A log-binomial Bayesian geoadditive semiparametric analysis of geographical inequalities in caesarean births in Ghana

BACKGROUND

Caesarean section is a clinical intervention aimed to save the lives of women and their newborns. In Ghana, studies have reported inequalities in use among women of different socioeconomic backgrounds. However, geographical differentials at the district level where health interventions are implemented, have not been systematically studied. This study examined geographical inequalities in caesarean births at the district level in Ghana. The study investigated how pregnancy complications and birth risks, access to health care and affluence correlate with geographical inequalities in caesarean section uptake.

METHODS

The data for the analysis was derived from the 2017 Ghana Maternal Health Survey. The log-binomial Bayesian Geoadditive Semiparametric regression technique was used to examine the extent of geographical clustering in caesarean births at the district level and their spatial correlates.

RESULTS

In Ghana, 16.0% (95% CI = 15.3, 16.8) of births were via caesarean section. Geospatial analysis revealed a strong spatial dependence in caesarean births, with a clear north-south divide. Low frequencies of caesarean births were observed among districts in the northern part of the country, while those in the south had high frequencies. The predominant factor associated with the spatial differentials was affluence rather than pregnancy complications and birth risk and access to care.

CONCLUSIONS

Strong geographical inequalities in caesarean births exist in Ghana. Targeted and locally relevant interventions including health education and policy support are required at the district level to address the overuse and underuse of caesarean sections, to correspond to the World Health Organisation recommended optimal threshold of 10% to 15%.

Antimalarial stocking decisions among medicine retailers in Ghana: implications for quality management and control of malaria

Global health efforts such as malarial control require efficient pharmaceutical supply chains to ensure effective delivery of quality-assured medicines to those who need them. However, very little is currently known about decision-making processes within antimalarial supply chains and potential vulnerabilities to substandard and falsified medicines. Addressing this gap, we report on a study that investigated decision-making around the stocking of antimalarial products among private-sector medicine retailers in Ghana. Licensed retail pharmacies and over-the-counter (OTC) medicine retail outlets were sampled across six regions of Ghana using a two-stage stratified sampling procedure, with antimalarial medicines categorised as 'expensive,' 'mid-range,' and 'cheaper,' relative to other products in the shop. Retailers were asked about their motivations for choosing to stock particular products over others. The reasons were grouped into three categories: financial, reputation/experience and professional recommendation. Reputation/experience (76%, 95% CI 72.0% to 80.7%) were the drivers of antimalarial stocking decisions, followed by financial reasons (53.2%, 95% CI 48.1% to 58.3%) and recommendation by certified health professionals (24.7%, 95% CI 20.3% to 29.1%). Financial considerations were particularly influential in stocking decisions of cheaper medicines. Moreover, pharmacies and OTCs without a qualified pharmacist were significantly more likely to indicate financial reasons as a motivation for stocking decisions. No significant differences in stocking decisions were found by geographical location (zone and urban/rural) or outlet (pharmacy/OTC). These findings have implications for the management of antimalarial quality across supply chains in Ghana, with potentially important consequences for malaria control, particularly in lower-income areas where people rely on low-cost medication.

A cross-sectional study of the psychological impact of the COVID-19 pandemic on camped refugees in Ghana

Vulnerable populations such as camped refugees are often exposed to spread of infectious diseases because of their living conditions, limited resources available to them and exclusion from social services. This study examined the psychological state of camped refugees in Ghana during the COVID-19 pandemic and how their background characteristics predict the severity of the pandemic's psychological impact. It covered 763 refugees aged 15 years and above resident in two (Krisan = 316 and Ampain = 447) camps. Nine COVID-19 Anxiety Scale indicators were used to examine the psychological state of camped refugees. A composite indicator was derived to examine the overall psychological impact. Logistic regression was used to examine the factors that were associated with severe psychological impact. The multivariate analysis revealed that sex of the respondent, marital status and age of head of household were the only socio-demographic factors associated with having a severe psychological impact of the pandemic. There was very strong evidence that respondents who had moderate (OR = 1.74, 95% CI = 1.12, 2.7) and high (OR = 1.66, 95% CI = 1.05, 2.63) knowledge of the disease had increased odds of severe psychological impact. Also, those with moderate (OR = 2.97, 95% CI = 1.78, 4.97) and high (OR = 12.98, 95% CI = 7.86, 21.42) adherence had increased odds of severe psychological impact. None of the pre-existing health conditions and challenges were not significantly associated with severe psychological impact. The limited number of significant socio-demographic covariates suggests that severe psychological impact of the pandemic was a problem in the general population, and thus interventions should target the general population of camped refugees. Also, health education should not only focus on enhancing knowledge and promoting preventive measures but also on managing psychological distress.

Geospatial clustering and correlates of deaths during the Ebola outbreak in Liberia: a Bayesian geoadditive semiparametric analysis of nationally representative cross-sectional survey data

OBJECTIVE

To investigate the extent of geospatial clustering of reported deaths during the Ebola outbreak in Liberia and the covariates associated with the observed clustering.

DESIGN

Cross-sectional study.

PARTICIPANTS

Male and female respondents from the 2019-2020 Liberia Demographic and Health Survey. The analysis covered 11 928 (women=7854 and men=4074) respondents for whom complete data were available.

OUTCOME MEASURES

The outcome variable was the death of a household member or relative during the Ebola outbreak in Liberia, coded 1 if the respondent reported death and 0 otherwise.

METHODS

We applied the Bayesian geoadditive semiparametric regression to examine the extent of geospatial clustering of deaths at the district-level and community-level development and socioeconomic factors associated with the observed clustering.

