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West Jr. K.P.,Johns Hopkins University | Christian P.,Johns Hopkins University | Labrique A.B.,Johns Hopkins University | Rashid M.,Partners in Population and Development | And 12 more authors.
JAMA - Journal of the American Medical Association | Year: 2011

Context: Maternal vitamin A deficiency is a public health concern in the developing world. Its prevention may improve maternal and infant survival. Objective: To assess efficacy of maternal vitamin A or beta carotene supplementation in reducing pregnancy-related and infant mortality. Design, Setting, and Participants: Cluster randomized, double-masked, placebo-controlled trial among pregnant women 13 to 45 years of age and their live-born infants to 12 weeks (84 days) postpartum in rural northern Bangladesh between 2001 and 2007. Interventions: Five hundred ninety-six community clusters (study sectors) were randomized for pregnant women to receive weekly, from the first trimester through 12 weeks postpartum, 7000 μg of retinol equivalents as retinyl palmitate, 42 mg of all-trans beta carotene, or placebo. Married women (n=125 257) underwent 5-week surveillance for pregnancy, ascertained by a history of amenorrhea and confirmed by urine test. Blood samples were obtained from participants in 32 sectors (5%) for biochemical studies. Main Outcome Measures: All-cause mortality of women related to pregnancy, still-birth, and infant mortality to 12 weeks (84 days) following pregnancy outcome. Results: Groups were comparable across risk factors. For the mortality outcomes, neither of the supplement group outcomes was significantly different from the placebo group outcomes. The numbers of deaths and all-cause, pregnancy-related mortality rates (per 100 000 pregnancies) were 41 and 206 (95% confidence interval [CI], 140-273) in the placebo group, 47 and 237 (95%CI, 166-309) in the vitamin A group, and 50 and 250 (95% CI, 177-323) in the beta carotene group. Relative risks for mortality in the vitamin A and beta carotene groups were 1.15 (95% CI, 0.75-1.76) and 1.21 (95% CI, 0.81-1.81), respectively. In the placebo, vitamin A, and beta carotene groups the rates of stillbirth and infant mortality were 47.9 (95% CI, 44.3-51.5), 45.6 (95%CI, 42.1-49.2), and 51.8 (95% CI, 48.0-55.6) per 1000 births and 68.1 (95% CI, 63.7-72.5), 65.0 (95% CI, 60.7-69.4), and 69.8(95%CI, 65.4-72.3) per 1000 live births, respectively. Vitamin A compared with either placebo or beta carotene supplementation increased plasma retinol concentrations by end of study (1.46 [95% CI, 1.42-1.50] μmol/L vs 1.13 [95% CI, 1.09-1.17] μmol/L and 1.18 [95% CI, 1.14-1.22] μmol/L, respectively; P<.001) and reduced, but did not eliminate, gestational night blindness (7.1% for vitamin A vs 9.2% for placebo and 8.9% for beta carotene [P<.001 for both]). Conclusion: Use of weekly vitamin A or beta carotene in pregnant women in Bangladesh, compared with placebo, did not reduce all-cause maternal, fetal, or infant mortality. Trial Registration clinicaltrials.gov Identifier: NCT00198822. ©2011 American Medical Association. All rights reserved. Source

Newbrander W.,Center for Health Services | Natiq K.,Silk Route Training and Research Organization | Shahim S.,Governance Institute of Afghanistan | Hamid N.,Management science for Health | Skena N.B.,Management science for Health
Global Public Health | Year: 2014

This study, conducted in five rural districts in Afghanistan, used qualitative methods to explore traditional practices of women, families and communities related to maternal and newborn care, and sociocultural and health system issues that create access barriers. The traditional practices discussed include delayed bathing of mothers and delayed breastfeeding of infants, seclusion of women after childbirth, restricted maternal diet, and use of traditional home remedies and self-medication instead of care in health facilities to treat maternal and newborn conditions. This study also looked at community support structures, transportation and care-seeking behaviour for maternal and newborn problems which create access barriers. Sociocultural barriers to better maternal-newborn health include shame about utilisation of maternal and neonatal services, women's inability to seek care without being accompanied by a male relative, and care-seeking from mullahs for serious health concerns. This study also found a high level of post-partum depression. Targeted and more effective behaviour-change communication programmes are needed. This study presents a set of behaviour-change messages to reduce maternal and newborn mortality associated with births occurring at home in rural communities. This study recommends using religious leaders, trained health workers, family health action groups and radio to disseminate these messages. © 2014 The Author(s). Published by Taylor & Francis. Source

