Ensuring financial access to emergency obstetric care: three years of experience with Obstetric Risk Insurance in Nouakchott, Mauritania.

INTRODUCTION: The high cost of emergency obstetric care (EmOC) is a catastrophic health expenditure for households, causing delay in seeking and providing care in poor countries. METHODS: In Nouakchott, the Ministry of Health instituted Obstetric Risk Insurance to allow obstetric risk sharing among all pregnant women on a voluntary basis. The fixed premium (US$21.60) entitles women to an obstetric package including EmOC and hospital care as well as post-natal care. The poorest are enrolled at no charge, addressing the problem of equity. RESULTS: 95% of pregnant women in the catchment area (48.3% of the city's deliveries) enrolled. Utilization rates increased over the 3-year period of implementation causing quality of care to decline. Basic and comprehensive EmOC are now provided 24/7. The program has generated US$382,320 in revenues, more than twice as much as current user fees. All recurrent costs other than salaries are covered. CONCLUSION: This innovative sustainable financing scheme guarantees access to obstetric care to all women at an affordable cost.

Effect of iron supplementation on the iron status of pregnant women: consequences for newborns.

We studied the effect of iron supplementation on the iron status of mothers and on biochemical iron status and clinical and anthropometric measures in their infants. The subjects were 197 pregnant women selected at 28 wk +/- 21 d of gestation at a mother-and-child health center in Niamey, Niger. Ninety-nine women received 100 mg elemental Fe/d throughout the remainder of their pregnancies and 98 received placebo. The prevalence of anemia and iron deficiency decreased markedly during the last trimester of pregnancy in the iron-supplemented group but remained constant in the placebo group. Three months after delivery, the prevalence of anemia was significantly higher in the placebo group. At delivery, there were no differences between the two groups in cord blood iron variables. Three months after delivery, serum ferritin concentrations were significantly higher in infants of women in the iron-supplemented group. Mean length and Apgar scores were significantly higher in infants with mothers in the iron group than in those with mothers in the placebo group.

Consequences of Schistosoma haematobium infection on the iron status of schoolchildren in Niger.

The relationship between iron status and degree of infection by Schistosoma haematobium was studied in 174 schoolchildren from Niger in an area endemic for urinary schistosomiasis. Iron deficiency was defined by a combination of three reliable indicators: a low serum ferritin level combined with a low transferrin saturation, a high erythrocyte protoporphyrin level, or both. Hematuria and proteinuria were found in 76.4% and 79.9% of the children, respectively, while 95.4% excreted eggs (geometric mean egg count of 31.5 eggs per 10 ml of urine). Anemia was observed in 59.7% of the subjects. The prevalence of iron deficiency was 47.1%. Anemia was associated with iron deficiency in 57.7% of the cases. The hemoglobin level and transferrin saturation decreased significantly when the degree of hematuria increased, while prevalence of anemia and prevalence of iron deficiency increased significantly. The hemoglobin level and the hematocrit were negatively correlated with egg count, while prevalence of anemia increased with increasing egg count. This inverse relationship between degree of infection by S. haematobium and iron status shows a deleterious consequence of urinary schistosomiasis on nutrition and hematopoietic status, which should be considered in the design of nutrition intervention programs.

PIP: The relationship between iron status and degree of infection by Schistosoma haematobium was examined in 174 schoolchildren from Niger in an area endemic for urinary schistosomiasis. Iron deficiency was defined by a combination of 3 reliable indicators: a low serum ferritin level combined with a low transferrin saturation, a high erythrocyte protoporphyrin level, or both. Hematuria and proteinuria were seen in 76.4% and 79.9% of the children, respectively, while 95.4% excreted eggs (geometric mean egg count of 31.5 eggs/10 ml of urine). Anemia was seen in 59.7% of the subjects. The prevalence of iron deficiency was 47.1%. Anemia was associated with iron deficiency in 57.7% of the cases. Hemoglobin level and transferrin saturation decreased significantly when the degree of hematuria increased, while prevalence of anemia and iron deficiency increased significantly. The hemoglobin level and hematocrit were negatively correlated with egg count, while anemia prevalence increased with increasing egg count. This inverse relationship between degree of infection by s. haematobium and iron status shows a deleterious consequence of urinary schistosomiasis on nutrition and hematopoietic status, which should be considered in the design of nutrition intervention programs.

Skin diseases of children in Mali: a public health problem.