RESULTS

Almost a quarter (24.8%) of all respondents reported the death of a household member or relative during the Ebola outbreak. The results show that deaths were clustered within districts in six (Grand Cape Mount, Bomi, Monsterrado, Margibi, Gbarpolu and Lofa) of the 15 counties in Liberia. Districts with high death clustering were all near or shared borders with Sierra Leone and Guinea. The community-level development indicators (global human footprint, gross cell production and population density) had a non-linear associative effect with the observed spatial clustering. Also, respondents' characteristics (respondent's age (non-linear effect), educational attainment and urban-rural place of residence) were associated with the observed clustering. The results show that death clustering during outbreaks was constrained to poor settings and impacts areas of moderate and high socioeconomic development.

CONCLUSION

Reported deaths during the Ebola outbreak in Liberia were not randomly distributed at the district level but clustered. The findings highlight the need to identify at-risk populations during epidemics and respond with the needed interventions to save lives.

Geographical hotspots and correlates of early sexual debut among women in Ghana

Objectives

Generalisation of sexual behaviour, including early sexual initiation, does not provide comprehensive knowledge of young people’s sexual attitudes, behaviours and challenges, given the high sociocultural diversity and economic inequalities within countries. This study examines geographical hotspots of early sexual initiation, at the district level in Ghana and the factors associated with the observed spatial patterns.

Methods

Data was derived from the 2017 Ghana Maternal Health Survey, covering 21,392 women aged 15–49 years. Early sexual debut denotes first sexual intercourse before attaining the legal age of sexual consent, which in Ghana, is 16 years. The Bayesian geoadditive semiparametric regression technique was used to examine geographical hotspots and correlates of the observed spatial patterns, classified into demographic, socioeconomic and pregnancy outcome factors.

Results

The results show that 26.7% (95% CI = 26.1–27.3) of women had their first sexual intercourse before attaining the age of 16 years. Hotspots of early sexual debut was observed predominantly among districts along the mainstream of the Volta Lake, which are also reported hotspots of child trafficking, labour and slavery. Demographic, socioeconomic and pregnancy related factors were identified to be correlated with the observed spatial clustering.

Conclusion

Policies and interventions such as sexual and reproductive health education should target at-risk population, simultaneously addressing other child abuses perpetuating the practice.

Ghana operates a decentralised health system, where health policies and interventions, including those for sexual and reproductive health are implemented at the district level. Yet, there are no studies that systematically identify districts where sexual behaviours, such as early sexual debut, require attention. This study uses spatial models and data from the 2017 Ghana Maternal Health Survey to identify areas (districts) with high concentration of women who initiated sex before the legal age of consent. Early sexual debut refers to first sexual intercourse before attainment of the legal age (16 years) of sexual consent. Early sexual initiation has been associated with adverse sexual and reproductive health outcomes such as unwanted pregnancies and STIs. The results show that about one in four women reported having early sexual intercourse. High early sexual intercourse was observed to be particularly concentrated among districts along the mainstream of the Volta Lake. With regards to the spatial correlates, for the districts in the Oti region, high early sexual debut was associated with low educational attainment and inability to read. For those in the Bono East and Eastern regions, women who had early sexual debut were more likely to have had a miscarriage, abortion or stillbirth. Younger women, those in co-habiting relationships and those not in union were more likely to have had early sexual debut in the districts in the Ashanti, Central and Northern regions. The findings call for intensification of sexual and reproductive health education in districts along the mainstream of the Volta Lake.

Spatiotemporal clustering and correlates of childhood stunting in Ghana: Analysis of the fixed and nonlinear associative effects of socio-demographic and socio-ecological factors

Childhood stunting remains a major public health issue in many low- and middle-income countries. In Ghana, the progress made is insufficient to reach the targets set by the 2025 World Health Assembly and the 2030 United Nations Sustainable Development Goals. Although studies have examined the socio-demographic determinants of childhood stunting, there has not been any systematic study to examine the spatial associative effects of the socio-demographic and socio-ecological factors at the district level, where health programmes are implemented and monitored. Bayesian geo-additive semiparametric regression technique was used to analyse five conservative rounds of Demographic and Health Surveys in Ghana, with socio-ecological covariates derived from the Demographic and Health Survey Program Geospatial Covariate datasets to examine the temporal trends in childhood stunting, the extent of geospatial clustering at the district level and their associative relationships with socio-demographic and socio-ecological factors. The findings show that childhood stunting in Ghana is not spatially randomly distributed but clustered. Clustering of high childhood stunting was observed amongst districts in the Upper West, Upper East, Northern, North East, Savannah, and Western North regions, whilst clustering of low childhood stunting was observed in districts in the Greater Accra, Volta, Bono and the Eastern regions. Whist socio-demographic factors were predominantly associated with clustering of districts with high childhood stunting, the socio-ecological factors were mainly associated with clustering of districts with low childhood stunting. The socio-ecological factors identified to have a nonlinear associative effect with childhood stunting were Insecticide Treated Net (ITN) coverage, nightlight composite, travel time to a main settlement and population density. The findings suggest that targeted interventions at the district level are essential to reducing childhood stunting in Ghana.

Collective influence of household and community capitals on agricultural employment as a measure of rural poverty in the Mahanadi Delta, India

The main determinants of agricultural employment are related to households' access to private assets and the influence of inherited social-economic stratification and power relationships. However, despite the recommendations of rural studies which have shown the importance of multilevel approaches to rural poverty, very few studies have explored quantitatively the effects of common-pool resources and household livelihood capitals on agricultural employment. Understanding the influence of access to both common-pool resources and private assets on rural livelihoods can enrich our understanding of the drivers of rural poverty in agrarian societies, which is central to achieving sustainable development pathways. Based on a participatory assessment conducted in rural communities in India, this paper differentiates two levels of livelihood capitals (household capitals and community capitals) and quantifies them using national census data and remotely sensed satellite sensor data. We characterise the effects of these two levels of livelihood capitals on precarious agricultural employment by using multilevel logistic regression. Our study brings a new perspective on livelihood studies and rural economics by demonstrating that common-pool resources and private assets do not have the same effect on agricultural livelihoods. It identifies that a lack of access to human, financial and social capitals at the household level increases the levels of precarious agricultural employment, such as daily-wage agricultural labour. Households located in communities with greater access to collective natural capital are less likely to be agricultural labourers. The statistical models also show that proximity to rural centres and access to financial infrastructures increase the likelihood of being a landless agricultural labourer. These findings suggest that investment in rural infrastructure might increase livelihood vulnerability, if not accompanied by an improvement in the provisioning of complementary rural services, such as access to rural finance, and by the implementation of agricultural tenancy laws to protect smallholders' productive assets.

