Program Note: Using UN process indicators to assess needs in emergency obstetric services: Gabon, Guinea-Bissau, and The Gambia.

PURPOSE: We report on assessments of the needs for emergency obstetric care in 3 West African countries. METHODS: All (or almost all) medical facilities were visited to determine whether there are sufficient facilities of adequate quality to manage the expected number of obstetric emergencies. RESULTS: Medical facilities able to provide emergency obstetric care were poorly distributed and often were unable to provide needed procedures. Too few obstetricians and other providers, lack of on-the-job training and supervision were among the challenges faced in these countries.

Is vacuum extraction still known, taught and practiced? A worldwide KAP survey.

OBJECTIVE: Is vacuum extraction-the method of first choice for assisting vaginal delivery in case of prolonged labor-losing ground in the developing world? And if it is, why? The paper tries to answer these disturbing questions, and examine their consequences. METHODS: A rapid Knowledge-Attitude-Practice (KAP) survey was conducted during 2003-2004 on the question of assisted vaginal delivery (AVD) by the use of the vacuum extractor. Public health specialists and obstetricians from 121 developing countries were consulted about their knowledge of the method in their country, its reputation (i.e. their attitude) and its use (practice). RESULTS: Overall 48% of the respondent countries have confirmed knowledge, positive attitude, teaching and countrywide use of the method, while 37% said the method is known and used by only a limited number of specialists who do not teach it, and 15% admitted no knowledge and therefore no use. CONCLUSION: Given the evidence-based international recognition of the benefits of vacuum extraction (if practiced correctly and for appropriate indications), it is unjust to deprive women with prolonged labor (and their fetuses) of a simple intervention that can contribute to reducing life threatening complications. This unsophisticated worldwide survey, while not providing in-depth explanations, calls for rehabilitation of vacuum extraction in countries where it is disappearing and surgical extraction is not yet readily accessible to all women with prolonged labor.

Can the process indicators for emergency obstetric care assess the progress of maternal mortality reduction programs? An examination of UNFPA Projects 2000-2004.

BACKGROUND: In view of the disappointing progress made in the last 20 years in reducing maternal mortality in low-income countries and before going to scale in implementing the new evidence-based strategies, it is crucial to review and assess the progress made in pilot countries where maternal mortality reduction programs focused on emergency obstetric care. OBJECTIVE: To review the process indicators recommended for monitoring emergency obstetric care and their application in field situations, examining the conditions under which they can be used to assess the progress of maternal mortality reduction programs. METHODS: Five of the six UN recommended process indicators were monitored annually for 5 years in selected districts of Morocco, Mozambique, India and Nicaragua. Trends are presented and discussed. RESULTS: With specific variations due to different local situations in the four countries and in spite of variations in quality of data collection, all indicators showed a consistent positive trend, in response to the inputs of the programs. CONCLUSIONS: The UN process indicators for emergency obstetric care should continue to be promoted, but with two important conditions: (1) data collection is carefully checked for quality and coverage; (2) efforts are made to match process and outcome indicators (maternal and perinatal mortality, incidence of complications).

"Good obstetrics" revisited: too many evidence-based practices and devices are not used.

INTRODUCTION: As countries are designing and implementing strategies to address maternal and newborn mortality and morbidity (Millennium Development Goals 5 and 4), it appears that a large number of evidence-based obstetric practices are not used in many settings, and this is a major obstacle to the improvement of quality obstetric care. OBJECTIVES: To remind readers of the existing, relatively easy-to-implement, evidence-based interventions that are currently not being universally applied in obstetric care and, second, to foster research to expand the evidence base further for obstetric care practices and devices, especially those that could be used in resource-poor settings. METHODS: We review possible reasons why changes into practices are difficult to obtain, and we list the key evidence-based interventions known to effectively deal with the main obstetric complications, with supporting references and sources of documentation. We also list some promising interventions that require more research before being recommended. CONCLUSION: Professionals and health services managers have a crucial role in producing the best quality obstetric and neonatal care through implementing the listed evidence-based interventions and make them accessible to all pregnant women and their newborns without delay, even in poor settings. Reasons for which progress is slow should be addressed. One of these reasons being the lack of access to scientific knowledge from the part of professionals in developing countries, we give the key references and also websites which are freely accessible through the Internet. It is hoped that this paper will stimulate the discussion on the dissemination and use of good obstetric practices, and contribute to better maternal and newborn health.