In order to estimate the importance as a public health problem of skin diseases, we investigated the prevalence and severity of skin diseases in a representative sample of children in Mali. 1817 children were randomly selected in 30 clusters by probability-proportional-to-size sampling in Koulikoro region. The mean prevalence (+/- 2 SD) of skin diseases was 34 +/- 4%. The most frequent dermatoses were pyoderma (12.3 +/- 1.6%), tinea capitis (9.5 +/- 2.5%), pediculosis capitis (4.7 +/- 1.4%), scabies (4.3 +/- 1.5%), and molluscum contagiosum (3.6 +/- 1%). The most troublesome dermatoses were scabies and severe pyoderma. Pyoderma was the only dermatosis associated with poor individual or household hygiene. Public health services were little used by the population for skin diseases, probably because of the lack of an adequate response by the services and the high cost of treatment. The high prevalence and the severity of many of the lesions, and the discomfort caused, make pyoderma and scabies a significant public health problem in Mali.

Midwives in Niger: an uncomfortable position between social behaviours and health care constraints.

Maternal mortality rates are very high in developing countries. In Niamey, the capital of Niger, maternal mortality rate is 280/100,000, in spite of a high concentration of health services and of health personnel. Several studies demonstrated that the efficiency of maternal health services was low, both because the quality and the quantity of work were insufficient. The usual response to the poor performances of health services in developing countries is mainly technical. If improvement of the training of health personnel and re-organization of health services are necessary, they are not sufficient. A good effectiveness of care cannot be achieved without a mutual confident relationship between providers and patients. Focus group discussions were held in Niamey with women users of maternal health services, with student midwives and experienced midwives. Sources of complaints between providers and patients appeared to be numerous. However, they are centered around two themes, delivery techniques and cultural requirements, which correspond to two types of constraints: technical constraints and social representations and practices of the population. A description of traditional practices and beliefs related to delivery were obtained through discussion groups with old women and traditional birth attendants (TBAs). Both women and midwives are tied up by the same social rules (e.g. linguistic taboos, respect and shame) but technical constraints force midwives to violate those rules, making the application of their technical skills very difficult. Thus, the mutual relationship between users and providers is source of dissatisfaction, which often degenerates into an open confrontation. Midwives must learn how to implement obstetrical techniques within specific cultural environments.

Traditional uvulectomy in Niger: a public health problem?

Although traditional uvulectomy, a procedure which consists of cutting away a part of the uvula, has been reported in several sub-Saharan African countries, in Maghreb and in Israel, epidemiological and anthropological data on this practice are rare. Severe complications may require hospitalization. The goal of this study was to assess the prevalence of this traditional procedure in Niamey, capital of Niger, the incidence of its severe complications and the beliefs and practices related to it. By the age of 5, 19.6% of the children in our survey had undergone uvulectomy. Severe complications of uvulectomy represented 7.8/1000 cases of hospitalization for children under 15 years of age. Complications were infections (including tetanus), hemorrhage and passage of the cut piece of uvula further down the respiratory tract. The children who had undergone uvulectomy belonged significantly more often to the Hausa ethnic group (66.2%) than to the majority Zarma ethnic group (18.3%) or to the other ethnic groups (15.5%). This can be explained by the fact that, in some Hausa subgroups, uvulectomy is systematically performed on the 7th day after birth, during the naming ceremony, to prevent death due to a 'swelling of the uvula'. In the other Hausa sub-groups and in the other ethnic groups, uvulectomy is solely a curative practice, both for children and adults, for vomiting, diarrhea, anorexia, the child's rejection of the breast, growth retardation and fever. Uvulectomy is performed in Niger by the barbers, whose functions are also to perform specialized surgery. These traditional surgeons claim there is no risk to this practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Sexual behaviour, AIDS and poverty in Sub-Saharan Africa.

Within the rapidly progressing pandemic of the acquired immunodeficiency syndrome (AIDS) Sub-Saharan Africa plays a disproportionally large role. The reported data indicate that heterosexual transmission is the predominant cause for the rapid spread in this, one of the world's poorest regions. Prostitution, though poorly understood in the African context, unstable family structure, lack of male circumcision, aversion to, and high cost of, condom use, and risky sexual behaviour, including multiple sexual contacts and partners, are causal and facilitating factors in the rapid spread of HIV infection. Virtually all of these factors are related to poverty. Education and information, which in the absence of an effective curative drug and/or vaccine, would be essential, is also a costly undertaking. Deeper understanding of and increased attention to the economic, as well as social and cultural, parameters of the Sub-Saharan AIDS endemic is needed for the implementation of preventive measures.

Iron status in Nigerian mothers and their newborns.

