Demographic Surveillance System Area Research Articles

Using testing history to estimate HIV incidence in mothers living in resource-limited settings: Maximizing efficiency of a community health survey in Mozambique.

Obtaining rapid and accurate HIV incidence estimates is challenging because of the need for long-term follow-up for a large cohort. We estimated HIV incidence among women who recently delivered in southern Mozambique by leveraging data available in routine health cards. A cross-sectional household HIV-testing survey was conducted from October 2017 to April 2018 among mothers of children born in the previous four years in the Manhiça Health Demographic Surveillance System area. Randomly-selected mother-child pairs were invited to participate and asked to present documentation of their last HIV test result. HIV-testing was offered to mothers with no prior HIV-testing history, or with negative HIV results obtained over three months ago. HIV incidence was estimated as the number of mothers newly diagnosed with HIV per total person-years, among mothers with a prior documented HIV-negative test. Among 5000 mother-child pairs randomly selected, 3069 were interviewed, and 2221 reported a previous HIV-negative test. From this group, we included 1714 mothers who had taken a new HIV test during the survey. Most of mothers included (83.3%,1428/1714) had a previous documented HIV test result and date. Median time from last test to survey was 15.5 months (IQR:8.0-25.9). A total of 57 new HIV infections were detected over 2530.27 person-years of follow-up. The estimated HIV incidence was 2.25 (95% CI: 1.74-2.92) per 100 person-years. Estimating HIV incidence among women who recently delivered using a community HIV-focused survey coupled with previous HIV-testing history based on patients' clinical documents is an achievable strategy.

Magnitude of low birthweight in malaria endemic settings of Nanoro, rural Burkina Faso: a secondary data analysis

Low birthweight (LBW) is a worldwide problem that particularly affects developing countries. However, limited information is available on its magnitude in rural area of Burkina Faso. This study aimed to estimate the prevalence of low birthweight and to identify its associated factors in Nanoro health district. A secondary analysis of data collected during a cross-sectional survey was conducted to assess the prevalence of low birthweight in Nanoro health and demographic surveillance system area (HDSS). Maternal characteristics extracted from antenatal care books or by interview, completed by malaria diagnosis were examined through a multi-level logistic regression to estimate odd-ratios of association with low birthweight. Significance level was set at 5%. Of the 291 neonates examined, the prevalence of low birthweight was 12%. After adjustment for socio-demographic, obstetric and malaria prevention variables, being primigravid (OR = 8.84, [95% CI: 3.72–21.01]), or multigravid with history of stillbirth (OR = 5.03, [95% CI: 1.54–16.40]), as well as the lack of long-lasting insecticide treated bed net use by the mother the night preceding the admission for delivery (OR = 2.5, [95% CI: 1.1–5.9]) were significantly associated with neonate low birthweight. The number of antenatal visits however did not confer any direct benefit on birthweight status within this study area. The prevalence of low birthweight was high in the study area and represents an important public health problem in Burkina Faso. In light of these results, a redefinition of the content of the antenatal care package is needed.

Pathogen-specific risk of seizure in children with moderate-to-severe diarrhoea: Case control study with follow-up.

To determine the pathogen-specific risk of seizure in under-five children hospitalised with moderate-to-severe diarrhoea (MSD) in rural settings. This was a prospective case-control study with follow-up, conducted in a sentinel facility of Global Enteric Multicenter Study in Mirzapur, a rural community of Bangladesh between 2007 and 2010. Children aged 0-59months who presented with MSD and seizure constituted the cases whereas those who did not have seizure comprised the controls. MSD was defined if the episodes were associated with dehydration or dysentery or required hospitalisation with diarrhoea or dysentery. All enrolled children were followed up at home within 50-90days of enrolment. A total of 64 cases and 128 randomly selected controls formed the analysable dataset. The result of logistic regression analysis after adjusting for potential confounders revealed that shigellosis (Shigella species, OR=5.34, 95% CI=2.37-12.04) particularly S. flexneri (OR=3.34, 95% CI=1.48-7.57), S. flexneri 6 (OR=23.24, 95% CI=2.79-193.85), S. sonnei (OR=6.90, 95% CI=2.34-19.85); norovirus (OR=6.77, 95% CI=1.69-27.11), fever (OR=16.75, 95% CI=1.81-154.70) and loss of consciousness (OR=35.25, 95% CI=1.71-726.20) were the independent risk factors for seizure in MSD children. At enrolment, cases had lower WHZ (P=0.006) compared to their peers, follow-up anthropometrics showed significant improvement in WHZ (P<0.001) and WAZ (P<0.05), whereas deterioration in HAZ (P<0.001) in both cases and controls. Childhood MSD episodes particularly due to Shigella and norovirus are often associated with seizure. Prompt identification and appropriate management of children with shigellosis may reduce occurrence and adverse consequences of seizure linked with MSD.