A prospective evaluation of clinical criteria and polymerase chain reaction assay of cerebrospinal fluid for the diagnosis of cytomegalovirus-related neurological diseases during AIDS.

OBJECTIVE: To study the predictive value of clinical criteria and polymerase chain reaction (PCR) assay of cerebrospinal fluid (CSF) for the diagnosis of cytomegalovirus (CMV)-related neurological disorders during AIDS. SETTING: Four infectious diseases departments in two tertiary referral teaching hospitals in Paris, France. DESIGN AND PARTICIPANTS: One-year prospective study involving 164 consecutive immunosuppressed HIV-seropositive patients undergoing lumbar puncture (LP). METHODS: A tentative diagnostic classification, based on strict operational criteria and PCR assay of CSF, was performed at the time of LP. At the end of the study, tentative diagnoses and PCR results were blindly and independently compared with the firm diagnoses, based on central nervous system histology, clinical outcome and/or viral culture of CSF. RESULTS: The tentative diagnosis showed CMV-related neurological disease in 38 patients, and CMV DNA was detected in 42. Among the 88 patients for whom a firm diagnosis was possible, 26 had a diagnosis of CMV-related neurological disease. The concordance between the tentative and firm diagnoses was 61%, with a kappa index of 0.40. In contrast, the sensitivity and specificity of PCR were respectively 92 and 94%, with positive and negative predictive values of 86 and 97%. The presence of CMV DNA in CSF was associated with an increased risk of death (P < 0.0001). CONCLUSIONS: Unlike clinical criteria, PCR detection of viral DNA in CSF can be used reliably for antemortem diagnosis of CMV-related neurological disease, a frequent complication of AIDS in this study. This rapid method should make a major impact on the management of these patients.

Gender and age differentials in risk factors for childhood malnutrition in Bangladesh.

A case-control study of risk factors of clinical marasmus was undertaken to determine which factors differed according to gender and age groups. Case patients were children whose mid-upper arm circumference measured less than 110 mm and control subjects were children matched for age and sex with an arm circumference more than 120 mm. Between June 1988 and June 1989, 164 such pairs of children aged 1 to 4 years were studied. The effect of various demographic, socioeconomic, environmental, and health factors was investigated in a multivariate analysis using conditional logistic regression. Results showed an increased risk of marasmus among children with siblings under 5 years old. This increased risk was observed irrespective of gender or age. Children who consumed formula foods also had an increased risk of marasmus. Again, this elevated risk was maintained for boys and girls. Overall, higher maternal education was associated with a reduced risk of marasmus; however, this was only statistically significant for boys and for children 18 months or older. Religion was also associated with marasmus but only in older children (> or = 18 months). These results indicate that better strategic planning is necessary to formulate effective interventions to reduce severe malnutrition, particularly in societies where strong age- and sex-preferential behavior exists.

PIP: Between June 1988 and June 1989, a study of 164 case-control pairs, 1-4 years mold, in the Maternal and Child Health-Family (MCH-FP) area in the Matlab of Bangladesh was conducted to examine risk factors of clinical marasmus within gender and age groups. 73% of marasmus cases were females 12-23 months old. For all the children, presence of siblings younger than 5 years old (odds ratio [OR] = 2.84; p .001), maternal education (OR = 0.29 for = or 5 years; p .001 for the trend), and ingestion of formula food (OR = 18.4; p .001) were significant risk factors for marasmus. Religion bordered on significance (OR = 0.49 for Hindu; p = .06). Both boys and girls faced an increased risk of marasmus if they had a sibling younger than 5 years old living in the same household (OR = 2.85; p = .05 and OR = 3.07; p .001, respectively). They both were also at increased risk of marasmus if they consumed formula (OR = 12.4; p = .01 and OR = 25.7; p .001). Boys were significantly less likely to develop marasmus if their mothers had any education (OR = 0.51 for 5 years and 0.12 for = 5 years; p .001). Yet, maternal education had only a weak effect on reducing the risk of developing marasmus in girls. Younger (18 months) and older children were both likely to develop marasmus if they had a sibling younger than 5 years old at home (OR = 2.37 and 3.27; p = .01 and .005, respectively). The risk of marasmus was much lower in older children if they had educated mothers and if they lived in Hindu families (OR = 0.2 for = or 5 years education and 1.19; p = .007 and .01, respectively). These findings suggest that the free services of the MCH program may not reach the disadvantaged due to age and sex biases and that maternal education does not benefit the nutritional status of the most vulnerable age group to marasmus, the very young.

