Pelvic organ prolapse and incontinence in developing countries: review of prevalence and risk factors.

INTRODUCTION AND HYPOTHESIS: Information on the prevalence, risk factors and social consequences of pelvic floor dysfunction (PFD) affecting women in 16 low-income and lower middle-income countries is reviewed. METHODS: Medline searches were performed for articles dealing with prevalence of PFD. RESULTS: Thirty studies were identified. The mean prevalence for pelvic organ prolapse was 19.7% (range 3.4-56.4%), urinary incontinence (UI) was 28.7% (range 5.2-70.8%) and faecal incontinence (FI) was 6.9% (range 5.3-41.0%). Risk factors for PFD are similar to those in more affluent countries particularly increased age and parity, but additionally, PFD is associated with other factors including poor nutrition and heavy work. The social consequences of PFD conditions can be devastating. CONCLUSIONS: Pelvic organ prolapse and urinary and faecal incontinence are significant problems in developing countries. Access to health care to manage these conditions is often limited, and women usually have to live with the consequences for the rest of their lives.

Congenital syphilis: a continuing but neglected problem.

Congenital syphilis was rare in most affluent countries but there has been a slight resurgence recently in several European countries. In large parts of the world and particularly sub-Saharan Africa congenital syphilis is a significant public health problem. The cornerstone of congenital syphilis control is antenatal screening and treatment of mothers with penicillin, which is a cost-effective intervention. In affluent countries it should be strengthened among those at high risk. Clinicians should be more vigilant for the possibility of babies being born with congenital syphilis, which is often asymptomatic. In developing countries not only does antenatal care screening need to be strengthened by implementing point-of-care decentralised screening and treatment but alternative innovative approaches to controlling congenital syphilis should be explored. There is an urgent need for international health agencies to support focused approaches to tackling the tragedy of continuing congenital syphilis. This could be a part of a pro-poor strategy to meet the Millennium Development Goals.

Forgotten but not gone: the continuing scourge of congenital syphilis.

Much attention is being given to the prevention of HIV infection in babies through transmission from the mother. By contrast, regrettably little concern is raised about the increasing numbers of babies born with congenital syphilis. In affluent countries congenital syphilis is very rare, but in many poor countries, including the newly independent countries of eastern Europe and the former Soviet Union, the numbers are high and increasing. In much of sub-Saharan Africa, around 10% of pregnant women are affected by syphilis. The prevention of congenital syphilis is more cost-effective than the prevention of mother-to-child transmission of HIV. The control of congenital syphilis could indirectly have a beneficial effect on the HIV epidemic by reducing susceptibility to infection. Although the procedure to prevent congenital syphilis through antenatal screening and treatment is well established, implementation of effective programmes in resource-poor settings has proved very difficult. A new and focused approach to tackling congenital syphilis is needed. It should combine different mixes of interventions, such as mass treatment, focused screening, and universal screening, according to the local epidemiology and available resources. A task-force approach to defining the most appropriate interventions together with support for some research should be a priority for support under the Global Health Fund.

Identifying maternal deaths in developing countries: experience in Jamaica

Multiple sources were used to idenify maternal deaths and their causes in a study out in Jamaica. These sources of information included a review of all deaths of women aged 12 to 49 years and included those occurring in hospitals (on maternity, surgical and medical wards and in casualty departments); reported to coroners' offices and the police; on whom post-mortems were carried out at hospital, public morgues and for the Ministry of National Security; obtained from interviews with public health staff in all parishes and which were registered with the Registrar General's Department. Some 193 maternal deaths were identified giving a maternal mortality rate of 10 per 10 000 live births. No one source independently identified all maternal deaths. Hospital in-patient records yielded 133 deaths (69 percent), death certificates 74 (38 percent). Deaths due to certain causes were far more likely to be identified from particular sources, e.g., those due to clinical mismanagement (complications of anaesthesia and blood transfusion) from hospital in-patient records; while deaths from ruptured ectopic pregnancy were more likely to come from coroners', police and morgue records. It is concluded that using multiple sources to identify maternal deaths in developing countries is an effective method to identify all maternal deaths. (AU)