Epidemiology of multimorbidity in conditions of extreme poverty: a population-based study of older adults in rural Burkina Faso

IntroductionMultimorbidity is a health issue of increasing importance worldwide, and is likely to become particularly problematic in low-income countries (LICs) as they undergo economic, demographic and epidemiological transitions. Knowledge of...

Determinants of maternal health care and birth outcome in the Dande Health and Demographic Surveillance System area, Angola.

ObjectivesMaternal health care improvement and reduction of maternal and child mortality are priorities of the global health agenda. In Angola, maternal mortality remains high and the risk of pregnancy-related death was 1 in 32 during 2015. This study aims to identify demographic and social factors influencing antenatal care and health facility delivery among women in Dande and to understand their impact on birth outcomes.MethodsThis study is based on community–based longitudinal data collected by the Dande Health and Demographic Surveillance System between 2009 and 2015. Data on pregnancy outcomes (10,289 outcomes of 8,066 women) were collected for all reported pregnancies, including sociodemographic information, health services utilisation and women’s reproductive history. Logistic regression was used to investigate the determinants of birth outcomes, antenatal care attendance and institutionalised delivery.FindingsOf the 10,289 pregnancy outcomes, 98.5% resulted in live births, 96.8% attended antenatal care, and 82.5% had four or more visits. Yet, 50.7% of the women delivered outside a health facility. Antenatal care attendance was a determinant of birth outcomes (stillbirth: unadjusted OR = 0.34 95% CI = 0.16–0.70; abortion: OR = 0.07 95% CI = 0.04–0.12). Older women, with lower education, living at a greater distance of a health facility and in rural areas, were less likely to use maternal health care. Having had previous pregnancies, namely resulting in live births, also decreased the likelihood of health care utilization by pregnant women.ConclusionsThe study identifies relevant social determinants for the utilisation of antenatal care, place of delivery and their impact on birth outcome, thereby providing insight on how best to address inequities in health care utilization.

Determinants of maternal health care and birth outcome in the Dande Health and Demographic Surveillance System area, Angola

Determinants of maternal health care and birth outcome in the Dande Health and Demographic Surveillance System area, Angola

Intermittent preventive treatment of pregnant women in Kintampo area of Ghana with sulphadoxine-pyrimethamine (SP): trends spanning 2011 and 2015

ObjectiveIn Ghana, intermittent preventive treatment during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is recommended for the prevention of malaria-related adverse outcomes. This study demonstrates the coverage of IPTp-SP use among pregnant women...

Gender differences in sociodemographic and behavioural factors associated with BMI in an adult population in rural Burkina Faso – an AWI-Gen sub-study

ABSTRACTBackground: The global health transition is linked with an increased burden of non-communicable diseases with cardiovascular diseases leading the epidemic. In sub-Saharan Africa (SSA), the prevalence of obesity has increased during the past decades and there is a need to investigate the associated driving factors. In Burkina Faso obesity remains low, especially in rural areas. In this study we recruited middle-aged adults, as part of a larger study on genetic and environmental contributions to cardiometabolic disease among Africans.Objectives: To investigate the distribution of BMI and prevalence of obesity in a cross-sectional population-based study and to determine the sociodemographic and behavioural correlates with BMI.Methods: Participants (N = 2,076) were recruited from the Nanoro Health and Demographic Surveillance System area and were aged 40–60 years. We applied hierarchical modelling to identify factors associated with BMI and structural equation modelling to identify mediated effects of sociodemographic and behavioural variables on BMI.Results: Data are presented on 2,076 participants (49.9% female). Men had significantly higher BMI than women with medians of 21.1 (19.2 – 23.4) vs 19.8 (18.1 – 21.6) (p < 0.001), and there were significantly more underweight women compared to men (31.0% vs 17.4%) (p < 0.001). More men were overweight and obese than women (11.9% vs 5.2% and 2.2% vs 1.4%). Socioeconomic status was the major contributor to increased BMI for men, and education was the main contributor in women. Tobacco smoking and chewing, and problematic alcohol consumption were associated with a decrease in BMI in men and women.Conclusion: Overweight and obesity are relatively low among adults in rural Burkina Faso, and men had a higher median BMI than women. Behavioural factors, including tobacco use and alcohol consumption, contributed to a decrease in BMI, whereas socioeconomic status and education (which were both generally low in this community) contributed to an increase in BMI.