The cumulative occurrence of resistance mutations in the HIV-1 protease gene is associated with failure of salvage therapy with ritonavir and saquinavir in protease inhibitor-experienced patients.

Salvage therapy with ritonavir (RTV) and saquinavir (SQV) failed to achieve virological and immunological improvement in 24 HIV-infected patients who discontinued triple therapy with RTV or indinavir (IDV) because of failure or intolerance to treatment. Changes in the HIV-1 protease gene sequence were analyzed prospectively in 14 patients. No primary protease mutation was found prior to the use of protease inhibitors. After 7 months of treatment with IDV or RTV, primary resistance mutations at codons pol 46 and/or pol 82 were observed in 11 of 13 patients. After 16 weeks on RTV-SQV, novel primary mutations related to SQV emerged in 7 of 13 patients, together with an increase in the number of secondary resistance mutations. Our observations indicate that the cumulative occurrence of resistance mutations in the protease gene was associated with failure of antiretroviral therapy. The presence of mutations to a first protease inhibitor may represent a risk factor for the failure of a subsequent treatment with a second line protease inhibitor.

Excess female deaths among rural Bangladeshi children: an examination of cause-specific mortality and morbidity.

Excess female over male mortality during childhood, well known in the northern Indian subcontinent, is particularly marked in rural Bangladesh. While the determinants of this phenomenon and the respective roles of cultural and economic factors are still debated, little data exist on cause-specific mortality, to identify the specific causes of death producing this differential. In 1986-1987 in Matlab, a study area under intensive demographic surveillance in rural Bangladesh, female children aged 1 to 4 years had a risk of dying 1.8 times higher than male children (95% confidence interval: 1.5-2.1). The causes of death which contributed the most to this excess female mortality were severe malnutrition and diarrhoeal diseases. The risks of dying were 2.5 and 2.1 higher for female than for male children for these two causes, respectively. Possible mechanisms are examined using data on incidence of selected diseases and admission rates to curative facilities. There was no gender difference in incidence of severe diarrhoeal diseases, but female children with diarrhoea were taken to the hospital significantly less often than male children. In contrast, there was a higher incidence of severe malnutrition in female than male children, and a lower rate of hospital admission. The data suggest that gender differentials in mortality may not be as much affected by preventive measures against diarrhoea as by efforts to provide equivalent curative services to female and male children.

Perinatal mortality in Matlab, Bangladesh: a community-based study.

Perinatal deaths, comprising stillbirths and deaths during the first week of life, were monitored over the eight-year period 1979 to 1986 in a rural Bangladeshi population of 196,000. The perinatal mortality rate was 75 per 1000 total births. The rate was 13% higher in males than females. Stillbirth and early neonatal mortality rates were 37 and 38 per 1000 total births, respectively. The major causes of perinatal deaths are presented, as well as some of the maternal determinants. During the period under study, perinatal mortality declined regularly and significantly over time in an area covered by an intensive Family Planning and Health Services programme, but not in the adjacent control area. This raises the issue of the impact of such a programme upon perinatal mortality, and the need to include a strong maternity care component into primary healthcare strategies if further reductions of perinatal mortality are to be achieved.

PIP: In 1986, as part of the ongoing Demographic Surveillance System of the International Centre for Diarrhoeal Disease Research, Bangladesh, health workers regularly visited households in Matlab district to record vital events and other demographic data. They recorded 497 fetal deaths and early neonatal deaths. Low birth weight contributed to 25% of fetal deaths followed by prolonged labor (19%), maternal medical problems (13%), malpresentation at term (12%), and twins (2%). The cause of fetal death for 28% could not be determined. Similarly, low birth weight causes 63% of very early neonatal deaths followed by prolonged labor (31%) and 37% and 15% respectively in 4-7 day old neonates. The 2nd leading cause of death for 4-7 day old neonates was neonatal tetanus (25%w0. Males were more likely to die from tetanus than females (relative risk=4.3; p=.015). The women at lowest risk included those 20-24 years old who were pregnant for the 2nd-3rd time, those 25-29 years old who were pregnant for the 4th-5th time, and those 30-34-years old who were pregnant for the 6th-7th time. Even though the perinatal mortality rates in the study and comparison areas in Matlab did not significantly differ (74 and 75 total births/1000), the rate fell significantly from 82 (1979) to 65 (1986) in the area where maternal and child health and family planning services (MCH-FP) existed (p.001). Further, the rate declined significantly more in the 2nd half of the study period (1983-1986) than in the 1st half (1979-1982) in the MCH-FP area (p.002). Moreover the difference between the 2 areas was only significant in the 2nd half (p.04). Perinatal mortality was highest from August to December. The researchers credit the tetanus toxoid as having more of an impact on reducing the perinatal mortality in the study area than family planning interventions.