Geospatial correlates of early marriage and union formation in Ghana

The practice of early marriage, although acknowledged as a human rights violation, continues to occur in many countries. Different studies have identified the associated factors in many developing countries. However, these factors often assume no geographical variation in these factors within countries. Again, cultural practices and beliefs which strongly influence the acceptance and practices of early marriage vary geographically. In addition, geographic clusters of high rates of early marriage and union formation are also unknown. Thus, area specific correlates of early child marriage are required for the development of location specific policies to aid the eradication of early child marriage. Using data from the 2010 Ghana Population and Housing Census, this study examines the extent of geospatial clustering in early marriage amongst girls and their spatially-varying associated factors at the district level. The findings reveal strong clustering of high early marriage amongst districts in the Upper West, Northern and Volta regions. Nationally, 6.96% (CI = 6.83, 7.08) of girls are married or in union before their 18^th birthday. The estimates range from 2.7% in the Jaman North district in Brong Ahafo region to 19.0% in the Gushiegu district in Northern region. Economic factors were observed as important spatially-varying associated factors. The findings suggest that targeted interventions are required in the effort to eradicate the practice in Ghana.

Operationalizing safe operating space for regional social-ecological systems

This study makes a first attempt to operationalize the safe operating space concept at a regional scale by considering the complex dynamics (e.g. non-linearity, feedbacks, and interactions) within a systems dynamic model (SD). We employ the model to explore eight 'what if' scenarios based on well-known challenges (e.g. climate change) and current policy debates (e.g. subsidy withdrawal). The findings show that the social-ecological system in the Bangladesh delta may move beyond a safe operating space when a withdrawal of a 50% subsidy for agriculture is combined with the effects of a 2°C temperature increase and sea level rise. Further reductions in upstream river discharge in the Ganges would push the system towards a dangerous zone once a 3.5°C temperature increase was reached. The social-ecological system in Bangladesh delta may be operated within a safe space by: 1) managing feedback (e.g. by reducing production costs) and the slow biophysical variables (e.g. temperature, rainfall) to increase the long-term resilience, 2) negotiating for transboundary water resources, and 3) revising global policies (e.g. withdrawal of subsidy) that negatively impact at regional scales. This study demonstrates how the concepts of tipping points, limits to adaptations, and boundaries for sustainable development may be defined in real world social-ecological systems.

Is shrimp farming a successful adaptation to salinity intrusion? A geospatial associative analysis of poverty in the populous Ganges-Brahmaputra-Meghna Delta of Bangladesh

The Ganges-Brahmaputra-Meghna delta of Bangladesh is one of the most populous deltas in the world, supporting as many as 140 million people. The delta is threatened by diverse environmental stressors including salinity intrusion, with adverse consequences for livelihood and health. Shrimp farming is recognised as one of the few economic adaptations to the impacts of the rapidly salinizing delta. Although salinity intrusion and shrimp farming are geographically co-located in the delta, there has been no systematic study to examine their geospatial associations with poverty. In this study, we use multiple data sources including Census, Landsat Satellite Imagery and soil salinity survey data to examine the extent of geospatial clustering of poverty within the delta and their associative relationships with salinity intensity and shrimp farming. The analysis was conducted at the union level, which is the lowest local government administrative unit in Bangladesh. The findings show a strong clustering of poverty in the delta, and whilst different intensities of salinization are significantly associated with increasing poverty, neither saline nor freshwater shrimp farming has a significant association with poverty. These findings suggest that whilst shrimp farming may produce economic growth, in its present form it has not been an effective adaptation for the poor and marginalised areas of the delta. The study demonstrates that there are a series of drivers of poverty in the delta, including salinization, water logging, wetland/mudflats, employment, education and access to roads, amongst others that are discernible spatially, indicating that poverty alleviation programmes in the delta require strengthening with area-specific targeted interventions.

A geospatial analysis of the impacts of maternity care fee payment policies on the uptake of skilled birth care in Ghana

Background

Many low and middle income countries have initiated maternity fee exemption and removal policies to promote use of skilled maternity care. After two and a half decades of these policies, uptake of skilled birth care remains low and inequalities continue to exist in many low and middle income countries. This study uses 2 decades of birth histories data to examine four maternity fee paying policies enacted in Ghana over the past 3 decades and their geospatial impacts on uptake of skilled delivery care.

Methods

Bayesian Geoadditive Semiparametric regression techniques were applied on four conservative rounds of Demographic and Health Surveys in Ghana to examine the extent of geospatial dependence in skilled birth care use at the district level and their associative relationships with maternity fee paying policies focusing on the temporal trends when the policies were functional.

Results

The results show that at the country-level, the policies had a positive influence on use of skilled delivery care; however their impacts on reducing between-district inequalities were trivial.

Conclusions

The findings suggest that targeted interventions at the district level are essential to strengthen maternal health programmes in Ghana.

Infrastructural challenges to better health in maternity facilities in rural Kenya: community and healthworker perceptions

Background

The efforts and commitments to accelerate progress towards the Millennium Development Goals for maternal and newborn health (MDGs 4 and 5) in low and middle income countries have focused primarily on providing key medical interventions at maternity facilities to save the lives of women at the time of childbirth, as well as their babies. However, in most rural communities in sub-Saharan, access to maternal and newborn care services is still limited and even where services are available they often lack the infrastructural prerequisites to function at the very basic level in providing essential routine health care services, let alone emergency care. Lists of essential interventions for normal and complicated childbirth, do not take into account these prerequisites, thus the needs of most health facilities in rural communities are ignored, although there is enough evidence that maternal and newborn deaths continue to remain unacceptably high in these areas.

