for HIV prevention work with sex workers are considered.

Independent association of hip circumference with metabolic profile in different ethnic groups.

OBJECTIVE: In whites, a larger hip circumference has been shown to be associated with a better metabolic profile, after adjustment for BMI and waist circumference. Our aim was to investigate this association in a variety of ethnic groups, some highly susceptible to type 2 diabetes. RESEARCH METHODS AND PROCEDURES: We measured weight, height, waist and hip circumferences, systolic and diastolic blood pressure, fasting and 2-hour postload glucose, triglycerides, and high-density lipoprotein-cholesterol in 1020 Melanesians, 767 Micronesians, 3697 Indians, and 2710 Creoles from Pacific and Indian Ocean islands. Leptin and body fat percentage were determined in Indian and Creole Mauritians only. RESULTS: In all ethnic groups, larger hip circumference was associated with lower glucose and triglyceride levels in both sexes and higher high-density lipoprotein levels in women only, after adjustment for waist circumference, BMI, and age. Adjustment for height or leptin did not materially change the results. DISCUSSION: In conclusion, we confirmed the protective association of relatively larger hips in four nonwhite ethnic groups. Leptin does not seem to play a mediating role in this association.

A genetic marker at the glucokinase gene locus for type 2 (non-insulin-dependent) diabetes mellitus in Mauritian Creoles.

The prevalence of Type 2 (non-insulin-dependent) diabetes mellitus is high in Mauritius, a multiethnic island nation in the southwestern Indian Ocean. Evaluation of candidate genes in the different ethnic groups represents a means of assessing the genetic component. As glucokinase is known to be a key regulator of glucose homeostasis in liver and pancreatic Beta-cells, the human gene was isolated and a dinucleotide repeat (CA)n marker was identified at this locus. A polymerase chain reaction assay was developed, and alleles differing in size were observed in individuals, according to the number of repeats in the amplified fragment. Eighty-five Creoles and 63 Indians of known glucose tolerance status were typed by amplification of genomic DNA for this dinucleotide (CA)n repeat marker. Four different alleles were observed including Z, the most common allele, and Z + 2, Z + 4, and Z + 10, which differed from Z by 2, 4, and 10 nucleotides respectively. In Mauritian Creoles, the frequency of the Z + 2 allele was greater in Type 2 diabetic subjects than in control subjects (23.8% vs 8.9%, p = 0.008), and the frequency of the Z allele was lower in Type 2 diabetic subjects (60% vs 75.6%, p = 0.03). Analysis with univariate logistic regression models indicated that the Z + 2 allele had the highest odds ratio, 3.08 (95% confidence interval 1.14-8.35, p = 0.0416), among the other risk factors (age, sex, body mass index, and waist/hip ratio). The multivariate odds ratio for Type 2 diabetes was 2.88 (95% confidence interval 0.98-8.50, p = 0.0551).(ABSTRACT TRUNCATED AT 250 WORDS)