Epidemiology and cause of deaths among women in rural Bangladesh.

A total of 542 women aged 15 to 44 years died during the 10-year period 1976 to 1985 in the control area of Matlab, an area with a population of 90,000, representative of many other rural areas of southern Bangladesh. The corresponding age-specific mortality rate was 290 per 100,000 women 15-44 years. These deaths have been analysed retrospectively, using information collected through the Demographic Surveillance System set up by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and verbal autopsies conducted in the homes. Of these deaths, 175 (32%) were due to infectious diseases, 163 (30%) to direct obstetric complications, 67 (12%) to injuries, and the remaining 26% to other causes. Cause-specific and proportionate mortality rates showed a positive association with age for deaths due to infectious diseases, non-infectious diseases and unspecified causes, and an inverse association with age for deaths due to injuries. These rates showed a peak in the intermediate age group 25 to 34 years for deaths due to direct obstetric causes. No consistent trends were visible when annual rates were studied over time. Prior to death, 42% of the women were attended by traditional practitioners, and 33% were not attended at all. Demographic impact is discussed, emphasizing the contribution of obstetric causes to overall mortality. Priorities for health policy implications are proposed, focusing upon a strong maternity care programme, and improved availability of female health personnel, in the context of the socio-cultural constraints imposed on women in poor rural areas.

Measles in rural Bangladesh: issues of validation and age distribution.

In the Third World, scientists have described thoroughly the pattern of measles in Africa. In Asia, however, the epidemiology of measles has been poorly described. In 1989, a measles surveillance system was initiated in Matlab, rural Bangladesh in order to monitor measles incidence in the area. The population (100,000), which has relatively low immunization coverage, has an excellent demographic surveillance system which allows accurate follow-up. The system works through trained community health workers who visit all households every fortnight and report possible cases of measles. Medical doctors review a proportion of index cases and cases in infants soon after the appearance of the rash. Of the 4673 cases reported in all age groups, 18% were visited by medics. Confirmation of diagnosis was related to the age at onset and overreporting by community health workers is documented. The incidence of measles was estimated at 43% of children < 5 years old. Of cases < 5 years of age, 14% occurred below the age at vaccination (incidence rate = 5.5%). A strong seasonal pattern is reported. Case-fatality rates are low. This is the first report which shows the effect of age on reliability of reported measles. It shows the misclassification likely to occur when reporting measles in large-scale surveys, particularly in infants. It also shows that the pattern of measles in this community resembles the pattern reported for African communities and calls for a review of immunization strategies with vaccination below 9 months of age.

Risk factors for clinical marasmus: a case-control study of Bangladeshi children.

A case-control study of risk factors of clinical marasmus was undertaken to guide intervention efforts in rural Bangladesh. Cases were children whose mid-upper arm circumference measured < 110 mm and controls were children matched for age and sex with arm circumference > 120 mm. Between June 1988 and June 1989, 164 such pairs of children aged 1-4 years were studied. The effects of various demographic, socioeconomic, environmental, and health factors, reported by mothers, were investigated in a multivariate analysis using conditional logistic regression. Results showed an increased risk of marasmus among children from families with other children under 5 years of age (odds ratio [OR] = 2.51; 95% confidence interval [CI]: 1.33-4.74), and children who consumed formula foods (OR = 16.41, 95% CI: 3.39-79.36). Higher maternal education was associated with reduced risk of marasmus, compared with no education, the OR for < 5 years of schooling = 0.57, 95% CI: 0.23-1.41; OR for > or = 5 years of schooling = 0.34, 95% CI: 0.15-0.76. The strong association of childhood marasmus with mother's education and child spacing supports the notion that non-nutritional factors should be essential components of efforts to reduce severe malnutrition in Bangladesh.

Is acute watery diarrhoea an important cause of morbidity and mortality among rural Bangladeshi children?

