Research on reducing maternal and neonatal mortality in south-west Ethiopia

Posted on by — No Comments ↓
Ethiopia is among the countries in the world with most maternal deaths. As part of our project to reduce maternal deaths, we have started several studies to get the necessary information to follow and improve our intervention. 

Monitoring maternal and neonatal deaths
We aim to set up a simple, cost-effective, and sustainable tool to monitor maternal and newborn deaths in a remote part of south-west Ethiopia. We shall set up a community-based birth and death registry using health extension workers.

Data from this research will help us to monitor the intervention programme to reduce maternal and neonatal deaths. The registry is a model for Ethiopia, and may also help other countries to set up birth registries.

We shall use, and compare several designs such as population based registries, direct demographic models (surveys) and institutional registries to measure maternal and neonatal mortality.
The research is collaboration between Ministry of Health in Ethiopia, Arba Minch Hospital, Gidole Hospital, Arba Minch University and University of Bergen.

Developing training programmes for health officers
Through the programme to reduce maternal and neonatal mortality we train non-clinician physicians (health officers) to carry out comprehensive emergency obstetric care. We regularly evaluate the outcomes of the operations they do.

On a separate web page we have outlined

Later, we shall also write about our experiences in setting up emergency obstetric services, at health centres and small rural hospitals. This will also outline the equipment needed to carry out such work.

A model rural hospital

Posted on by — No Comments ↓

There are unfortunately many hospitals in Ethiopia and in Africa that do not work as expected. They lack staff, or equipment. Often they lack staff doing essential interventions such as caesarean sections.

Gidole Hospital is a district hospital in south-west Ethiopia. It was a busy mission hospital. When the expatriate staff left, the hospital more or less collapsed. There were fewer patients, and patients had to be transported to a referral hospital for emergency surgery.

Now the hospital works as a rural hospital again. Two dedicated health officers do essential obstetrics, including caesarean sections. They also do essential surgery such as management of fractures, and treatment of severe wounds. These improvements have also brought about other changes: more patients with other diseases use the hospital and patient revenues has increased.

In my definition, a rural hospital should:

  • have a good antenatal programme and be able to routinely do emergency obstetrics, including caesarean sections
  • be able to handle wounds and common fractures
  • be able to diagnose and treat common infections in paediatrics and internal medicine
  • should have tuberculosis and ART programmes
  • have a good relationship with the population in its catchment area

The hygienic standard at the hospital is acceptable. The floors are often washed, and the patients receive clean bedclothes. In addition, the hospital should be able to make enough income to sustain work and keep staff.

Gidole Hospital does not have a doctor now. It works adequately with non-clinician physicians. 

Curriculum for training NPC in Emergency Obstetrics and Surgery

Posted on by — No Comments ↓

As there is a severe shortage of trained health staff in rural Africa, we try to solve this issue by using doctors and non-physician clinicians (NPC).

Surgical care is the safe provision of preoperative, operative, and post-operative surgical and anaesthesia services. Unfortunately, there are too few surgeons in Africa, and it is unlikely that a modest increase in the number of surgeons and anaesthesiologists will occur. By enabling NPC to do some essential operations, we may increase benefits while lessening harm among populations where the unmet need of surgical care is great.

We train health officers (NPC) in Emergency Obstetrics and Surgery in south Ethiopia. It is a programme for public institutions, and it consists of four months basic training, followed by two months of supervisory visits to their home institutions. The curriculum can be downloaded here. An important part of the project is also to support the rural hospitals and health centres with essential equipment.

You can read more about our training programme and our experiences here.

Be careful when presenting your results

Posted on by — No Comments ↓

Be careful when presenting your results

Recently, the journal nature had an editorial entitled: “Mind the spin. Scientists – and their institutions – should resist the ever-temptation to hype their results”.

Nature referred to the recently concluded HIV vaccine trial in Thailand. Before publishing the results, the researchers said in a preliminary announcement in September, the trial that a vaccine combination reduced the risk of HIV infection by nearly one-third. Some even said “It’s the largest step forward that’s ever occurred in the HIV-vaccine field.”

Now the results have been published in New England Journal of Medicine. The first media announcement and the results do not match. Unfortunately, the data do not back up the early optimism.

For researchers and research students it is important to be careful when presenting the results. Please do not be tempted to hype the results. And hype means: “Promote or publicize (a product or idea) intensively, often exaggerating its importance or benefits”.

The comments in Nature provide a good learning about presenting results: Please read Nature 2009, 461: 1187: Jury still out on HIV vaccine results.

Article-level metric

Posted on by — No Comments ↓

A citation index allows the user to establish which later documents cite which earlier documents. The impact factor is a measure reflecting the average number of citations to articles published in science journals. It is frequently used as a proxy for the relative importance of a journal within its field.

Both the Citation index and Impact factors are used to measure how good an article is. This is a misunderstood and a misleading way of using such measures. Unfortunately institutions and governments use citation index to fund researchers.

Recently, the PLoS and BioMedCentral journals give authors some information on citations, but also tell you how many times the article has been downloaded. This is called article-level metrics, and measures individual papers.

However, it is important to recognize that also such metrics are prone to errors. An article that is mentioned in a newspaper, is likely to be downloaded more often that articles that do not receive such media attention.

Although these new metrics provide us with more information, it is not yet clear how best to use these measures. Currently, both PLoS and BioMedCentral simply present the data.

But, there is only one way of deciding whether a paper is important and to you, and that is to read it, critically analyse it, and come to your own conclusions.

Bibliography on Konso

Posted on by — No Comments ↓

The Konso people (population in 2007 245.000; CSA 2007) live in the Konso area of south Ethiopia. Konso (now called Karat) is a town in south-western Ethiopia, and is the administrative centre of the Konso special woreda of the Southern Nations, Nationalities, and Peoples Region.