An evaluation of iron status was carried out on 364 Nigerian pregnant women from Niamey at delivery and in cord blood from their newborns. Anemia, defined as a low hematocrit value, was observed in 46% of pregnant women. Iron deficiency, recognized by a combination of, at least, 2 abnormal values in the 3 independent indicators measured (serum ferritin level, erythrocyte protoporphyrin concentration and transferrin saturation) was present in 47.8% of pregnant women. Anemia was associated with iron deficiency in 60.1% of cases in anemic mothers. A correlation between maternal and newborn iron indicators was found. This study points out the necessity for developing strategies in Sahelian countries to combat iron deficiency during pregnancy by specific measures in combination with more general interventions.

Severe obstetric morbidity of the third trimester, delivery and early puerperium in Niamey (Niger).

Epidemiological data about maternal morbidity are rare. The present study, carried out in Niamey, capital of Niger, was designed to measure the incidence of maternal morbidity among women delivering in hospital. Severe complications occurred in 232 of the 4,081 deliveries during the study period (6,450/100,000 live births). Maternal morbidity ratio was 11 times higher than the maternal mortality ratio. Incidence rates of the major morbidities (per 100,000 live births) were: obstructed labour 3,614, hypertensive disorders of pregnancy 1,159, haemorrhage 855, and puerperal sepsis 220. The incidence and case fatality rates of severe complications were both high, suggesting a lack of efficiency of maternal health services in spite of a high concentration of health personnel and a large accessibility to services in Niamey.

[Determinants of risk factors associated with severe maternal morbidity: application during antenatal consultations]. / Le poids des facteurs de risque de la morbidité maternelle grave: application à la fiche de consultation prénatale.

In order to assess the incidence of severe maternal mortality (SMM) and search for associated determinants of risk factors, a population-based survey of 20,326 pregnant women was conducted in six counties in West Africa (MOMA study). Complete files were available for 19,545 (96.2%) women. The rate of SMM, assessed with an overall indicator, was 6.7% (5.7-6.4). The relationship between SMM and various socio-economic features, gyneco-obstetrical antecedents and characteristics of the current pregnancy was studied. Multivariate analysis identified 10 factors of risk of SMM. Prevalence, adjusted odds-ratio, positive predictive value and adjusted attributable risk were determined for these ten factors. By decreasing order of positive predictive value, these factors were: hemorrhage during pregnancy (51.5%), antecedent cesarean (27.1%), high blood pressure (diastolic pressure 10 (18.9%), systolic pressure 14 (14.6%)), antecedent multiple pregnancy (15.8%), height 150 cm (12.9%), lack of fetal movements (12.6%), history of 3 stillborns (9.3%), age over 35 years (8%), nulliparity (7.3%), presence of disease during the pregnancy (7.1%). These results show the importance of antenatal consultation during which these factors are easily identifiable.

[Potential role of prenatal care in reducing maternal and perinatal mortality in sub-Saharan Africa]. / Rôle potentiel de la consultation prénatale dans la lutte contre la mortalité maternelle et la mortalité néonatale en Afrique sub-saharienne.

Prenatal care has been implemented in developing countries according to the same mode as applied in industrialized countries without considering its real effectiveness in reducing maternal and neonatal mortality. Several recent studies suggest that the goals should be revisited in order to implement a program of prenatal care based on real scientific evidence. Based on the current literature, we propose a potentially effective content for prenatal care adapted to the context of developing countries. Four antenatal consultations would be enough if appropriately timed at 12, 26, 32 and 36 weeks pregnancy. The purpose of these consultations would be: 1) to screen for three major risk factors, which, when recognized, lead to specific action: uterine, scare, malpresentation, premature rupture of the membranes; 2) to prevent and/or detect (and treat) specific complications of pregnancy: hypertension, infection (malaria, venereal disease, HIV, tetanus, urinary tract infection); anemia and trace element deficiencies, gestational diabetes mellitus; 3) to provide counseling, support and information for pregnant women and their families (including the partner) concerning: severe signs and symptoms of pregnancy and delivery, community organization of emergency transfer, delivery planning. These potentially effective actions can only have a real public health impact if implemented within an organized maternal health system with a functional network of delivery units, if truly quality care is given, and if the relationships between health care providers and the population are based on mutual respect. Sub-Saharan African women use prenatal care extensively when it is accessible; this opportunity must be used to implement evidence-based actions with appropriate and realistic goals.

[Reducing maternal mortality in developing countries: theory and practice]. / La réduction de la mortalité maternelle dans les pays en voie de développement: théorie et pratique.