Knowledge and Adherence to the National Guidelines for Malaria Case Management in Pregnancy among Healthcare Providers and Drug Outlet Dispensers in Rural, Western Kenya

BackgroundAlthough prompt, effective treatment is a cornerstone of malaria control, information on provider adherence to malaria in pregnancy (MIP) treatment guidelines is limited. Incorrect or sub-optimal treatment can adversely affect the mother and fetus. This study assessed provider knowledge of and adherence to national case management guidelines for uncomplicated MIP.MethodsWe conducted a cross-sectional study from September to November 2013, in 51 health facilities (HF) and a randomly-selected sample of 39 drug outlets (DO) in the KEMRI/CDC Health and Demographic Surveillance System area in western Kenya. Provider knowledge of national treatment guidelines was assessed with standardized questionnaires. Correct practice required adequate diagnosis, pregnancy assessment, and treatment with correct drug and dosage. In HF, we conducted exit interviews in all women of childbearing age assessed for fever. In DO, simulated clients posing as first trimester pregnant women or as relatives of third trimester pregnant women collected standardized information.ResultsCorrect MIP case management knowledge and practice were observed in 45% and 31% of HF and 0% and 3% of DO encounters, respectively. The correct drug and dosage for pregnancy trimester was prescribed in 62% of HF and 42% of DO encounters; correct prescription occurred less often in first than in second/ third trimesters (HF: 24% vs. 65%, p<0.01; DO: 0% vs. 40%, p<0.01). Sulfadoxine-pyrimethamine, which is not recommended for malaria treatment, was prescribed in 3% of HF and 18% of DO encounters. Exposure to artemether-lumefantrine in first trimester, which is contraindicated, occurred in 29% and 49% of HF and DO encounters, respectively.ConclusionThis study highlights knowledge inadequacies and incorrect prescribing practices in the treatment of MIP. Particularly concerning is the prescription of contraindicated medications in the first trimester. These issues should be addressed through comprehensive trainings and increased supportive supervision. Additional innovative means to improve care should be explored.

Pesticide exposures in a malarious and predominantly farming area in Central Ghana.

In areas where malaria is endemic, pesticides are widely deployed for vector control, which has contributed to reductions in malaria deaths. Pesticide use for agrarian purposes reduces pest populations, thus improving crop production and post-harvest losses. However, adverse health effects have been associated with pesticide exposure, ranging from skin irritation to neurotoxicity and carcinogenicity. Though misuse of these pesticides can lead to widespread potential dangers, the debilitating effects are usually underappreciated in many developing countries. To evaluate the pattern of pesticide usage among rural communities in the Kintampo area of Ghana, a cross-sectional survey was conducted among 1455 heads of households randomly sampled from among 29,073 households in the Kintampo Health and Demographic Surveillance System area of Ghana to estimate the prevalence of pesticide use and indications for use among this rural populace. Seventy-one percent (1040/1455) of household heads reported having used pesticides on either their farms or homes, most commonly for control of weeds (96.4%, 1003/1040) or insects (85.4%, 888/1040). Dichlorodiphenyltrichloroethane (DDT) was used by 22.9% (238/1040) of respondents. The majority of households who reported use of pesticides said women in their households assisted in the spraying efforts (69.3%, 721/1040); of these women, 50.8% (366/721) did so while carrying their babies on their backs. Only 28.9% (301/1040) of the study participants wore protective devices during pesticide applications. Frequent symptoms that were reported after spraying, included cough (32.3%; 336/1040), difficulty in breathing (26.7%; 278/1040) and skin irritation (39.0%; 406/1040). Pesticide use among community members in the Kintampo area of Ghana is common and its potential health impacts warrant further investigation.

