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Despite substantial progress over the past twenty-five years, maternal and child mortality remain high in sub-Saharan Africa. Although there is overwhelming evidence that medical interventions can improve individual health outcomes under trial conditions, the evidence of their impacts at the population level, and of how to scale those impacts, has been more elusive. A central challenge lies in integrating effective medical interventions into high-quality, strengthened health systems and scaling those systems sustainably. The goal of this study was to characterize baseline health and socio-economic conditions in Vatovavy region (population ~900,000), Madagascar, ahead of the scale-up of an HSS initiative that has demonstrated effectiveness after ten years at a district level (~200,000 population) We carried out a population-representative household survey between July and September 2023 across the three districts of Vatovavy (Ifanadiana, Mananjary, and Nosy Varika). A total of 4,997 households (24,000 individuals) were selected using a stratified two-stage cluster sampling design. Face-to-face interviews were conducted with all consenting adults to collect information on demographics, socioeconomic conditions, healthcare access, and health outcomes. Mortality rates were estimated using synthetic life table methods, and health care coverage indicators were defined according to standard DHS guidelines. Health care inequalities were estimated by wealth quintile and by geographic accessibility to health facilities. The regional maternal mortality ratio was estimated at 695 deaths per 100,000 live births (95% CI: 576–832), nearly twice the national average, with marked differences across districts. The under-five mortality rate was 101 per 1,000 live births (95% CI: 90–113), also exceeding national levels. Only 26% of children aged 12–23 months were fully vaccinated, and one-third of births took place in health facilities. Ifanadiana district had notably higher health coverage and lower mortality rates than the other districts. Pronounced inequalities were observed across wealth quintiles and geographic accessibility groups, particularly in Nosy Varika district. This baseline survey reveals poor maternal and child health outcomes ahead of the HSS scale-up in Vatovavy, with strong inter-district variability linked to uneven health system support. Results in Ifanadiana underscore the benefits of ongoing HSS efforts, while persistent geographic inequities call for stronger community-based approaches. These findings provide population-level benchmarks for assessing future intervention impacts.
Early careseeking for sick children can make the difference between life and death. Verbal autopsy (VA) studies of the cause of death typically ask about severe symptoms such as seizures and possibly mild or moderate symptoms such as rash, but without examining the relationship between caregivers' perception of illness severity and appropriate careseeking. Verbal and social autopsy (VASA) is a newer method that builds on VA by also examining social factors related to death. From seven VASA studies conducted in Africa and Asia we developed a 2-sign method based on activity level and feeding behavior and a multiple sign method of identifying mild, moderate and severe illness of neonates and 1-11-month-olds. We then examined the relationship of caregivers' perception of their child's condition at illness onset and several covariates to seeking formal health care during the fatal illness. The 2-sign and multiple sign methods effectively distinguished mild, moderate, and severe illnesses, respectively, of neonates and 1-11-month-olds. Careseeking was almost uniformly decreased for severely ill neonates (8.4%-41.8% vs mild: 15.0%-66.7% and moderate: 30.5%-68.5%, p = 0.12- < 0.001), but multivariate analysis revealed that older age in all six African countries (AOR 1.11 [95% CI 1.02, 1.21], p = 0.02 to 1.10 [1.04, 1.16], p < 0.001) and moderate illness in three (4.83 [1.06, 21.96], p = 0.04 to 4.35 [1.59, 11.93], p = 0.005) were associated with careseeking, while severe illness was no longer significant. Similar to neonates, older age in three of five countries (1.26 [1.01, 1.58], p = 0.046 to 1.10 [1.03, 1.16], p = 0.003) and moderate illness in one (2.24 [1.17, 4.30], p = 0.016) were drivers of careseeking for 1-11-month-olds. Careseeking was increased in some countries for infectious illnesses but not for intrapartum- or prematurity-related conditions. Child mortality studies should assess severity level and caregivers' response at various illness stages. Because older infants have more specific illness signs, the 2-sign method should be used only for neonates. Behavior change messages encouraging careseeking for moderate illness signs should be developed. The 2-sign method can serve as a practical tool for this purpose for illnesses of neonates. Effective interventions may require overcoming local barriers to careseeking and bringing delivery and newborn care closer to communities to prevent and treat early onset neonatal illnesses.