Methods

This study uses data gathered through qualitative interviews in Kitonyoni and Mwania sub-locations of Makueni County in Eastern Kenya to understand community and provider perceptions of the obstacles faced in providing and accessing maternal and newborn care at health facilities in their localities.

Results

The study finds that the community perceives various challenges, most of which are infrastructural, including lack of electricity, water and poor roads that adversely impact the provision and access to essential life-saving maternal and newborn care services in the two sub-locations.

Conclusions

The findings and recommendations from this study are important for the attention of policy makers and programme managers in order to improve the state of lower-tier health facilities serving rural communities and to strengthen infrastructure with the aim of making basic routine and emergency obstetric and newborn care services more accessible.

The geography of maternal and newborn health: the state of the art

As the deadline for the millennium development goals approaches, it has become clear that the goals linked to maternal and newborn health are the least likely to be achieved by 2015. It is therefore critical to ensure that all possible data, tools and methods are fully exploited to help address this gap. Among the methods that are under-used, mapping has always represented a powerful way to ‘tell the story’ of a health problem in an easily understood way. In addition to this, the advanced analytical methods and models now being embedded into Geographic Information Systems allow a more in-depth analysis of the causes behind adverse maternal and newborn health (MNH) outcomes. This paper examines the current state of the art in mapping the geography of MNH as a starting point to unleashing the potential of these under-used approaches. Using a rapid literature review and the description of the work currently in progress, this paper allows the identification of methods in use and describes a framework for methodological approaches to inform improved decision-making. The paper is aimed at health metrics and geography of health specialists, the MNH community, as well as policy-makers in developing countries and international donor agencies.

Two decades of maternity care fee exemption policies in Ghana: have they benefited the poor?

OBJECTIVE

To investigate, the impact of maternity-related fee payment policies on the uptake of skilled birth care amongst the poor in Ghana.

METHODS

Population data representing 12 288 births between November 1990 and October 2008 from four consecutive rounds of the Ghana demographic and health surveys were used to examine the impact of four major maternity-related payment policies: the full-cost recovery 'cash and carry' scheme; 'antenatal care fee exemption'; 'delivery care fee exemption' and the 'National Health Insurance Scheme (NHIS)'. Concentration curves were used to analyse the rich-poor gap in the use of skilled birth care by the four policy interventions. Multilevel logistic regression was used to examine the effect of the policies on the uptake of skilled birth care, adjusting for relevant predictors and clustering within communities and districts.

FINDINGS

The uptake of skilled birth care over the policy periods for the poorest women was trivial when compared with their non-poor counterparts. The rich-poor gap in skilled birth care use was highly pronounced during the 'cash and carry' and 'free antenatal care' policies period. The benefits during the 'free delivery care' and ' NHIS' policy periods accrued more for the rich than the poor. There exist significant differences in skilled birth care use between and within communities and districts, even after adjusting for policy effects and other relevant predictors.

CONCLUSIONS

The maternal care fee exemption policies specifically targeted towards the poorest women had limited impact on the uptake of skilled birth care.

Evaluating the impact of the community-based health planning and services initiative on uptake of skilled birth care in Ghana

Background

The Community-based Health Planning and Services (CHPS) initiative is a major government policy to improve maternal and child health and accelerate progress in the reduction of maternal mortality in Ghana. However, strategic intelligence on the impact of the initiative is lacking, given the persistant problems of patchy geographical access to care for rural women. This study investigates the impact of proximity to CHPS on facilitating uptake of skilled birth care in rural areas.

Methods and Findings

Data from the 2003 and 2008 Demographic and Health Survey, on 4,349 births from 463 rural communities were linked to georeferenced data on health facilities, CHPS and topographic data on national road-networks. Distance to nearest health facility and CHPS was computed using the closest facility functionality in ArcGIS 10.1. Multilevel logistic regression was used to examine the effect of proximity to health facilities and CHPS on use of skilled care at birth, adjusting for relevant predictors and clustering within communities. The results show that a substantial proportion of births continue to occur in communities more than 8 km from both health facilities and CHPS. Increases in uptake of skilled birth care are more pronounced where both health facilities and CHPS compounds are within 8 km, but not in communities within 8 km of CHPS but lack access to health facilities. Where both health facilities and CHPS are within 8 km, the odds of skilled birth care is 16% higher than where there is only a health facility within 8km.

Conclusion

Where CHPS compounds are set up near health facilities, there is improved access to care, demonstrating the facilitatory role of CHPS in stimulating access to better care at birth, in areas where health facilities are accessible.

Examining intersectoral integration for malaria control programmes in an urban and a rural district in Ghana: a multinomial multilevel analysis

BACKGROUND

Intersectoral integration is acknowledged to be essential for improving provision of health care and outcomes, yet it remains one of the main primary health care strategic challenges. Although this is well articulated in the literature, the factors that explain differentials in levels of intersectoral integration have not been systematically studied, particularly in low and middle-income countries. In this study, we examine the levels and determinants of intersectoral integration amongst institutions engaged in malaria control programmes in an urban (Kumasi Metropolitan) district and a rural (Ahafo Ano South) district in Ghana.

METHODS

Interviews were conducted with representatives of 32 institutions engaged in promoting malaria prevention and control. The averaging technique proposed by Brown et al. and a two-level multinomial multilevel ordinal logistic regression were used to examine the levels of integration and the factors that explain the differentials.

RESULTS

The results show high disparity in levels of integration amongst institutions in the two districts. Integration was higher in the rural district compared to the urban district. The multivariate analysis revealed that the district effect explained 25% of the variations in integration. The type of institution, level of focus on malaria and source of funding are important predictors of intersectoral integration.