Konso, named after the Konso people, is known for its religious traditions, waga sculptures, and nearby fossil beds (the latter an archaeological site of early hominids). The site was added to the UNESCO World Heritage Tentative List in 1997.

Konso society is largely agricultural, and involves the irrigation and terracing of mountain slopes. Staple crops include sorghum and maize, with cash crops including chat, cotton and coffee. Cattle, sheep, and goats are raised for food and milk. During the last 30 years, the people have repeatedly been affected by drought and famine.

We have recently started to develop a bibliography on the Konso area. With some people from Konso we collect information about publications. We also aim to make unpublished university thesis and books available to the public.

Tuberculosis recurrence in cured smear-positive patient

Posted on by — No Comments ↓

Datiko DG and Lindtjørn B. Tuberculosis recurrence in smear-positive patients cured under DOTS in southern Ethiopia: retrospective cohort study. BMC Public Health 2009, 9:348

Abstract
Background: Decentralization of DOTS has increased the number of cured smear-positive tuberculosis (TB) patients. However, the rate of recurrence has increased mainly due to HIV infection. Recurrence rate could be taken as an important measure of long-term success of TB treatment. We aimed to find out the rate of recurrence in smear-positive patients cured under DOTS in southern Ethiopia.

Methods: We did a retrospective cohort study on cured smear-positive TB patients who were treated from 1998 to 2006. Recurrence of smear-positive TB was used as an outcome measure. Person-years of observation (PYO) were calculated per 100 PYO from the date of cure to date of interview. Kaplan-Meier and Cox-regression methods were used to determine the survival and the hazard ratio (HR).

Results: 368 cured smear-positive TB patients which were followed for 1463 person-years. Of these, 187 patients (50.8%) were men, 277 patients (75.5%) were married, 157 (44.2%) were illiterate, and 152 patients (41.3%) were farmers. 15 of 368 smear-positive patients had recurrence. The rate of recurrence was 1 per 100 PYO (0.01 per annum). Recurrence was not associated with age, sex, occupation, marital status and level of education.

Conclusion: High recurrence rate occurred among smear-positive patients cured under DOTS. Further studies are required to identify factors contributing to high recurrence rates to improve disease free survival of TB patients after treatment.

The pdf file can be downloaded at http://www.biomedcentral.com/content/pdf/1471-2458-9-348.pdf

Some lessons learned

Posted on by — No Comments ↓

To be able to reduce maternal mortality, two conditions should be met: Staff should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by the pregnant women.

About six months ago, we started to do caesarean sections at Saula Hospital in the inner part of Gamu Gofa. About 800.000 people live in these remote mountains.

Saula Hospital is a new hospital, which had not done any surgery before. We trained two operators (four months), two anaesthetist nurses (three months) and two scrub nurses. In addition we equipped the hospital with surgical instruments, an oxygen concentrator, suction machines and resuscitation equipment. Two experiences staff from Arba Minch Hospital taught the hospital staff how to handle and sterilize surgical equipments.

Our experience shows:

  1. It is possible to start emergency obstetric services, including operations such as caesareans sections and repair of uterine ruptures at places such as Saula. Non-specialists did the operations.
  2. The midwives correctly use partographs.
  3. Our review shows the indications to do surgery were correct. I believe the operations have saved many lives of mothers and neonates.
  4. Many women have severe complications already at admission to the hospital. This explains the high CS rate of about 20 %. It underlines that pregnant women in this remote part of Ethiopia come late for treatment.
  5. The number of uterine ruptures is high.
  6. Because of the late treatment, several of the women have developed vesico-vaginal fistulas.
  7. The complication rate for this newly started hospital is higher compared with operations done by non-clinician physicians at well-established hospitals. This underlines the importance in developing good and sound routines to ensure safe surgery.
  8. In our programme we review all operations, and we use a no-blame strategy to discuss complications.

One of the important lessons from Saula Hospital is to extend training the operators and anaesthetist nurses to five months at places where they shall start to do emergency operations. We also believe it is important to support and supervise such institutions for some years.

Now that Saula Hospital has set up the surgical and delivery services, emphasis must be to train midwives and nurses from the remote health centres to refer women to the hospital at an early.

Open courses

Posted on by — No Comments ↓

Recently, Jimmy Atkinson at Web Health Blog told me about open access courses on health and medical topics.

These seminars and courses are free for anyone to use. Although they do not provide credits, they can become valuable resources in your goal to become more aware of national and international health and medical issues

The courses also include good courses by for example Harvard Medical School, Johns Hopkins Bloomberg School of Public Health, MIT and TUFTS. You will find good courses in epidemiology and statistics.

Please visit their website to read bout the available courses.

30,000 women have an untreated vesicovaginal fistula

Posted on by — No Comments ↓

In Ethiopia about 30,000 women have an untreated vesicovaginal fistula. Most often this is the result of complications of neglected, prolonged or obstructed labour.

At our new Fistula Unit in Arba Minch we collaborate with the Fistula Hospital in Addis Ababa in Ethiopia. This hospital in Addis Ababa is dedicated only to the care of women with obstetric fistulae, and treating other physical and social injuries.

In their experience, this vesicovaginal fistula often results in other injuries. More than half of the patients will be divorced and excluded from religious activities, their home, public transport and health institutions. Patients with fistulas have more than a ‘hole’ between the bladder and vagina, and often have physical, psychological and social problems, stress and urge urinary incontinence, hydronephrosis, renal failure, rectovaginal fistulae, secondary infertility, vaginal scarring and damage to the nerves (foot drop).

You can read a review of the experiences from the Fistula Hospital in Addis Ababa in a paper in by Professor Gordon Williams in The Surgeon (February 2007 Vol 5 No 1).