To assess the relative importance of acute watery diarrhoea (AWD) and other types of acute diarrhoea as causes of morbidity and mortality among infants and 1-4 years old children, we examined 3 different data sources from the Matlab field project of the International Centre for Diarrhoeal Disease Research, Bangladesh. In infants, prevalence rates for AWD and non-watery diarrhoeas were similar. In children, prevalence of AWD was 1.8 times lower than prevalence of other acute diarrhoeas. In infants, admission rate to a diarrhoea hospital was 4.1 times higher for AWD than for other acute diarrhoeas (P less than 0.001). In children, admission rate was only 1.7 times higher for AWD than for acute diarrhoeas (P less than 0.001). Infant mortality was 1.7 times higher for AWD than for other acute diarrhoeas, but child mortality was 3 times lower for AWD. These data suggest that, while diarrhoeal disease control programmes should give more importance to oral rehydration therapy in infants, field management of the other types of acute diarrhoea should receive more emphasis in children.

Deaths from injuries and induced abortion among rural Bangladeshi women.

Information about injuries and violence as causes of death of women is scarce and often incomplete, and particularly so regarding women in the rural areas of South Asia. This report provides detailed specific information collected in Matlab, a sub-district of rural Bangladesh. Of 1139 women (aged 15-44 yr) who died there during the 11-yr period from 1976 to 1986, 207 (18%) were victims of unintentional injuries or violence. In this study, unintentional injuries include domestic and traffic accidents, drowning and snake-bites, while violent deaths are defined as due to intentional injury and include homicide, suicide and lethal complications of induced abortion. Injuries and violence accounted for 31% of all deaths among women aged 15-19 yr. This proportion dropped significantly with age to 10% among women aged 35-44 yr. Unmarried women suffered a higher proportion of such deaths (36%) than married women (15%). Violent deaths during pregnancy and complications of induced abortion among young unmarried women deserve special attention. In the male-dominated society under study, suicide and homicide are observed to be two frequent consequences of illegitimate pregnancy. Although this study suffers from the absence of data on non-fatal injuries and attempted violence, it may serve as a basis for recommending preventive measures.

Contraceptive use and breast-feeding duration in rural Bangladesh.

The association between contraceptive use and breast-feeding duration was investigated in 2380 women in rural Bangladesh where women usually stop breast-feeding once pregnant. Life table analysis showed that women receiving regular injections of depo medroxy progesterone acetate (DMPA) and those using non-hormonal contraception breast-fed significantly longer than women using no contraception. In contrast, women using oral contraceptives (combination of 0.5 mg norgestrel and 0.05 mg ethinyl oestradiol) did not breast-feed longer than women using no contraception. It is suspected that prolongation of breast-feeding obtained by delaying the next pregnancy with this oral contraceptive was offset by the depressing effect of oestradiol on lactation. Thus, in communities where prolonged breast-feeding is associated with improved child survival, non-hormonal contraceptive methods, or injectable DMPA, should be preferred for lactating women to oestrogen-containing oral contraceptives.

PIP: Researchers used the life table method to analyze data on 2380 lactating women with at least 1 5 year old child alive in March 1988 to examine the association between contraceptive use and lactation in rural Matlab, Bangladesh. 51.6% of the women used the contraceptive method of 3 monthly intramuscular injections of 150 mg depo medroxy progesterone acetate (DMPA). 23.7% used a combined oral contraceptive (COC) (.5 mg norgestrel and .05 ethinyl estradiol). 24.6% used a nonhormonal method, especially tubectomy and IUDs. Women who did not use contraceptive were more likely to be pregnant when they stopped breast feeding (47.8%) than their counterparts who had used contraception (5.5%) (p.001). Women who used a nonhormonal method or received DMPA breast fed a mean of 43 and 45 months respectively which compared to the duration of mothers who did not use contraception and were not pregnant at the end of the follow up (44 months). Mothers who did not use contraception and were pregnant at then end of the follow up breast fed on average 31 months. Therefore pregnancy was a common cause for breast feeding cessation. DMPA users breast fed significantly longer than women not using contraceptives (45 months vs. 40 months) (p.001). Further nonhormonal contraceptive users had a significantly longer breast feeding duration than noncontraceptive users (p.01). These associations remained significant even after adjusting for parity and maternal education (p.001 and p=.024 respectively). On the other hand, COC users breast fed on average 40 months which was similar to the mean duration of noncontraceptive users. In fact, COC use significantly increased breast feeding cessation when the researchers adjusted for pregnancy or excluded women who were pregnant at the end of the follow up (p.001). The researchers believed that cessation occurred with COC users because estradiol depressed lactation rather than contraceptive failure. In conclusion, contraceptive use delays pregnancy which in turn protects breast feeding and may improve child survival.

Introducing the low-dose pill to Bangladesh; issues of continuation and failure.