CONCLUSION

Although not causal, integrated malaria control programmes could be important for improving malaria-related health outcomes in less developed regions as evident from the rapid decline in malaria fatality rates observed in the Ahafo Ano South district. Harmonisation of programmes should be encouraged amongst institutions and the public and private sectors should be motivated to work in partnership.

Are women deciding against home births in low and middle income countries?

BACKGROUND

Although there is evidence to tracking progress towards facility births within the UN Millennium Development Goals framework, we do not know whether women are deciding against home birth over their reproductive lives. Using Demographic and Health Surveys (DHS) data from 44 countries, this study aims to investigate the patterns and shifts in childbirth locations and to determine whether these shifts are in favour of home or health settings.

METHODS AND FINDINGS

The analyses considered 108,777 women who had at least two births in the five years preceding the most recent DHS over the period 2000-2010. The vast majority of women opted for the same place of childbirth for their successive births. However, about 14% did switch their place and not all these decisions favoured health facility over home setting. In 24 of the 44 countries analysed, a higher proportion of women switched from a health facility to home. Multilevel regression analyses show significantly higher odds of switching from home to a facility for high parity women, those with frequent antenatal visits and more wealth. However, in countries with high infant mortality rates, low parity women had an increased probability of switching from home to a health facility.

CONCLUSIONS

There is clear evidence that women do change their childbirth locations over successive births in low and middle income countries. After two decades of efforts to improve maternal health, it might be expected that a higher proportion of women will be deciding against home births in favour of facility births. The results from this analysis show that is not the case.

Geographical access to care at birth in Ghana: a barrier to safe motherhood

BACKGROUND

Appropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning. In this study, we develop a uniquely detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana, a high-burden country typical of many in sub-Saharan Africa.

METHODS

We assembled detailed spatial data on the population, health facilities, and landscape features influencing journeys. These were used in a geospatial model to estimate journey-time for all women of childbearing age (WoCBA) to their nearest health facility offering differing levels of care at birth, taking into account different transport types and availability. We calibrated the model using data on actual journeys made by women seeking care.

RESULTS

We found that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the 'partial' standard or better. Nearly half (45%) live that distance or further from 'comprehensive' EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. Poor levels of access were found in many regions that meet international targets based on facilities-per-capita ratios.

CONCLUSIONS

Detailed data assembly combined with geospatial modelling can provide nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes because they fail to take account of the location and accessibility of services relative to the women they serve.

Estimating unmet need for contraception by district within Ghana: an application of small-area estimation techniques

The importance of meeting the unmet need for contraception is nowhere more urgent than in the countries of sub-Saharan Africa, where the fertility decline is stalling and total unmet need exceeds 30 per cent among married women. In Ghana, where fertility levels vary considerably, demographic information at sub-national level is essential for building effective family planning programmes. We used small-area estimation techniques, linking data from the 2003 Ghana Demographic and Health Survey to the 2000 Ghana Population and Housing Census, to derive district-level estimates of contraceptive use and unmet need for contraception. The results show considerable variation between districts in contraceptive use and unmet need. The prevalence of contraceptive use varies from 4.1 to 41.7 per cent, while that of the use of modern methods varies from 4.0 to 34.8 per cent. The findings identify districts where family planning programmes need to be strengthened.

Targeting women at risk of unintended pregnancy in Ghana: Should geography matter?

Unintended childbearing in Ghana is estimated to be about 0.7 births per woman, thus contributing to the high total fertility rate of more than 4 births. About one-third of women of reproductive age have an unmet need for family planning and there are strong geographic differences between and within ecological zones. Spatial analysis of risk of unintended pregnancies planning can reveal differences in the provision and usage of contraceptive commodities, thereby providing information of areas where programmes should be strengthened. This study uses data from the 1998 and 2003 Ghana Demographic and Health Surveys to examine geographical variation in the risk of unintended pregnancies among women in the three ecological zones of Ghana (Savannah, Forest, and Coastal). The data was analysed using multilevel logistic regression. Approximately 55% of Ghanaian women (married or in union) are at risk of unintended pregnancies and there are differences between urban and rural women, with rural women more likely to have their demand for contraception unmet. After adjusting for the socio-economic and demographic factors, the results show little differences between ecological zones in the levels of women exposed to the risk of unintended pregnancy, but they demonstrate significant within community effects, which influence the risk of unintended pregnancies for women within the community. Communities, therefore, can be used as units for targeting services aimed at increasing coverage of contraceptive commodities.

Orphanhood and vulnerability: a conduit to poor child health outcomes in Rwanda

The HIV epidemic in sub-Saharan Africa has caused many children to become orphaned and vulnerable. Recent studies show that orphaned and vulnerable children (OVC) lack the basic necessities for survival and development. These children are particularly at high risk of poor health and poverty. Although the poor health outcomes of these children are well documented, the complexities of the factors that mediate their health outcomes have not been systematically studied. The aim of this paper is to examine how the complex relationships between and within the proximate and socio-economic determinants mediate the poor health outcomes of children through their OVC status. The analyses considered graphical chain modelling of morbidity data from a sample of 3745 children aged below five years from the 2005 Rwandan Demographic and Health Survey. The results show that OVC status influences the risk of childhood morbidity both directly and indirectly and also as a conduit through which other significant proximate factors and socio-economic factors operate.

