A survey was carried out in urban and rural areas of the district of Anantapur, Andhra Pradesh state, India, between July 1, 1984-June 30, 1985 by a team of 6 interviewers and 1 supervisor to identify investigate, and study the causative factors/characteristics of the causes of maternal deaths. They visited each of the 15 hospitals in the district collecting information about maternal deaths that occurred in the reproductive age range of 15-49 years. 22 health centers and 50% of subcenters were also visited, registers were examined, and staff and families were also interviewed. The hospitals and centers served 569,500 people. During the 1st phase in the rural area all main village centers, 181 village subcenters, and 1192 other villages in the district with a total population of 1,090,640 were covered. During the 2nd phase all towns in the urban zones, 10 primary centers, 65 subcenters, and 135 others were visited. The maternal mortality rate was 7.9/1000 live births, well above the national average. 36% of female mortality occurred in women in reproductive age, but fewer than 1/2 of these deaths were registered and only 1/3 figured in center and subcenter records. In rural areas maternal mortality was 8.3/1000, ahead of the urban rate of 5.4/1000. 63% of 284 deaths detailed were related to live births, 14% to stillbirths, 10% to abortions, and 13% to obstructed labor. 19% of total maternal deaths occurred before birth, 12% during labor, and 69% after delivery. Among clinical causes of death sepsis accounted for 36%, hemorrhage for 12%, eclampsia for 9%, retention of placenta for 7%, and infectious hepatitis for 10%. 80% of these deaths could have been avoided by timely antenatal care, treatment of previous complaints, and medical attention and hospitalization at the right time.
In 1984 an insurance plan for child immunization was introduced in the counties of Wuji, Linzhang, an Zunhua, and in the city of Xingtai in the province of Hebei, China. The remuneration of village physicians and payment for vaccination services was linked to their effectiveness. In Wuji county children under 2 up to the age of 7 could be enrolled. If a child contracted measles, $8.50 was paid as compensation, $29 for tetanus, $43 for diphtheria, and $57 for poliomyelitis. If death was caused by one of these diseases, $85 was paid. 84% of children of this age range participated in the plan. 36% of the money from policy purchases of $36,000 was allocated to compensation and administration and 64% to municipal health centers for replacement of supplies and to village doctors performing vaccinations whose annual income ranged between $86 and $286 plus $37 for vaccinations. In the 1st year 31 cases were compensated for a total of $600. In the other countries similar schemes were operational: rural doctors pitched in with 5-20-25% of compensation, and the health care system paid the rest. In 1987, two-thirds of cities in the province adopted this plan enlisting 2,559,780 children (31% of those under 7) and accumulating a total fund of $2,500,000. A 1987 sample of 36, 992 children indicated a 94% coverage for BCG (bacillus Calmette-Guerin), 85% for poliomyelitis, 80% for DPT (diphtheria-pertussis-tetanus), 80% for measles, 90% for Japanese B encephalitis and epidemic meningitis. In 1986, there were 273,000 fewer cases of measles, polio, diphtheria, pertussis, epidemic meningitis, and Japanese encephalitis with 4200 fewer deaths, and 3000 fewer incapacities (or possibly 1,000,000, 15,000 and 5000 fewer, respectively, because of nonreporting). Measles morbidity declined from 16/100,000 in 1986 to 3.7/100,000 in the first 11 months of 1987.
More than 2 billion people in the world are infected with the hepatitis B virus, of whom 280 million are chronic carriers. This virus is responsible for up to 80% of primary hepatic cancer, which is one of three main causes of cancer deaths in east and southeast Asia as well as Africa. Mainly young people are at risk of getting infected and becoming chronic carriers. 70-90% of infants who are infected at birth will become chronic carriers. The virus is transmitted via body fluids, especially blood. It can be transmitted among children and from mother to child during the perinatal period. The vaccination program against hepatitis B is an important tool for preventing its spread. Vaccines contain the viral surface antigen (HBsAG) and are produced from plasma by recombinant DNA techniques. If it is administered properly, a 95% rate of immunization against hepatitis B is achieved. Over the years, more than 40 million doses have been administered. A complete regimen of three doses produces excellent seroconversion rates. The minimum time required between doses is 4 weeks, but a longer interval is preferable between the second and third doses. Since the probability of perinatal infection is low, the first dose may be administered from the sixth week in conjunction with the first dose of diphtheria-pertussis-tetanus (DPT) vaccine. The subsequent doses should coincide with the administration of other vaccines. The hepatitis B vaccine could be administered simultaneously with measles, DPT, poliomyelitis, and BCG vaccines. Complete immunization against hepatitis B costs $2.80 for three doses--an amount that could decline in the coming years.
