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Carine Ronsmans

Publications and source records attributed to Carine Ronsmans.

At least 19 recordsLinked to original sources
PubMed2006

Maternal health in poor countries: the broader context and a call for action.

In this paper, we take a broad perspective on maternal health and place it in its wider context. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women's empowerment. We also consider outcomes beyond mortality, in particular, near-misses and long-term sequelae, and the implications of the close association between the mother, the fetus, and the child. We make links to a range of global survival initiatives, particularly neonatal health, HIV, and malaria, and to reproductive health. Finally, after examining the political and financial context, we call for action. The need for strategic vision, financial resources, human resources, and information are discussed.

Developing Countries↗
PubMed2006

Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis.

BACKGROUND: Little is known about socioeconomic differences in access to life-saving obstetric surgery, yet access to a caesarean for women is essential to achieve low levels of maternal mortality. We examined population-based caesarean rates by socioeconomic groups in various developing countries. METHODS: We used data from 42 Demographic and Health Surveys in sub-Saharan Africa, south and southeast Asia, and Latin America and the Caribbean. We report caesarean rates by wealth quintile and the absolute and relative difference between the richest and poorest quintiles. We also categorise the sample into richer and poorer halves and examine caesarean rates within rural areas. FINDINGS: Caesarean rates were extremely low among the very poor: they were below 1% for the poorest 20% of the population in 20 countries and were below 1% for 80% of the population in six countries. Only in five countries did the very poor have caesarean rates exceeding 5%. At the other extreme are seven countries, mostly in Latin America, where caesareans are far in excess of the suggested maximum threshold of 15% for at least 40% of the population. INTERPRETATION: In the poorest countries-mostly in sub-Saharan Africa-large segments of the population have almost no access to potentially life-saving caesareans, whereas in some mid-income countries more than half the population has rates in excess of medical need. These data deserve the immediate attention of policymakers at national and international levels.

Adult↗
PubMed2006

Maternal mortality: who, when, where, and why.

The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world compared with about one in 30 000 in Northern Europe. Such a discrepancy poses a huge challenge to meeting the fifth Millennium Development Goal to reduce maternal mortality by 75% between 1990 and 2015. Some developed and transitional countries have managed to reduce their maternal mortality during the past 25 years. Few of these, however, began with the very high rates that are now estimated for the poorest countries-in which further progress is jeopardised by weak health systems, continuing high fertility, and poor availability of data. Maternal deaths are clustered around labour, delivery, and the immediate postpartum period, with obstetric haemorrhage being the main medical cause of death. Local variation can be important, with unsafe abortion carrying huge risk in some populations, and HIV/AIDS becoming a leading cause of death where HIV-related mortaliy rates are high. Inequalities in the risk of maternal death exist everywhere. Targeting of interventions to the most vulnerable--rural populations and poor people--is essential if substantial progress is to be achieved by 2015.

Adolescent↗
PubMed2006

A comparison of socio-demographic and psychological factors between patients consenting to randomisation and those selecting treatment (the ProtecT study).

BACKGROUND: Patient preferences for treatment can pose problems for the conduct of randomised controlled trials: patients with a preference may refuse participation and thereby potentially compromise external validity. Moreover, randomising patients with a preference may affect treatment efficacy and threaten internal validity. AIMS: This study compared baseline characteristics and short-term psychological outcomes of patients who selected their treatment and those who agreed to random allocation. METHODS: Men participating in the prostate testing for cancer and treatment (ProtecT) study and who were randomised to active monitoring (n=138) were compared with those who had refused randomisation and selected this management (n=180). Socio-demographic data were collected at baseline, and anxiety and depression data were collected at baseline and six month follow-up. Socio-demographic characteristics were compared across these two groups in univariable analyses, and then linear regression was used to compare levels of anxiety and depression at follow-up with adjustments for confounders. RESULTS: Participants who selected active monitoring were more affluent (based on occupation details) and had less anxiety at baseline than those who were randomised. There were no differences with respect to age and marital status. Levels of anxiety and depression at six months follow-up were similar across the two groups of men. CONCLUSIONS: This study found some differences at baseline between the socio-demographic and psychological status of those randomised and self-selecting treatment, but no psychological differences at short-term follow-up. Further empirical evidence is required to assess whether preferences impact upon the process and outcome of randomised controlled trials.

Aged↗
PubMed2006

Equity in use of home-based or facility-based skilled obstetric care in rural Bangladesh: an observational study.