Geographic access to healthcare continues to pose a significant challenge for pregnant women in rural areas of sub-Saharan Africa, resulting in consistently high rates of maternal mortality. Geographic barriers can persist even in settings where financial barriers have been reduced and health system strengthening (HSS) efforts are in place. The aim of this study is to gain a precise understanding of spatiotemporal changes in access to and utilization of maternal care services in a rural district of Madagascar benefiting from HSS support. We collected geolocated monthly information at the village level on antenatal care visits, deliveries and postnatal visits from the registries of 18 public primary health centers in Ifanadiana District, from 2016 to 2018. Similar data were collected from a district-representative cohort via surveys on over 1500 households done in 2016 and 2018. We estimated precise travel time from each village to the nearest health center to understand spatio-temporal variations in maternal care access, and to assess the impact of geographic barriers via statistical analyses while controlling for health system factors. Women who lived within a one-hour walk from a health facility in the HSS catchment area had rates of per capita utilization of most maternal health services were roughly twice that those who lived 1–2 h away and three times higher than those who lived over 2 h away (e.g. relative change for delivery at a health center was 0.60 [0.53–0.67] and 0.40 [0.36–0.45] for women living 1–2 h and over 2 h from a facility, respectively). The exception was the first antenatal care visit (ANC1), for which travel time had more modest effect (e.g. relative change of 0.72 [0.67–0.77] over 2 h). Improvements to primary care services due to HSS in this setting were only observed among women living within two hours from health centers. Statistical models revealed that women’s travel time from a health facility was the strongest determinant of maternal care service utilization. This study shows how a combination of geo-located health system information and population-representative data can help assess the impact of geographical barriers to maternal care in rural areas of sub-Saharan Africa. It highlights that women who live more than 2 h from a health facility had virtually no access to maternal health services despite efforts in place to reduce financial barriers to care and strengthen the health system.
Plasmodium falciparum multidrug resistance transporter 1 (Pfmdr1) gene mutations are associated with altered response to artemisinin-based combination therapy (ACT), particularly the combinations containing the partner drugs lumefantrine and amodiaquine (i.e., artemether-lumefantrine [AL] and artesunate-amodiaquine [ASAQ]). Past studies of Pfmdr1 single nucleotide polymorphisms (SNPs) at codons 86, 184, and 1246 have shown different responses to AL and ASAQ. To determine whether infection with parasites carrying specific Pfmdr1 SNPs leads to increased risk of recurrent parasitaemia (recrudescent or new infection), data from 3,915 samples from 16 therapeutic efficacy studies from 13 African countries between 2013 and 2019 were analysed. Patients treated with AL and infected with parasites carrying Pfmdr1 N86 were at greater risk of recurrent infection than those whose parasites carried 86Y. After treatment with ASAQ, individuals infected with parasites that carried Pfmdr1 86Y were more likely to experience a recurrent infection. These results support prior studies that suggested: (1) patients given AL and infected with parasites carrying N86 were more likely to experience a recurrent infection; (2) patients given ASAQ and infected with parasites carrying 86Y were more likely to experience a recurrent infection. These findings suggest that ACT and Pfmdr1 genotype may influence outcome after Plasmodium falciparum infection.
Madagascar has a lower HIV prevalence than countries on the African continent. The 2003-4, 2008-9 and 2021 Demographic and Health surveys and the 2018 Multiple Indicator Cluster survey reports were analysed. Between 2003 and 2021, there was a significant increase in the percentage of people reporting sex with multiple partners: for women from 2.6