Zeng W.,Brandeis University | Cros M.,Brandeis University | Wright K.D.,Center for Health Services | Shepard D.S.,Brandeis University
Health Policy and Planning | Year: 2013

To strengthen Haiti's primary health care (PHC) system, the country first piloted performance-based financing (PBF) in 1999 and subsequently expanded the approach to most internationally funded non-government organizations. PBF complements support (training and technical assistance). This study evaluates (a) the separate impact of PBF and international support on PHC's service delivery; (b) the combined impact of PBF and technical assistance on PHC's service delivery; and (c) the costs of PBF implementation in Haiti. To minimize the risk of facilities neglecting potential non-incentivized services, the incentivized indicators were randomly chosen at the end of each year. We obtained quantities of key services from four departments for 217 health centres (15 with PBF and 202 without) from 2008 through 2010, computed quarterly growth rates and analysed the results using a difference-in-differences approach by comparing the growth of incentivized and non-incentivized services between PBF and non-PBF facilities. To interpret the statistical analyses, we also interviewed staff in four facilities. Whereas international support added 39% to base costs of PHC, incentive payments added only 6%. Support alone increased the quantities of PHC services over 3 years by 35% (2.7%/quarter). However, support plus incentives increased these amounts by 87% over 3 years (5.7%/quarter) compared with facilities with neither input. Incentives alone was associated with a net 39% increase over this period, and more than doubled the growth of services (P < 0.05). Interview findings found no adverse impacts and, in fact, indicated beneficial impacts on quality. Incentives proved to be a relatively inexpensive, well accepted and very effective complement to support, suggesting that a small amount of money, strategically used, can substantially improve PHC. Haiti's experience, after more than a decade of use, indicates that incentives are an effective tool to strengthen PHC. © 2012 Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2012; all rights reserved. Source

Jerene D.,Project Performance | Melese M.,Project Performance | Kassie Y.,Project Performance | Alem G.,Amhara Regional Health Bureau | And 4 more authors.
International Journal of Tuberculosis and Lung Disease | Year: 2015

SETTING: Amhara and Oromia regions, Ethiopia. OBJECTIVE : To determine the yield of a household contact investigation for tuberculosis (TB) under routine programme conditions. DESIGN: Between April 2013 and March 2014, TB clinic officers conducted symptom-based screening for household contacts (HHCs) of 6015 smear-positive TB (SS TB) index cases. Based on quarterly reported programme data, we calculated the yield in terms of number needed to screen (NNS) and number needed to test (NNT). RESULT S : Of 15 527 HHCs screened, 6.1% had presumptive TB (8.5% in Oromia vs. 3.9% in Amhara). All forms of TB and SSTB were diagnosed in respectively 2.5% (Oromia 3.9% vs. Amhara 1.2%) and 0.76% (Oromia 0.98% vs. Amhara 0.55%) of contacts. The NNS to detect a TB case all forms and SS TB was respectively 40 and 132. The NNT to diagnose a TB case all forms and SSTB was respectively 2.4 and 8. Of 1687 eligible children aged ,5 years, 323 were started on isoniazid preventive therapy. CONCLUS IONS : The yield of the household contact investigation was over 10 times higher than the estimated prevalence in the general population; household contact investigations can serve as an entry point for childhood TB care. © 2015 The Union. Source

Colvin C.J.,University of Cape Town | Konopka S.,Center for Health Services | Chalker J.C.,Center for Pharmaceutical Management | Jonas E.,Center for Health Services | And 3 more authors.
PLoS ONE | Year: 2014

Background: Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes - ART initiation, retention in care, and long-term ART adherence - remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV. Methods: Searches were conducted for studies addressing the population of interest (HIV-infected pregnant and postpartum women), the intervention of interest (ART), and the outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. A four-stage narrative synthesis design was used to analyze findings. Review findings from 42 included studies were categorized according to five themes: 1) models of care, 2) service delivery, 3) resource constraints and governance challenges, 4) patient-health system engagement, and 5) maternal ART interventions. Results: Low prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions. Conclusions: There has been a lack of emphasis on the experiences, needs and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade. © 2014, Public Library of Science. All rights reserved. Source

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