BACKGROUND: Few studies have assessed whether the poorest people in developing countries benefit from giving birth at home rather than in a facility. We analysed whether socioeconomic status results in differences in the use of professional midwives at home and in a basic obstetric facility in a rural area of Bangladesh, where obstetric care was free of charge. METHODS: We routinely obtained data from Matlab, Bangladesh between 1987 and 2001. We compared the benefits of home-based and facility-based obstetric care using a multinomial logistic and binomial log link regression, controlling for multiple confounders. FINDINGS: Whether or not a midwife was used at home or in a facility differed significantly with wealth (adjusted odds ratio comparing the wealthiest and poorest quintiles 1.94 [95% CI 1.69-2.24] for home-based care, and 2.05 [1.72-2.43] for facility-based care). The gap between rich and poor widened after the introduction of facility-based care in 1996. The risk ratio (RR) between the wealthiest and poorest quintiles was 1.91 (adjusted RR 1.49 [95% CI 1.16-1.91] when most births with a midwife took place at home compared with 2.71 (1.66 [1.41-1.96]) at the peak of facility-based care. INTERPRETATION: In this area of Bangladesh, a shift from home-based to facility-based basic obstetric care is feasible but might lead to increased inequities in access to health care. However, there is also evidence of substantial inequities in home births. Before developing countries reinforce home-based births with a skilled attendant, research is needed to compare the feasibility, cost, effectiveness, acceptability, and implications for health-care equity in both approaches.

Adult↗
PubMed2006

Attending home vs. clinic-based deliveries: perspectives of skilled birth attendants in Matlab, Bangladesh.

In an effort to make skilled attendance at birth more accessible, some countries in Asia have begun major initiatives to promote the option of home delivery with a midwife. Yet there is little empirical evidence from the region to suggest that home-based care is as safe or effective as care in medical facilities. Qualitative research involving key informant and in-depth interviews and group discussions was carried out in 2003 and 2004 in Matlab, a rural area of Bangladesh, to examine the feasibility of home- vs. facility-based delivery from the perspective of 13 skilled birth attendants. The findings illuminate major constraints encountered during home deliveries, including poor transportation, inappropriate environment for delivery, insufficient supplies and equipment, lack of security, and inadequate training and medical supervision, which may prevent the provision of skilled care. Most difficult was the pressure by families to adhere to traditional childbirth norms and convincing families to accept the need for referral. The advantages highlighted of attending births in a health facility were the safe, clean environment, availability of supplies, ability to accommodate other work activities and make quick referrals, and higher coverage. The study illuminates practical, cultural and medical issues that need to be taken into consideration when choosing between home- and facility-based strategies and designing safe motherhood interventions.

Bangladesh↗
PubMed2006

Comparison of family reporting of pregnancy status with a post-mortem beta-HCG test in deceased women: a study in Pointe-Noire, Congo.

OBJECTIVE: To compare family reports of pregnancy status in deceased women with a biological assessment of pregnancy using a post-mortem beta-HCG test. METHOD: We investigated the deaths of females of reproductive age registered at the Pointe Noire morgue from June 30 to October 18, 2001. A physician interviewed relatives about the circumstances of death, in particular whether the woman had been pregnant at the time of death, and whether she had delivered or had an abortion (induced or spontaneous) within the past 6 weeks. The bodies were then examined and blood samples taken for beta-HCG testing. RESULTS: Among 368 deaths of women of reproductive age registered, 34 deaths were identified as pregnancy-related: 23 by both the family interview and the beta-HCG test, five by beta-HCG test only and six were beta-HCG negative but the family had reported a recent delivery. CONCLUSION: In this setting, the approach based on family reports underestimates mortality during pregnancy by 24% and mortality during pregnancy or within 6 weeks postpartum by 15%.

Adult↗
PubMed2005

Reliability of data on caesarean sections in developing countries.

OBJECTIVE: To examine the reliability of reported rates of caesarean sections from developing countries and make recommendations on how data collection for surveys and health facility-based studies could be improved. METHODS: Population-based rates for caesarean section obtained from two sources: Demographic and Health Surveys (DHS) and health facility-based records of caesarean sections from the Unmet Obstetric Need Network, together with estimates of the number of live births, were compared for six developing countries. Sensitivity analyses were conducted using several different definitions of the caesarean section rate, and the rates obtained from the two data sources were compared. FINDINGS: The DHS rates for caesarean section were consistently higher than the facility-based rates. However, in three quarters of the cases, the facility-based rates for caesarean sections fell within the 95% confidence intervals for the DHS estimate. CONCLUSION: The importance of the differences between these two series of rates depends on the analyst's perspective. For national and global monitoring, DHS data on caesarean sections would suffice, although the imprecision of the rates would make the monitoring of trends difficult. However, the imprecision of DHS data on caesarean sections precludes their use for the purposes of programme evaluation at the regional level.