Chiefs of state attending the Millennium Summit (2000) set a goal of reducing maternal mortality by 75% before 2015. Based on knowledge of the epidemiology of maternal mortality/morbidity and on growing experience in the field, the international community defined a relatively low-cost program of evidence-based initiatives. However implementation of that program has been stymied by the reality that increasing geographical accessibility to a full range of quality emergency obstetric care of quality will require large investments of money and time. Increasing financial accessibility remains difficult given the low standard of living of populations and budget cutbacks by national governments. The problems facing women and health workers are mostly overlooked by public health policy. There is need for a multi-disciplinary approach with equal participation of specialists in public health, gyneco-obstetrics, anthropology, health care economics, political science and social and community mobilization.

[Pregnancy and delivery in western Africa. Towards a lower risk motherhood?]. / Grossesse et accouchement en Afrique de l'Ouest. Vers une maternité à moindre risque?

The maternal mortality ratio is the health indicator displaying the greatest disparity between industrialized and developing countries. Medical causes have been better known since a decade ago but the non medical causes must be studied to develop appropriate strategies. Socio-economic causes play an important role but the poor performances of the maternal health services are directly responsible for the great majority of the deaths. The lack of qualified personnel, the poor management of those who are qualified, the misallocation of the rare resources, the poor relationships between health personnels and their clients, the shortages of supplies, essential drugs and blood lead to a poor quality of care to pregnant women. The Safe Motherhood Initiative has led to the development of simple but efficient strategies which would allow to dramatically reduce maternal and neonatal mortality as well as handicaps. This requires a political commitment of the governments of West Africa but, in spite of the strong advocacy of major donor agencies and international organizations, programs have yet to be implemented.

[Pregnancy and delivery in western Africa. High risk motherhood]. / Grossesse et accouchement en Afrique de l'Ouest. Une maternité à haut risque.

According to the World Health Organization, 585,000 women die each year from a pregnancy-related cause, 99% of whom are from developing countries. The first International Conference on Safe Motherhood in 1987 sensitized the world community to this drama. Ever since, maternal mortality and its medical causes are better known. The maternal mortality ratio is highest in West Africa (1,020 maternal deaths per 100,000 live borns) when it is 27/100,000 in industrialized countries. Direct obstetric causes account for 80% of the deaths: hemorrhage, infection, dystocia, hypertension and abortion. Indirect causes are essentially anemia, malaria, hepatitis C and AIDS. Severe maternal morbidity is 6 to 10 times more frequent than maternal mortality but it also leads to handicaps which end up often in women's social rejection. However, WHO estimates that 95% of these deaths and handicaps are avoidable, and at a low cost.

Evaluation of iron status in Chadian pregnant women: consequences of maternal iron deficiency on the haematopoietic status of newborns.

An assessment of iron status was performed on 112 pregnant women at delivery (and on their newborns in 70 cases) and on 114 menstruating women in N'Djamena, Chad. Anaemia (according to the haematocrit value) was observed in 25.0% of pregnant women and in 23.7% of menstruating women. Iron deficiency was defined as the combination of a low serum ferritin level (less than or equal to 12 micrograms/l), a low transferrin saturation (less than 16%) and/or a high erythrocyte protoporphyrin (greater than 3 micrograms/g Hb). A moderate increase in the serum ferritin level (between 13 and 50 micrograms/l) associated with a low transferrin saturation and/or a high erythrocyte protoporphyrin concentration indicated iron-deficiency in an inflammatory context. Iron deficiency was present in 66.9% of pregnant women and in 30.7% of menstruating women. Anaemia was associated with iron deficiency in 78.6% of cases in anaemic pregnant women and in 44.4% of cases in anaemic menstruating women. A correlation between maternal and newborn haematopoiesis was found, and some iron parameters in newborns were related to the iron status of mothers.

Are pediatric wards in developing countries only places to die? A study of prior to hospitalization risk factors of death among 0-2 year old hospitalized children in Niamey, capital of Niger.

The 461 0-2-year-old children admitted to the paediatric ward of the National Hospital in Niamey over a 2-month period were closely followed up from admission to discharge or death. The in-hospital mortality rate was 30 per cent, a great proportion of deaths occurring during the first 24 h of hospitalization. Malnutrition was highly prevalent (76 per cent). Children referred from other health facilities (72 per cent) did not experience a higher probability of survival. Using multivariate analysis, three variables remained significantly associated with death: nutritional status, consultation of a traditional practitioner, and a neonate disease. Neonate diseases are the third major cause of death because of a high case fatality rate. For the other causes, the main underlying factor is malnutrition. Most in-hospital deaths are due to events that occurred prior to hospitalization. The role of hospitals' pediatric wards of developing countries is discussed.