Adolescents’ Willingness and Intentions to Use Contraceptives in Rural Ghana

Efforts made to improve the availability and access to family planning services to adolescents in Ghana have not yielded the desired results. Adolescents in the Kintampo Health and Demographic Surveillance System area are no exception. This study explored contraceptive use intentions, preferences and their determinants among adolescents in rural Ghana. This was to contribute evidence towards achieving universal access to reproductive health. A cross-sectional study design was used to collect Sexual and Reproductive Health data in the Kintampo districts in 2011. A total of 1805 female adolescents were randomly sampled from a resident female adolescent population of 16,795. This study used intention and/or willingness of adolescents to use contraceptives as the outcome variable and the explanatory variables were demographic and socioeconomic factors. Descriptive and inferential statistical analyses were done. The findings indicated 54.3% of adolescents’ were willing to use contraceptives. Injectable was the most preferred contraceptive method among adolescents (48.6%); this was followed by the pill (29.6%) with the least being foam or jelly (0.2%). The most commonly cited reason for not intending to use contraception was adolescents’ opposition to family planning (31.5%) followed by a fear of side effects (25.8%). Age and education influenced adolescents’ willingness to use contraceptives in the future. Formal education of the young generation coupled with knowledge of contraceptive methods could yield positive outcomes for contraceptive use and ultimately reproductive health of the adolescent population in the near future.

"Not too far to walk": the influence of distance on place of delivery in a western Kenya health demographic surveillance system.

BackgroundMaternal health service coverage in Kenya remains low, especially in rural areas where 63% of women deliver at home, mainly because health facilities are too far away and/or they lack transport. The objectives of the present study were to (1) determine the association between the place of delivery and the distance of a household from the nearest health facility and (2) study the demographic characteristics of households with a delivery within a demographic surveillance system (DSS).MethodsCensus sampling was conducted for 13,333 households in the Webuye health and demographic surveillance system area in 2008–2009. Information was collected on deliveries that had occurred during the previous 12 months. Digital coordinates of households and sentinel locations such as health facilities were collected. Data were analyzed using STATA version 11. The Euclidean distance from households to health facilities was calculated using WinGRASS version 6.4. Hotspot analysis was conducted in ArcGIS to detect clustering of delivery facilities. Unadjusted and adjusted odds ratios were estimated using logistic regression models. P-values less than 0.05 were considered significant.ResultsOf the 13,333 households in the study area, 3255 (24%) reported a birth, with 77% of deliveries being at home. The percentage of home deliveries increased from 30% to 80% of women living within 2km from a health facility. Beyond 2km, distance had no effect on place of delivery (OR 1.29, CI 1.06–1.57, p = 0.011). Heads of households where women delivered at home were less likely to be employed (OR 0.598, CI 0.43–0.82, p = 0.002), and were less likely to have secondary education (OR 0.50, CI 0.41–0.61, p < 0.0001). Hotspot analysis showed households having facility deliveries were clustered around facilities offering comprehensive emergency obstetric care services.ConclusionHouseholds where the nearest facility was offering emergency obstetric care were more likely to have a facility delivery, but only if the facility was within 2km of the home. Beyond the 2-km threshold, households were equally as likely to have home and facility deliveries. There is need for further research on other factors that affect the choice of place of delivery, and their relationships with maternal mortality.