Benin↗
PubMed2005

HIV and the magnitude of pregnancy-related mortality in Pointe Noire, Congo.

OBJECTIVES: The extent to which HIV affects pregnancy-related mortality in countries with high HIV/AIDS and maternal mortality is poorly understood. The objectives of this study were to investigate the mortality of women of reproductive age by both HIV and pregnancy status, and quantify the excess mortality attributable to HIV during pregnancy in Pointe Noire, Congo. DESIGN: Prospective mortuary investigation of all deaths in women aged 15-44 years, during 112 consecutive days. METHODS: Mortality rates by HIV and pregnancy were computed. During the study period, 378 corpses were examined, blood was tested for HIV and pregnancy, relatives were interviewed and hospital files were reviewed. Denominators were obtained from a census with women-years assigned to pregnancy and/or HIV based on levels of fertility and HIV prevalence in the city. RESULTS: The mortality rate was 32 times higher [95% confidence interval (CI), 25-39] among HIV-positive than among HIV-negative women. The relative increase in mortality associated with HIV was much higher in non-pregnant [rate ratio (RR), 41; 95% CI, 32-52] than in pregnant women (RR, 4; 95% CI, 2-9). Among HIV-positive women, pregnancy appeared to confer a survival benefit. CONCLUSION: These findings have important implications for the interpretation of trends in maternal mortality in the context of HIV. The apparent survival benefit of pregnant HIV-positive women is largely due to their low fertility in the latest stage of the disease. As the HIV epidemic matures and more women become severely ill, any potential adverse effects associated with HIV and pregnancy may be increasingly offset by selection effects, and maternal mortality may not increase further.

Adult↗
PubMed2005

Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals.

BACKGROUND: This study examines near-miss obstetric events in African hospitals as to the frequency, nature, and ratio of near miss to death and considers whether these could become useful indicators for monitoring the performance of obstetric services in Africa. METHODS: Prospective or retrospective reviews of medical records were conducted in nine referral hospitals in three countries (Benin, Côte d'Ivoire, and Morocco). We calculated the incidence of near-miss obstetric events, near-miss cases, and maternal deaths related to hemorrhage, hypertensive diseases of pregnancy, dystocia, infections, and anemia and analyzed these according to hospital and timing relative to admission. RESULTS: The incidence of near-miss cases was varied, and in some hospitals extremely large: from 1% to almost a quarter of all deliveries were near misses. Near-miss cases were 15 times more common than deaths (ranging from a ratio of 9:1-108:1). Most of the women with near-miss events (NMEs) (83%) were already in a critical condition on arrival at the hospital (range 54-90%), and two in three were referred from another facility. The most frequent types of NMEs were hemorrhage and hypertensive diseases of pregnancy, but anemia was the leading cause in three first referral level hospitals in Benin and Côte d'Ivoire. Near-miss events due to infections were rare. CONCLUSIONS: Near-miss events are extremely common in some African hospitals, with a high proportion arriving in critical conditions. Near-miss events must be estimated separately for those already in a critical condition on arrival and those developing after admission; the first as a good indicator of the effectiveness of emergency referrals and the second as a potential tool for monitoring the performance of obstetric services.

Benin↗
PubMed2005

Current strategies for the reduction of maternal mortality.

The purpose of this article is to review current strategies for the reduction of maternal mortality and the evidence pertinent to these strategies. Historical, contextual and current literature were examined to identify the evidence base upon which recommendations on current strategies to reduce maternal mortality are made. Current safe motherhood strategies are designed based mostly on low grade evidence which is historical and observational, as well as on experience and a process of deductive reasoning. Safe motherhood strategies are complex public health approaches which are different from single clinical interventions. The approach to evidence used for clinical decision making needs to be reconsidered to fit with the practicalities of research on the effectiveness of strategies at the population level. It is unlikely that any single strategy will be optimal for different situations. Strengthening of the knowledge base on the effectiveness of public health strategies to reduce maternal mortality is urgently required but will need concerted action and international commitment.

Abortion, Induced↗
PubMed2004

Obstetric audit in resource-poor settings: lessons from a multi-country project auditing 'near miss' obstetrical emergencies.

