On the way to universal coverage of maternal services in Iringa rural District in Tanzania. Who is yet to be reached?

Background: Strategies to tackle maternal mortality in sub-Saharan Africa include expanding coverage of reproductive services.Even where high, more vulnerable women may not access services. No data is available on high coverage determinants. We investigated this in Tanzania in a predicted high utilization area. Methods: Data was collected through a household survey of 464 women with a recent delivery. Primary outcomes were facility delivery and ≥4 ANC visits. Determinants were analysed using multivariate regression. Results: Almost all women had attended ANC, though only 58.3% had ≥4 visits. ≥4 visits were more likely in the youngest age group (OR 2.7 95% CI 1.32–5.49, p=0.008), and in early ANC attenders (OR 3.2 95% CI 2.04–4.90, p<0.001). Facility delivery was greater than expected (87.7%), more likely in more educated women (OR 2.7 95% CI 1.50–4.75, p=0.002), in those within 5 kilometers of a facility (OR 3.2 95% CI 1.59–6.48, p=0.002), and for early ANC attenders (OR 2.4 95% CI 1.20–4.91, p=0.02). Conclusion: Rural contexts can achieve high facility delivery coverage. Based on our findings, strategies to reach women yet unserved should include promotion of early ANC start particularly for the less educated, and improvement of distant communities' access to facilities.

Impact of cost sharing on utilization of primary health care Services: providers versus household perspectives

This study is set to match and compare results of the analysis of impacts of cost sharing on households with those on health-care providers in two selected districts in Tanzania. The setting is intended to establish and compare concurrently the impact of cost sharing on health-care utilization as viewed from both the providers and beneficiary households. The findings of the study indicate that quality of primary health care has improved as a result of the introduction of cost sharing. Attendance and hence utilization in health facilities has also increased. Mortality rate, at least for one district has not worsened. By implication then, cost sharing appears to have a positive impact on the provision of primary health care, except for a few cases that fail to consult because of the fees. An appropriately managed exemption facility is likely to eliminate the negative impact.

Non-use of Formal Health Services in Malawi: Perceptions from Non-users

Background The study upon which this paper is based was undertaken to understand users’ and non-users’ perceptions concerning facilitators and barriers to equitable and universal access to health care in resource-poor countries such as Malawi. In this study, non-users of health services were defined as people who were not in need of health services or those who had stopped using them due to significant barriers. Methods A total of 80 interviews with non-users of health services were conducted in Rumphi, Ntchisi, Phalombe and Blantyre Districts of Malawi. Interviews focused on why informants were not using formal health services at the time of data collection. In order to identify non-users, snowballing was used health surveillance assistants, village headmen and community members also helped. One focus group discussion was also conducted with non-users of health services who were members of the Zion Church. Results Informants described themselves as non-users of health services due to several reasons: cost of health services; long distances to health facilities; poor attitude of health workers; belief in the effectiveness of traditional medicines; old age and their failure to walk. Others were non-users due to their disability; hence they could not walk over long distances or could not communicate effectively with health providers. Some of these non-users were complete non-users, namely members of the Zion Church and those who believed in traditional medicine, and they stated that nothing could be done to transform them into users of health services. Other non-users stated that they could become users if their challenges were addressed e.g. for those who were non-users of health services due to poor attitudes of health workers, they stated that if these health workers were transferred they would be able to access health services. Conclusions Public health education targeting both health workers and non-users, ensuring a functional outreach program and addressing other health system challenges such as shortage of drugs and human resources would assist in transforming non-users into users of health services.

A review of patients with advanced cervical cancer presenting to palliative care services at Queen Elizabeth Central Hospital in Blantyre, Malawi

Background Cervical cancer is the commonest cancer affecting women in Malawi, which has the highest rate of this disease in the world. Most cases are diagnosed at an advanced stage. Aim To describe the symptom burden, palliative care interventions, and outcomes of cervical cancer patients who entered care at Tiyanjane Clinic in Blantyre, Malawi, between January and December 2012. Methods We reviewed the case files of 72 patients presenting to our hospital-based palliative care service over one year. Results The mean age was 49.5 years. Twenty-six patients (36%) were HIVpositive and the majority of these (n = 22; 85%) were on antiretroviral medication at presentation to palliative care. Pain (n = 66; 92%), vaginal discharge (n = 44; 61%), and unpleasant odour (n = 37; 51%) were commonly reported. Over a third of patients (n = 26; 36%) reported pain in two or more sites. Fourteen patients (19%) reported vaginal bleeding. Spousal breakdown (through widowhood or divorce) was noted in over half (n = 41; 57%) of all cases. Pain relief was provided to 69 (96%) of the patients (morphine to 40 patients; 56%). Common interventions provided included metronidazole tablets (used vaginally), sanitary items, and counselling. At the end of the study period, 18 patients (25%) were still under the care of palliative services. Conclusions Access to medications such as morphine, metronidazole and tranexamic acid can improve quality of life, even when radiotherapy is limited. Health care teams require necessary skills and training, including how to perform a comprehensive assessment, with an emphasis on the provision of psychosexual counselling, to assist with the complexity of symptoms occurring in this vulnerable group.

Evaluation of Educational Environment for Medical Students of a Tertiary Pediatric Hospital in Tehran, Using DREEM Questionnaire

Background: Tertiary pediatric hospitals usually provide excellent clinical services, but such centers have a lot to do for educational perfection. Objectives: This study was performed to address under-graduate educational deficits and find feasible solutions. Patients and Methods: This cross-sectional study was done in a target population of 77 sixth year undergraduate medical students (response rate = 78%) who spent their 3-month pediatric rotation in the Children’s Medical Center, the Pediatrics Center of Excellence in Tehran, Iran. The Dundee ready educational environment measure (DREEM) instrument was used for assessing educational environment of this subspecialized pediatric hospital. Results: Among 60 students who answered the questionnaires, 24 were male (40%). Participants’ age ranged from 23 to 24 years. The mean total score was 95.8 (48%). Comparison of scores based on students’ knowledge showed no significant difference. Problematic areas were learning, academic self-perception, and social self-perception. Conclusions: Having an accurate schedule to train general practitioner, using new teaching methods, and providing a non-stressful atmosphere were suggested solutions.