The quality of care is related to death rates: hospital inpatient management of infants with acute gastroenteritis in Jamaica

The quality of care of random samples of about 40 infants admitted with acute gastroenteritis to each of five hospitals in Jamaica was assessed. Low levels of adherence to consensus care criteria appeared to be correlated with high levels of hospital-specific severity standardized mortality ratios X100 (SSMRs): poor adherence, SSMR 127-230; intermediate adherence, SSMR 95 ; good adherence, SSMR 14. The main deficiencies in care at certain hospitals were: non-weighing of infants, incomplete physical examination, inadequate estimation of fluid requirements, and irregular recording of fluid intake. To improve the effective care of infants with gastroenteritis, a quality assurance program is required (AU)

Quality assessment of medical care in Jamaica

With the extension of primary health care it is important that attention be directed to ensuring that its quality is acceptable, particularly where resources are limited. In Jamaica, care was assessed in respect of 12 tracer conditions and a confidential inquiry into maternal deaths provided additional information. The tracer conditions were chosen to reflect important health problems and represent age and sex groups and aspects of medical care. The tracer conditions selected for study were acute gastroenteritis in children under 5 years, measles, appendicitis, diabetes mellitus plus keto-acidosis and peripheral gangrene, hypertension, stroke, abortions and maternity care, pelvic inflammatory disease, and inguinal hernia. While death registration data suggested that maternal mortality was at a relatively low level, obstetricians felt that many maternal deaths were avoidable. The results of this study indicate that before quality assurance programs can be routinely implemented, the following requirements should be fulfilled: (1) concern at the political level, health manager and health worker levels about not only quantitative equity but also the optimal affordable quality of promotive, preventive and clinical care, (2) agreement on the objectives of health care services, (3) clearly defined responsibility for undertaking the collection, analysis and presentation of the data on which the interpretation of quality assessment depends, and (4) inclusion in the assessment of decisions on the specific aspects of service evaluation. (AU)

Maternal deaths in Jamaica

A confidential inquiry into maternal deaths in Jamaica revealed that almost two-thirds were attributable to pre-eclampsia/eclampsia, or sepsis. Avoidable factors that might have increases the probability of death were identified, and recommendations aimed at reducing maternal mortality were presented (AU)

Maternal mortality in Jamaica

A confidential inquiry into all maternal deaths in Jamaica during 3 years (1981 to 1983) was carried out. 192 maternal deaths were identified by a variety of means. The maternal mortality rate of 10.8 per 10000 live births was considerably higher than the official rate of 4.8. The most common causes of death were hypertensive disease of pregnancy (10 percent), pulmonary embolus (8 percent), and sepsis (8 percent). Maternal mortality was closely related to both age and parity. The lowest rates were for women of para 2-4 aged 20-24 years and para 3-4 aged 25-29 years. The largest groups of avoidable factors were: non-use of and deficiencies in antenatal care; inadequacy in ensuring the delivery in hospital of women at high risk; and delays in taking action when signs of complications developed before, during, and after delivery.(AU)

Maternal mortality in Jamaica: a confidential enquiry into all maternal deaths in Jamaica 1981 to 1983

This paper presents an analysis and confidential enquiry into all maternal deaths occurring in Jamaica during the years 1981 to 1983. Details were obtained of all maternal deaths, irrespective of whether they occurred in hospitals or at home, during this three year period. Anonymous case summaries were prepared for all maternal deaths. These case summaries contained general characterisitics of the women, e.g. age and parity, details of the health care (if any) they had received and specific circumstances surrounding their deaths. Each case summary was independently assessed by two practicising Jamaican obstetricians from a panel of seven. They were specifically asked to comment as to whether there were any avoidable factors present in each death which, in their opinion and given their knowledge of current generally accepted standards of satisfactory medical care in Jamaica, may have increased the likelihood of death. Such departures from accepted standards include failure of patients to utilize or cooperate with services, as well as failure to provide or offer adequate care (AU)