In response to government plans to introduce a low-dose pill to the national family planning program of Bangladesh, a comparison of the performance of low-dose and standard-dose pills among a rural Bangladeshi population was conducted. Continuation rates were found to be better among users of the low-dose pill and there was no evidence that failure rates were higher. The relative risk (standard-dose vs. low-dose) over the first 30 months following adoption was 1.25 for first method continuation, and 1.29 for extended use failure. This paper, thus, provides evidence that low-dose pills may be a suitable method of contraception for rural Bangladeshi women.

Maternal tetanus: magnitude, epidemiology and potential control measures.

Maternal tetanus, defined as tetanus occurring during pregnancy or within 6 weeks after any type of pregnancy termination, is one of the most easily preventable causes of maternal mortality. It includes postpartum or puerperal tetanus resulting from septic procedures during delivery, postabortal tetanus resulting from septic abortion and tetanus incidental to pregnancy, resulting from any type of wound during pregnancy. This review of published and unpublished hospital and community studies concludes that between 15,000 and 30,000 cases of maternal tetanus occur each year. Complete coverage of reproductive-aged women by tetanus toxoid is the most cost-effective way to eliminate this often neglected cause of maternal death.

Persistent diarrhea as a cause of childhood mortality in rural Bangladesh.

To determine the importance of persistent diarrhea in childhood mortality a multiple-step verbal autopsy method was used to study 1934 deaths in Matlab, Bangladesh. We found that most of the deaths from acute watery diarrhea occurred in infancy, whereas the peak of non-watery diarrhea deaths was in children over 12 months of age. Children suffering from persistent diarrhea and malnutrition were at highest risk of dying during their third year of life. Children with infectious diseases have a two to four times higher risk of dying if they are malnourished, and for diarrhea the risk is 17 times as high. Forty-nine percent of the diarrheal deaths were in children with malnutrition associated with persistent diarrhea. These results imply that fluid and dietary management are key aspects in the treatment of diarrhea, particularly for those episodes which persist. We conclude that attempts to reduce diarrhoeal deaths with vertical ORT programmes will not have major impact unless other interventions are directed to the persistent diarrhoea-malnutrition complex.

The effect of maternal and child health and family planning services on mortality: is prevention enough?

OBJECTIVE: To examine the impact on mortality of a child survival strategy, mostly based on preventive interventions. DESIGN: Cross sectional comparison of cause specific mortality in two communities differing in the type, coverage, and quality of maternal and child health and family planning services. In the intervention area the services were mainly preventive, community based, and home delivered. SUBJECTS: Neonates, infants, children, and mothers in two contiguous areas of rural Bangladesh. INTERVENTIONS: In the intervention area community health workers provided advice on contraception and on feeding and weaning babies; distributed oral rehydration solution, vitamin A tablets for children under 5, and ferrous fumarate and folic acid during pregnancy; immunised children; trained birth attendants in safe delivery and when to refer; treated minor ailments; and referred seriously ill people and malnourished children to a central clinic. MAIN OUTCOME MEASURES: Overall and age and cause specific death rates, obtained by a multiple step "verbal autopsy" process. RESULTS: During the two years covered by the study overall mortality was 17% lower among neonates, 9% lower among infants aged 1-5 months, 30% lower among children aged 6-35 months, and 19% lower among women living in the study area than in those living in the control area. These differences were mainly due to fewer deaths from neonatal tetanus, measles, persistent diarrhoea with severe malnutrition among children, and fewer abortions among women. CONCLUSIONS: The programme was effective in preventing some deaths. In addition to preventive components such as tetanus and measles immunisation, health and nutrition education, and family planning, curative services are needed to reduce mortality further.

Utilization of medically-trained birth attendants in rural Bangladesh.

Using case-control methodology, this study compared the characteristics of women who requested medically-trained birth attendants at home with those who did not, in order to identify constraints to service delivery and suggest program changes to increase service utilization in a rural area of Bangladesh. By several different measures, prior contact with medical professionals were much more common among cases than controls, with the greatest differences observed in the frequency of antenatal visits. At least one antenatal visit was the strongest predictor that a woman would call a medically-trained birth attendant, though primiparity, proximity to the provider, previous contact with the clinic, and education (both of the mother and her spouse) were also predictive. Recommendations include increasing contact through antenatal visits, and extending midwife coverage through training and supervision of traditional birth attendants. This study demonstrates the usefulness of case-control methodology in evaluating health care utilization.