On the spatial inequalities of institutional versus home births in Ghana: a multilevel analysis

Spatial inequalities related to the choice of delivery care have not been studied systematically in Sub-Saharan Africa where maternal and perinatal health outcomes continue to worsen despite a range of safe motherhood interventions. Using retrospective data from the 1998 and 2003 Demographic and Health Surveys, this paper investigates the extent of changes in spatial inequalities associated with type of delivery care in Ghana with a focus on rural-urban differentials within and across the three ecological zones (Savannah, Forest and Coastal). More than one-half of births in Ghana continue to occur outside health institutions without any skilled obstetric care. While this is already known, we present evidence from multilevel analyses that there exist considerable and growing inequalities, with regard to birth settings between communities, within rural and urban areas and across the ecological zones. The results show evidence of poor and disproportionate use of institutional care at birth; the inequalities remained high and unchanged in both urban and rural communities within the Savannah zone and widening in urban communities of the Forest and Coastal zones. The key policy challenges in Ghana, therefore, include both increasing the uptake of institutional delivery care and ensuring equity in access to both public and private health institutions.

Activity-dependent refinement in the goldfish retinotectal system is mediated by the dynamic regulation of processes withdrawal: an in vivo imaging study

Imaging of regenerating optic fibers in living adult goldfish was used to visualize arbor restructuring during activity-dependent refinement. A small number of neighboring retinal ganglion cells were labeled with DiI and observed in the tectum of the living animal for 5-7 hours during the period of activity-dependent refinement. In contrast to earlier stages of regeneration, many optic arbors were surprisingly stable, showing little or no change. The observed changes were mainly retractions, and these were affected by retinotopic position and activity. Axon branches in retinotopic positions changed by much smaller amounts than ectopic axons, but in fish with retinal tetrodotoxin impulse blockade, no systematic difference was observed as a function of tectal position. Otherwise, impulse blockade had no notable effects.

Characterization of the block structure and molecular weight of sodium alginates

Sodium alginates are widely used within the pharmaceutical sciences, yet the molecular characteristics of these materials are frequently not stated. In this study, a range of characterization techniques is applied to five sodium alginate samples and the data compared, both between techniques and with the information obtained from the manufacturer. The mannuronic acid to guluronic acid (MG) ratio and the distribution of uronic acid residues of five sodium alginate samples have been measured using circular dichroism and NMR, with circular dichroism yielding MG ratios between 42.1 and 63.6%, depending on the grade of alginate used. The MG ratios obtained from NMR studies were in broad agreement with these values, and the technique also yielded information on the distribution of uronic acid residues within each batch; this was again found to vary considerably (NG > 1 values ranging from 6.9 to 17.5). It was noted that samples with similar MG ratios could have markedly different chain-distribution characteristics. The uronic acid ratio ranges obtained from the manufacturers were found to be in good agreement with those found experimentally. Intrinsic viscosity measurements were used to compare the molecular weights of the samples; values between approximately 12,000 and 180,000 were obtained for the different batches. The study has enabled comparison of different methods for characterization of sodium alginate samples, highlighting their relative merits and the possible protocols that might be adopted. A critical discussion is given of the individual and combined use of these techniques and the relevance of such studies to the rational design and quality control of alginate-based pharmaceutical systems.

Alternative psychotherapeutic practice among middle class Americans: II: Some conceptual and practical comparisons

This article will contextualize ethnographic and clinical features that distinguish one particular alternative healing method (Self-Acceptance Training) from 'main-stream' psychotherapeutic procedures. Factors common to many psychotherapies are listed and a series of contrasts and comparisons made by examining definitions of: (1) presenting problems, (2) inciting events, (3) phasic development, (4) taxonomic classifications, (5) therapeutic interventions, and (6) prognostic formulations. The alternative method of treatment described in a companion publication ('SAT') is used to make some specific comparisons (Zatzick and Johnson 1997). Basch's (1980) concise recording of a dynamic therapy is borrowed for purposes of a comparative hypothetical treatment of his patient through a Self-Acceptance Training session. Some directions for future work are suggested.

Alternative psychotherapeutic practice among middle class Americans: I: Case studies and follow-up

Historically, alternative psychotherapeutic procedures have florished worldwide in various inspirational, spiritualistic and shamanistic versions. However, few investigations have described these interventions in detail, or followed the clinical outcomes longitudinally. This present report is an ethnographic and clinical description of one particular American practitioner's alternative method as it is used with middle class clientele in several regions of the USA. Two case studies are presented in detail while nine individual cases are qualitatively reviewed with one month and one year treatment outcomes reported. A condensed ethnobiographical study of the practitioner's personal and professional life is included.

Childhood epilepsy in Papua New Guinea

A prospective study of 40 children with epilepsy was carried out between June 1990 and August 1991 at Port Moresby General Hospital. Half of the children had yet to start school. Significant features in their past medical histories were acute meningitis (38%), tuberculous meningitis (10%), febrile convulsions (10%) and head trauma (5%). Most cases had grand mal epilepsy (80%). The majority of the children with epilepsy (90%) were treated with a single drug, which was usually phenobarbitone. 22% had received more than one drug, but not simultaneously. Significant side-effects requiring change of treatment occurred in 10%. Disturbed behaviour was reported in 55% and 22% had a poor social outcome. 45% had complete control of fits clinically. This study showed that in Port Moresby acute meningitis is a significant cause of epilepsy in young children, the majority of whom present with grand mal epilepsy, which is usually controlled by phenobarbitone, a readily available and cheap drug and still a useful anticonvulsant in the developing world.