Factors Associated with Elderly Depression among Rural Bangladeshi Individuals

Background: Depression is a chronic disorder, which often remains undiagnosed. There is a gross lack of evidence-based information about depressive illnesses among adult individuals from rural Bangladesh. Objective: The present study aimed to determine the factors that are associated with depressive illness but remain undiagnosed among rural healthy adult individuals. Methodology: A cross-sectional study was conducted in the Demographic Surveillance System area of rural Mirzapur sub-district, during April to September 2010. A total of 130 apparently healthy individuals [no history of hypertension, cardiovascular diseases, hepatic (serum alanine transaminase; ALT) or renal (serum creatinine) dysfunction; diabetic mellitus (fasting blood sugar)] aged 40 years and above were randomly selected from the DSS database. Level of depression was assessed using 30-item Geriatric Depression Scale. Results: Forty-two percent of the healthy participants were found to have mild depression, 17% were severely depressed. In multivariate analysis, females had a 2.79 [95% CI-0.94-8.26] times higher risk for depression compared to males. Healthy elderly individuals (≥60 years) had a 2.79 [0.94-8.33] times higher risk for depression compared to their middle-aged counterparts (40-59 years). Furthermore, individuals who consumed a vegetable-based diet were at 2.47 [0.85-7.15] times higher risk for depression; individuals with low monthly income were at 2.57 [0.94-7.01] times higher, and those with poor wealth index were 1.55 [1.07-2.25] times more likely to suffer from depression compared to their counterparts after adjusting for vitamin B12, folic acid, ALT, and blood hemoglobin. Conclusion: Healthy elderly individuals from rural Bangladesh were more depressed than middle-aged adults; and females with poor socio-economic status were at higher risk for depression than males.

Changing emergence of Shigella sero-groups in Bangladesh: observation from four different diarrheal disease hospitals.

BackgroundShigellosis continues to be a public health challenge for developing countries, including Bangladesh. The aim of the study is to demonstrate recent changes in Shigella sero-groups and their geographical diversity.MethodsData were extracted from data archive of four diarrheal disease surveillance systems. A 2% sub sample from urban Dhaka Hospital (2008–2011; n = 10,650), and 10% from urban Mirpur Treatment Centre (2009–2011; n = 3,585), were enrolled systematically; whereas, all patients coming from the Health and Demographic Surveillance System area in rural Matlab (2008–2011; n = 6,399) and rural Mirzapur (2010–2011; n = 2,812) were included irrespective of age, sex, and disease severity. A fresh stool specimen was collected for identification of Shigella spp. Of them, 315 (3%) were positive for Shigella in Dhaka, 490 (8%) from Matlab, 109 (3%) from Mirpur and 369 (13%) from Mirzapur and considered as analyzable sample size.ResultsAmong all Shigella isolates regardless of age, significant decreases in percentage of S. flexneri over time was observed in Mirpur (55→29%; p value of χ2-for trend = 0.019) and Mirzapur (59→47%; p = 0.025). A non-significant decrease was also seen in Dhaka (58→48%), while in Matlab there was a non-significant increase (73→81%). Similar patterns were observed among under-5 children at all sites. Emergence of S. sonnei was found in Dhaka (8→25%; p<0.001) and Mirpur (10→33%; p = 0.015), whereas it decreased in Mirzapur (32→23%; p = 0.056). The emergence of S. boydii was seen in all ages in Mirzapur [(3→28%; p<0.001); (3→27%; p<0.001)]. On the other hand, we saw non-significant percent reductions in S. boydii in Dhaka [overall (25→16%); under-5 (16→9%)]. Decreasing rates of Shigella dysenteriae were observed in Matlab, Mirpur and Mirzapur; whereas, in Dhaka it remained unchanged.Conclusion and SignificanceEmergence of S. sonnei and S. boydii as important infectious diarrhea etiologies and variations in geographical diversity underscore the need for monitoring, with possible implications for vaccine development.

Biochemical and Dietary Indicators among Vegetarians and Non-Vegetarians: Findings from a Cross Sectional Study in Rural Bangladesh