This paper outlines the practical steps involved in setting up and running multi-professional, in-depth case reviews of 'near miss' obstetrical complications. It draws on lessons learned in 12 referral hospitals in Benin, Côte d'Ivoire, Ghana and Morocco. A range of feasibility indicators are presented which measured the implementation and frequency of audit activities, the quality of participation, adherence to the planned protocol for the near-miss audits, the quality of audit discussions and the sustainability of the project. Although the principles of the audit approach were well accepted and implemented everywhere, near-miss audits appeared most successful in first referral level hospitals. Contextual factors that determine the successful implementation of near-miss audit include staff finding adequate time for audit activities, financial incentives to groups rather than individuals, involvement of senior staff and hospital managers, the ease of communication in smaller units, the employment of social workers for the incorporation of women's views at audits, and the strength of external support provided by the research team. The poor quality of information recorded in case notes was recognized everywhere as a deficiency, but did not present a major obstacle to effective case reviews. Ownership and leadership within the hospital, more easily achieved in the first-level referral hospitals, were probably the most important determinants of successful implementation. Sustainability requires a commitment to audit from policy makers and managers at higher levels of the health system and some devolution of resources for implementing recommendations.

Africa↗
PubMed2004

The population impact of HIV on fertility in sub-Saharan Africa.

OBJECTIVES: To examine new evidence from studies on the estimates of the fertility rate ratio comparing HIV-infected and uninfected women, of the population change in total fertility attributable to HIV, and to review the evidence of changes in fertility in HIV-uninfected women. DESIGN: A review and analysis of data from the many individual studies that have examined the associations between HIV/AIDS and fertility. METHODS: Data from sub-Saharan Africa were collected from published studies, personal communications and the Demographic and Health Surveys. A mathematical model was used to demonstrate the impact of the HIV/AIDS epidemic on the number of births in Uganda. RESULTS: Fertility was lower among HIV-infected women than HIV-uninfected women, with the exception of those aged 15-19 years, in whom the selective pressure of sexual debut on pregnancy and HIV infection led to higher fertility rates among the HIV infected. This fertility differential resulted in a population-attributable decline in total fertility of 0.37% (95% confidence interval 0.30%, 0.44%) for each percentage point of HIV prevalence. The evidence for fertility changes in HIV-uninfected women was ambiguous. An estimated reduction of 700 000 births occurred in Uganda, as a result of the reduced fertility in HIV-infected women and premature mortality among reproductive age women. CONCLUSION: Large fertility differentials existed between HIV-infected and uninfected women, with substantial variation by age. The extent to which these could be attributed to the direct impact of the epidemic on both infected and uninfected women, as opposed to pre-existing differences in their fertility, merits further study.

Adolescent↗
PubMed2004

Long-term effects of reproductive history on all-cause mortality among adults in rural Bangladesh.

A woman's risk of dying is altered during pregnancy and immediately postpartum. Moreover, physiological and social changes associated with pregnancy may have long-term effects on mortality. Comparing these long-term associations among women and their husbands may provide insights into the nature of such a relationship. In this cohort study, we examine the association between reproductive history and all-cause mortality among ever-married women and men after age 45 in Matlab, Bangladesh, using data collected between 1982 and 1998 for a unique demographic surveillance system. No association was found between parity and mortality among women, but a small decrease in men's mortality was found to be associated with their wives' parity. Survival for both sexes was greatly enhanced by an increasing number of surviving children, regardless of parity or other social factors. A "healthy pregnant woman effect" coupled with the social and economic advantages of having surviving children may explain the observed effects.

Bangladesh↗
PubMed2003

Labour complications remain the most important risk factors for perinatal mortality in rural Kenya.

OBJECTIVES: To identify and quantify risk factors for perinatal mortality in a Kenyan district hospital and to assess the proportion of perinatal deaths attributable to labour complications, maternal undernutrition, malaria, anaemia and human immunodeficiency virus (HIV). METHODS: A cross-sectional study of 910 births was conducted between January 1996 and July 1997 and risk factors for perinatal mortality were analysed. FINDINGS: The perinatal mortality rate was 118 per 1000 births. Complications of labour such as haemorrhage, premature rupture of membranes/premature labour, and obstructed labour/ malpresentation increased the risk of death between 8- and 62-fold, and 53% of all perinatal deaths were attributable to labour complications. Placental malaria and maternal HIV, on the other hand, were not associated with perinatal mortality. CONCLUSIONS: Greater attention needs to be given to the quality of obstetric care provided in the rural district-hospital setting.

Adolescent↗