The hospital of Attat in central Ethiopia serves 300,000 people. In 1987 there were 777 deliveries in the hospital, maternal mortality was 21.2/1000 live births, and the rate of stillbirths was 212/1000 total births. In 1976 a residence or tokul with 15 beds was inaugurated for pregnant women with obstetrical problems to mitigate obstetrical emergencies because of the difficulty of transportation to the hospital. Average stay was 15 days with prenatal care by a hospital nurse visiting the tokul once a day. There were 15 villages around the hospital with 15,000 inhabitants, and a 5-member development committee met with a public health matters. In 1987 a total of 151 pregnant women were admitted, most with a history of obstetrical problems. 34 had caesareans (19 of 25 with previous caesareans), 7 had assisted delivery, and 30 had spontaneous delivery. Only 7 of 15 with previous uterine rupture gave birth via the abdominal route, the others delivered vaginally. There were 635 deliveries of women who entered the hospital directly. Only 142 out of 151 women who stayed at the tokul gave birth in the hospital: 9 of them went home. Many of the direct hospital cases had severe problems: 45 suffered uterine rupture and 23 had craniotomy of the stillborn fetus. 88 (25%) of 348 abnormal deliveries required caesarean section, while there were 44 (72%) caesareans in 61 abnormal deliveries in the tokul group. 13 women died in the direct admission group vs. none in the tokul cases. The maternal mortality rate was 21.2/1000 live births. Rupture of the uterus caused 5 deaths, eclampsia 3, hepatic coma 2, grave sepsis 2, and placenta previa 1. There were 161 fetal deaths in 635 pregnancies of the direct referral group. The stillborn rate was 253.5 vs. 28.2/1000 births in the tokul group.
In developing countries, 60-80% of births are conducted by traditional births attendants (TBAs), especially in rural areas without access to obstetrical service. During 1976 and 1985 a total of 24,000 pregnant women received prenatal assistance from a home obstetric service in a suburban zone of the city of Benin, Bendel state, Nigeria, which was set up in 1976 to care for 90,000 people. During the study period of 1982-85 a total of 12,052 women received prenatal assistance. A sample of 600 women with an average age of 24, an average of 3.5 pregnancies, and 3.5 births/mother was interviewed by a questionnaire: the abortion rate was 32/1000 pregnancies, maternal mortality was 13/1000 live births, neonatal mortality was 19/1000 live births, and child mortality under 5 was 133/1000 live births. 204 of the 600 women had complaints including 62 cases of pain in the abdomen, 46 cases of headache, and 21 cases of feebleness and dizziness. 478 women gave birth in their homes, but 9 of them were hospitalized with hypertension, or premature or difficult birth. 196 of this group received assistance from midwives at home or in the maternity unit, and the rest were assisted by TBAs without the supervision of a midwife. 11 cases of neonatal deaths occurred. 51 of 54 mothers interviewed subsequently stated that they would recommend the service, 22 had used it for more than 1 pregnancy, and 39 had given birth at home with the assistance of a TBA without the help of a midwife. 14 TBAs were also interviewed who said that they were willing to work with qualified midwives, and 11 already had done so. Delivery at home with the assistance of midwives decreased from 9.7% in 1982 to .9% in 1985, while births assisted by TBAs increased by 2% in the maternity unit and by more than 6.5% in the home, a fact that points to the role and importance of TBAs particularly in view of difficulties with transportation.
In 1979, the immunization coverage of children under 5 was 40% in Malavani, a slum of Bombay with 100,000 inhabitants. During the period 1980-87 the percentage of children receiving a 3rd vaccination dose against diphtheria-pertussis-tetanus (DPT) and poliomyelitis increased from 66% in 1980 to 82% in 1983, and dropped again to 74% in 1987 resulting in an almost zero incidence of polio. Since 1979 various methods have been used to involve nursing mothers and their infants to reduce the rate of discontinuation between the 1st DPT and polio vaccination. 5 subcenters serve the weekly health care of children under 5 with vaccination, weighing, as well as the education of mothers about nutrition, immunization and family planning. 971 children obtained their vaccination with their older brothers in 3 phases in the course of 3 months. Community consultation for children under 5 and their mothers was also organized. 563 nursing infants were identified, of whom 502 received health care in the course of 6 months. 89% received DPT and antipolio vaccination. Under a scheme funded by the Aga Khan Foundation 200 children volunteers also paid door-to-door visits to 1200 families that comprised 6000 persons distributing UNICEF flyers and providing instruction in oral rehydration for diarrhea management. They achieved an 85% rate of 3rd vaccination dose completion. This grassroots community approach improved coverage at reduced costs indicating the value of voluntary community action.