Well-planned vegetarian diet provides numerous health benefits and is appropriate for all stages of life cycle. On the other hand, vegetarians often suffer from lower level or are deficient with different micro as well as macro nutrients. This ultimately led the study to determine and compare dietary intake and biochemical concentration of macro and micronutrients of vegetarian and non-vegetarian individuals. This cross sectional study was conducted during April-September 2010. Sixty six vegetarian and 66 non-vegetarian healthy adult aged 40 years and above were enrolled from the Demographic Surveillance System area of Mirzapur sub-district under Tangail district of rural Bangladesh. Five milliliters (5.0 ml) of venous blood was collected for the biochemical analysis. Dietary assessment involved 24-hour food recall method. This study revealed that, vegetarians had similar BMI compared to non-vegetarians. Biochemical analysis unveiled mean level of folic acid to be significantly higher (23.1±12.7 vs. 16.9±8.8, p=0.002) and mean level of vitamin B12 (134.9±46.2 vs. 217.6±95.6, p<0.001) to be significantly lower in vegetarians compared to non-vegetarians. From dietary history, mean calorie intake (1671.9±788.5 kcal vs. 1908.9±574.5 kcal, p=0.013) and macronutrient (median value; per day) consumption was found lower [carbohydrate (334.5 gm vs. 385.1 gm, p=0.048); protein (34.9 gm vs. 53.9 gm, p<0.001); fat (7.7 gm vs. 12.7 gm, p=0.020)] in non-vegetarian group compared to vegetarian individuals. In multivariate analysis of biochemical indicators, individuals being vegetarian impacted on decreased level of vitamin B12 (74.02 pmol/L) and increased level of folic acid (6.34 nmol/L). Multivariate analysis of dietary indicators revealed, individuals being vegetarian has an impact on decreased intake of protein (7.85 gm) and increased intake of log transformed β-carotene (0.61 mcg). These results suggest that, vegetarians in rural Bangladesh have lower intake of protein and micronutrients specially vitamin B 12; but increased intake of folic acid and β-carotene. Assessment of these outcomes affirms further study

Assessing the impact of malaria interventions on morbidity through a community-based surveillance system

The ACCESS Programme aims at understanding and improving access to prompt and effective malaria treatment in rural Tanzania with a set of integrated interventions targeting both users and providers. The aim of this article is to evaluate the programme's impact on the community and health facility burden of malaria and to investigate the value of community-based reporting for routine malaria control programme monitoring. This work was implemented within the Ifakara Demographic Surveillance System (DSS) between 2004 and 2008. At community level the DSS staff routinely collected data on reported history of fever and severe malaria (convulsions) based on a 2-week recall. In parallel, we collected in-patient and out-patient fever and malaria diagnoses data from the 15 health facilities in the area. Treatment-seeking surveys conducted in the study area and nationally representative data were used to validate our measure of community fever. Between 2005 and 2008, community-reported fever incidence rates in children under the age of 5 years declined by 34%, from 4.9 to 3.2 average cases per child per year, whereas convulsions, a marker of severe malaria morbidity in children, decreased by 46%, from 4263 to 2320 cases for every 100,000 children per year. The decrease in the community rates was paralleled by a decrease in the health facility fever rates, although the number of fever cases seen in health facilities did not change because of population growth. Our data showed very good internal and external consistency with independent local and national surveys. There is an evidence of a substantial decline in the community burden of malaria morbidity between 2005 and 2008 in the Kilombero and Ulanga DSS areas in Tanzania, most likely as a result of malaria control efforts. The good internal and external consistency of the data shows that history of fever in the previous 2 weeks in children under the age of 5 years can be used as a morbidity monitoring tool.

Mortality and health among internally displaced persons in western Kenya following post-election violence, 2008: novel use of demographic surveillance.

To evaluate mortality and morbidity among internally displaced persons (IDPs) who relocated in a demographic surveillance system (DSS) area in western Kenya following post-election violence. In 2007, 204 000 individuals lived in the DSS area, where field workers visit households every 4 months to record migrations, births and deaths. We collected data on admissions among children < 5 years of age in the district hospital and developed special questionnaires to record information on IDPs. Mortality, migration and hospitalization rates among IDPs and regular DSS residents were compared, and verbal autopsies were performed for deaths. Between December 2007 and May 2008, 16 428 IDPs migrated into the DSS, and over half of them stayed 6 months or longer. In 2008, IDPs aged 15-49 years died at higher rates than regular residents of the DSS (relative risk, RR: 1.34; 95% confidence interval, CI: 1.004-1.80). A greater percentage of deaths from human immunodeficiency virus (HIV) infection occurred among IDPs aged > or = 5 years (53%) than among regular DSS residents (25-29%) (P < 0.001). Internally displaced children < 5 years of age did not die at higher rates than resident children but were hospitalized at higher rates (RR: 2.95; 95% CI: 2.44-3.58). HIV-infected internally displaced adults in conflict-ridden parts of Africa are at increased risk of HIV-related death. Relief efforts should extend to IDPs who have relocated outside IDP camps, particularly if afflicted with HIV infection or other chronic conditions.