Effect of melittin on prostaglandin production by guinea-pig uterus

Melittin, an activator of phospholipase (PL) A-2, increased the outputs of prostaglandin (PG) F-2 alpha and 6-keto-PGF-1 alpha, but not of PGE-2, from Day-7 guinea-pig uterus superfused in vitro. Reducing the extracellular calcium concentration (by omitting calcium chloride from the superfusing fluid) partially inhibited the stimulatory effect of melittin on uterine PG production. TMB-8 (an intracellular calcium antagonist) completely prevented the stimulation of PGF-2 alpha and 6-keto-PGF-1 alpha output by melittin, although the production of both PGs tended to increase after stopping the melittin and TMB-8 treatments. TMB-8 also inhibited the increases in outputs of PGF-2 alpha, 6-keto-PGF-1 alpha and PGE-2 and prevented contraction of the uterus induced by exogenous PLA-2. Trifluoperazine (a calmodulin antagonist) had no inhibitory effect on the increases in outputs of PGF-2 alpha and 6-keto-PGF-1 alpha produced by melittin; it potentiated the stimulatory effect of melittin on 6-keto-PGF-1 alpha output and allowed melittin to increase PGE-2 output. When melittin was applied twice to the superfused uterus with an interval of 1 h between each treatment, partial refractoriness of the responses to melittin was seen: the magnitudes of the increases in PGF-2 alpha and 6-keto-PGF-1 alpha outputs were 40-50% less after the second treatment than after the first treatment. These results show that melittin stimulates the synthesis of PGF-2 alpha and PGI-2 (measured as 6-keto-PGF-1 alpha) in guinea-pig uterus by mechanisms which are calcium dependent.(ABSTRACT TRUNCATED AT 250 WORDS)

A prion-like protein from chicken brain copurifies with an acetylcholine receptor-inducing activity

The mammalian prion protein (PrPC) is a cellular protein of unknown function, an altered isoform of which (PrPSc) is a component of the infectious particle (prion) thought to be responsible for spongiform encephalopathies in humans and animals. We report here the isolation of a cDNA that encodes a chicken protein that is homologous to PrPC. This chicken prion-like protein (ch-PrLP) is identical to the mouse PrP at 33% of its amino acid positions, including an uninterrupted stretch of 24 identical residues, and it displays the same structural domains. In addition, ch-PrLP, like its mammalian counterpart, is attached to the cell surface by a glycosyl-phosphatidylinositol anchor. We find that ch-PrLP is the major protein in preparations of an acetylcholine receptor-inducing activity that has been purified greater than 10(6)-fold from brain on the basis of its ability to stimulate synthesis of nicotinic receptors by cultured myotubes. The ch-PrLP gene is expressed in the spinal cord and brain as early as embryonic day 6; and in the spinal cord, the protein appears to be concentrated in motor neurons. Our results therefore raise the possibility that prion proteins serve normally to regulate the chemoreceptor number at the neuromuscular junction and perhaps in the central nervous system as well.

Development of central projections of lumbosacral sensory neurons in the chick

The development of central projections of sensory neurons in lumbosacral dorsal root ganglia (DRGs) was examined by using horseradish peroxidase labeling techniques in chick embryos from stage 23 (E4) to stage 39 (E13). Our results show that primary afferents reach the spinal cord by stage 23. Afferent axons extend in the primordium of the dorsal funiculus for several segments rostral and caudal to their segment of entry for over 24 hours before invading the gray matter at stage 28 (E6). Sensory fibers grow into the vicinity of motoneuron dendrites by stage 32 (E7.5), about the time that reflexes and apparent monosynaptic EPSPs can first be elicited. Dense projections into the dorsal laminae of the spinal cord, presumably representing cutaneous afferents, appear somewhat later, at about stage 39 (E13), when the segmental projection pattern begins to resemble the mature pattern.

Alexithymia and chronic respiratory disease. A review of current research

Alexithymia within a chronic respiratory illness population has been given considerable attention in the psychiatric/psychological literature over the course of the past 5 years. Various observations as to the alexithymic trait within the chronic respiratory diseases (asthma, chronic bronchitis/emphysema, and tuberculosis) have revealed significant findings as to the manner in which alexithymia manifests itself and impacts on chronic respiratory disease. The present paper reviews the literature on alexithymia that has emanated from National Jewish Hospital and Research Center/National Asthma Center and raises questions for future research as regards alexithymia in chronic respiratory diseases.

Alexithymia in chronic bronchitis/emphysema patients. Communication of subjective symptomatology

Affective, somatic, and collateral experiences of alexithymic and nonalexithymic patients to their chronic bronchitis/emphysema was analyzed in reference to 11 symptom categories of the Bronchitis/Emphysema Symptom Checklist. Unlike alexithymic asthmatics who tend to minimize their self-reports of physical and emotional difficulties during acute illness episodes, chronic bronchitis/emphysema alexithymics do not differ from nonalexithymics in their self-reports of physical and emotional difficulties.

Proton nuclear magnetic resonance investigation of the mechanism of flavin C-4a adduct formation induced by oxidized nicotinamide adenine dinucleotide binding to monoalkylated pig heart lipoamide dehydrogenase

The active center thiol of monoalkylated pig heart lipoamide dehydrogenase, EHR, is induced to form an adduct to the enzyme-bound flavin adenine dinucleotide (FAD) at the C-4a position upon binding oxidized nicotinamide adenine dinucleotide (NAD+) [Thorpe, C., & Williams, C. H., Jr. (1976) J. Biol. Chem. 251, 7726-7728]. In light of hypotheses on covalent electron transfer between pyridine nucleotide and flavin, the induction of the thiol-flavin C-4a adduct by NAD+ is reasonably envisioned as involving a covalent bond between the modified flavin and the NAD+. The double-resonance proton nuclear magnetic resonance technique of cross saturation was used to probe the existence of covalent bond formation between the modified flavin of EHR and its inducer molecule, NAD+. Cross-saturation of the free NAD+ signals was not observed even though the spin-lattice relaxation time of NAD+ and the rate of exchange between free NAD+ and NAD+ bound to EHR were well within the limits required for cross-saturation. We conclude that a noncovalent interaction between NAD+ and FAD induces the formation of the thiol-flavin C-4a covalent adduct in EHR. A model by which NAD+ binding induces nucleophilic attack by the nascent thiolate of EHR is discussed.