Inconsistencies in the Relationship Between Contraceptive Use and Fertility in Bangladesh

Contraceptive prevalence increased by nine percentage points from 1993 to 2000 in Bangladesh, but there was almost no decline in the total fertility rate. Data from the 1999-2000 Bangladesh Demographic and Health Survey and from the Matlab Demographic Surveillance System area collected between 1978 and 2001 were analyzed to explain the lack of change in fertility and to examine relationships among contraceptive prevalence, the abortion ratio, desired fertility and total fertility. After a maternal and child health and family planning program was initiated in part of Matlab in 1977, the total fertility rate in the intervention area declined from 4.8 in 1979 to 2.9 in 2000, while fertility in the comparison area dropped from 6.3 to 3.5. Over this period, contraceptive prevalence rose from 30% to 70% and from 16% to 50% in the two areas, respectively; meanwhile, the abortion ratio fell from 4.3 to 3.6 in the intervention area, but rose from around two to 8.2 in the comparison area. Trends in desired fertility in each area were similar, declining from about 4.0 children per woman in 1979 to about 2.5 children in 2000. Among women at each level of parity, fertility generally decreased as the number of sons increased, and fertility was highest for women without sons. Preference for male children and parental concern over infant and child mortality may partially explain the difference between desired family size and fertility. A reduction in breast-feeding and an increase in use of less-effective contraceptive methods might be responsible for the inconsistency in the relationship between contraceptive use and fertility.

Effect of large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania

Insecticide-treated nets have proven efficacy as a malaria-control tool in Africa. However, the transition from efficacy to effectiveness cannot be taken for granted. We assessed coverage and the effect on child survival of a large-scale social marketing programme for insecticide-treated nets in two rural districts of southern Tanzania with high perennial malaria transmission. Socially marketed insecticide-treated nets were introduced step-wise over a 2-year period from May, 1997, in a population of 480000 people. Cross-sectional coverage surveys were done at baseline and after 1, 2, and 3 years. A demographic surveillance system (DSS) was set up in an area of 60000 people to record population, births, and deaths. Within the DSS area, the effect of insecticide-treated nets on child survival was assessed by a case-control approach. Cases were deaths in children aged between 1 month and 4 years. Four controls for each case were chosen from the DSS database. Use of insecticide-treated nets and potential confounding factors were assessed by questionnaire. Individual effectiveness estimates from the case-control study were combined with coverage to estimate community effectiveness. Insecticide-treated net coverage of infants in the DSS area rose from less than 10% at baseline to more than 50% 3 years later. Insecticide-treated nets were associated with a 27% increase in survival in children aged 1 month to 4 years (95% CI 3-45). Coverage in such children was higher in areas with longer access to the programme. The modest average coverage achieved by 1999 in the two districts (18% in children younger than 5 years) suggests that insecticide-treated nets prevented 1 in 20 child deaths at that time. Social marketing of insecticide-treated nets has great potential for effective malaria control in rural African settings.

The Sisterhood Method of Estimating Maternal Mortality: The Matlab Experience

This study reports the results of a test of validation of the sisterhood method of measuring the level of maternal mortality using data from a Demographic Surveillance System (DSS) operating since 1966 in Matlab, Bangladesh. The records of maternal deaths that occurred during 1976-90 in the Matlab DSS area were used. One of the deceased woman's surviving brothers or sisters, aged 15 or older and born to the same mother, was asked if the deceased sister had died of maternity-related causes. Of the 384 maternal deaths for which siblings were interviewed, 305 deaths were correctly reported, 16 deaths were underreported, and the remaining 63 were misreported as nonmaternal deaths. Information on maternity-related deaths obtained in a sisterhood survey conducted in the Matlab DSS area was compared with the information recorded in the DSS. Results suggest that in places similar to Matlab, the sisterhood method can be used to provide an indication of the level of maternal mortality if no other data exist, though the method will produce negative bias in maternal mortality estimates.