A micro-analysis of "senility": the responses of the family and the health professionals

In research on 167 post-hospitalized older people, thirty individuals were described by their families as being senile. In comparisons of the behaviorally impaired with those who have only a physical condition, it was found that the behaviorally impaired were significantly more likely to be placed in a nursing home than were those with serious physical impairment. In this sub-group, the family also was much more likely to seek-out health professionals for advice in the disposition of the patient, although mental health professionals were rarely consulted. Through a case study analysis, we analyze the interactions between the patients, their families and the health professions as a three-stage process where the patient's behaviors become increasingly specified and elaborated. As a result behaviors formerly tolerated become a formal problem where the solution is likely to be institutionalization.

Determination of a low pK for histidine-159 in the S-methylthio derivative of papain by proton nuclear magnetic resonance spectroscopy

Proton NMR spectroscopy was used to study the ionization behavior of His-159 in a derivative of papain (papain-S-SCH3). In this catalytically inactive derivative of papain, the active-site thiol group of Cys-25 is S-methyl-thiolated so that it cannot form a thiolate anion. The pH dependence of the chemical shift of the C epsilon 1 H resonance of His-159 indicated a pK of 3.45 +/- 0.07 at 45 degrees C in 2H2O with no added ions other than those required for titration. In acetate buffers at an ionic strength of 0.05, the pK increased to 3.87 +/- 0.12. Conversion of papain-S-SCH3 to active papain at pH* 4.17 (at 45 degrees C and an ionic strength of 0.05) caused the position of the C epsilon 1 H resonance to change from a position indicative of partial protonation of His-159 to a position indicative of full protonation, consistent with the existence of an imidazolium-thiolate ion-pair interaction between His-159 and Cys-25 in the active enzyme.

Perturbations in the free energy and enthalpy of ionization of histidine-159 at the active site of papain as determined by fluorescence spectroscopy

Fluorometric titrations of papain, succinyl-papain, and the corresponding methylthio derivatives of Cys-25 (papain-S-SCH3 and succinyl-papain-S-SCH3) were determined. Removal of the methylthio group from Cys-25 resulted in an increase of approximately 4 pK units in the fluorometrically determined pK value. The correspondence between the ionization behavior as determined by proton NMR and fluorometric titrations indicated that fluorescence titrations reflect the ionization behavior of His-159 in both the active enzyme and the methylthio derivative. The ionic strength dependence of the pK was analyzed in terms of simple electrostatic theory and was shown to be consistent with the charge on the protein. The temperature dependence of the pK values of His-159 indicated an increase in the heat of ionization from about 0 to 8 kcal/mol upon removal of the methylthio blocking group from Cys-25. Measurements of the effect of solvent on the pK's and heats of ionization of simple model compounds indicated that the observed shift in enthalpy of ionization of His-159 upon removal of th methylthio group from Cys-25 is not unreasonable in light of the accompanying perturbation is more than 4 pK units in the pK of His-159. The perturbations in enthalpies and free energies are attributed to formation of an ion pair. The ionization behavior of His-159 in thiol-blocked derivatives of papain is consistent with the involvement of His-159 in the deacylation step in papain catalysis.

Effect of cysteine-25 on the ionization of histidine-159 in papain as determined by proton nuclear magnetic resonance spectroscopy. Evidence for a his-159--Cys-25 ion pair and its possible role in catalysis

Papain was succinylated in order to increase its solubility above pH 8 so that proton NMR spectroscopy could be used to study the ionization of His-159 at the active site of the enzyme. The pH dependence of NMR spectra of catalytically active succinyl-papain and the methylthio derivative of the active-site cysteinyl residue of succinyl-papain (succinyl-papain-S-SCH3) were determined between pH 6 and 10. The pH dependence of the C epsilon 1 H resonance of His-159 in catalytically active succinyl-papain indicates that His-159 has a pK of about 8.6 in the catalytically active form of the enzyme. The position of this resonance in succinyl-papain-S-SCH3 indicates that when the active-site cysteinyl residue is methylthiolated, His-159 is completely deprotonated between pH 6 and 10. This result is taken as evidence for an imidazolium--thiolate ion-pair interaction between His-159 and Cys-25 wherein neutralization of the charge on the thiolate anion by methylthiolation would be expected to cause a marked decrease in the pK of His-159. A possible catalytic role for the ion pair in the acylation step in papain-catalyzed reactions is proposed wherein attack of a substrate by the imidazolium--thiolate ion pair is accompanied by an increase in the acidity of the imidazolium group that facilitates expulsion of the leaving group of the substrate.

Quality of drawing as a factor in the interpretation of figure drawings

Examined the drawings of 32 poliomyelitis patients and their matched controls to see whether figure drawings primarily reflect the subject's projection of psychological state, ability to draw, or some combination of these two factors. An overview of the literature is also given. Drawings from disabled and nondisabled subjects were reliably rated for quality, with no significant quality difference found between groups. Analyses of variance were then used to compare the drawings on several different measures of drawing size, completion and movement that might be assumed on the basis of the literature, to reflect the subjects' projection of disability status. Results showed that quality of drawing was a significant factor in 13 of the 17 comparisons while disability status proved to be a significant factor in only one of the 17 comparisons. There were no significant interactions. Therefore, the overall findings are consistent with the hypothesis that quality of drawing-rather than projective mechanisms-may at times be the overwhelming determinant of clinical and research findings with figure drawings.

Dependence of the catalytic activity of papain on the ionization of two acidic groups

The pH dependence of kcat/Km for the papain-catalyzed hydrolysis of ethyl hippurate, N-alpha-benzoyl-L-citrulline methyl ester, and the p-nitroanilide, amide, and ethyl ester derivatives of N-alpha-benzoyl-L-arginine was determined below pH 6.4. The value of kcat/Km was observed to be modulated by two acid ionizations rather than a single ionization as previously believed. For the five substrates studied, the average pK values for the two ionizations are 3.78 +/- 0.2 and 3.95 +/- 0.1 at T/2 0.3, 25 degrees C. The observation that similar pK values were obtained with different substrates was taken as evidence that the kinetically determined pK values are close in value to true macroscopic ionization constants for ionization of groups on the free enzyme.