Background Globally, puerperal sepsis accounts for an estimated 8–12% of maternal deaths, but evidence is lacking on the extent to which clean delivery practices could improve maternal survival. We used data from the control arms of four cluster-randomised controlled trials conducted in rural India, Bangladesh and Nepal, to examine associations between clean delivery kit use and hand washing by the birth attendant with maternal mortality among home deliveries. Methods We tested associations between clean delivery practices and maternal deaths, using a pooled dataset for 40,602 home births across sites in the three countries. Cross-sectional data were analysed by fitting logistic regression models with and without multiple imputation, and confounders were selected a priori using causal directed acyclic graphs. The robustness of estimates was investigated through sensitivity analyses. Results Hand washing was associated with a 49% reduction in the odds of maternal mortality after adjusting for confounding factors (adjusted odds ratio (AOR) 0.51, 95% CI 0.28–0.93). The sensitivity analysis testing the missing at random assumption for the multiple imputation, as well as the sensitivity analysis accounting for possible misclassification bias in the use of clean delivery practices, indicated that the association between hand washing and maternal death had been over estimated. Clean delivery kit use was not associated with a maternal death (AOR 1.26, 95% CI 0.62–2.56). Conclusions Our evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, although the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings. Our findings indicating kit use does not improve maternal survival, suggests that the soap is not being used in all instances that kit use is being reported.
This chapter attends to contemporary developments in exile Tibetan medicine and conceptions of health. It focuses on the role of the Dharamsala Men-Tsee-Khang and Tibetan medicine in addressing problems of public health in the Tibetan exile community. The chapter explores the significance of the re-emergence of the traditional Tibetan medical concepts 'bu and srin bu in the exile context. It examines the notion that many prevalent exile diseases are construed as diseases of place: they are seen as resulting from the physical, social and moral predicaments of exile. This leads on to the argument that traditional Tibetan medicine is particularly apt at dealing with what could be called 'diseases of exile' because of its emphasis on localistic aetiologies, aetiologies that link diseases to organisms or spirits pertaining to particular places. Keywords: Dharamsala Men-Tsee-Khang; Tibetan exile community; Tibetan Refugees; Traditional Tibetan Medicine
This study reports the clinical, ophtalmological and parasitological examination for onchocerciasis in 4 882 people, living in 23 villages located in 8 different areas of west Africa. The disease is hyperendemic in the whole sample and no major differences occur when comparing the indices of Onchocerca volvulus infection. However, all the complications (eye, skin and lymph node lesions) are less common in the four forest clusters than in to the four savanna clusters. The disease seems to be relatively well tolerated in areas where transmission of Onchocerca volvulus is carried out by Simulium species other than S. damnosum s.s. and S. sirbanum. The striking epidemiological differences of onchocerciasis is probably associated with several vector-parasite complexes, which may indicate the existence of different strains of O. volvulus.
Abstract An estimated 2.4 million newborn infants died in 2020, 80% of them in sub-Saharan Africa and South Asia. To achieve the Sustainable Development Target for neonatal mortality reduction, countries with high mortality need to implement evidence-based, cost-effective interventions at scale. Our study aimed to estimate the cost, cost-effectiveness, and benefit-cost ratio of a participatory women’s groups intervention scaled up by the public health system in Jharkhand, eastern India. The intervention was evaluated through a pragmatic cluster non-randomised controlled trial in six districts. We estimated the cost of the intervention from a provider perspective, with a 42-month time horizon for 20 districts. We estimated costs using a combination of top-down and bottom-up approaches. All costs were adjusted for inflation, discounted at 3% per year, and converted to 2020 International Dollars (INT$). Incremental cost-effectiveness ratios (ICERs) were estimated using extrapolated effect sizes for the impact of the intervention in 20 districts, in terms of cost per neonatal deaths averted and cost per life year saved. We assessed the impact of uncertainty on results through one-way and probabilistic sensitivity analyses. We also estimated benefit-cost ratio using a benefit transfer approach. Total intervention costs for 20 districts were INT$ 15,017,396. The intervention covered an estimated 1.6 million livebirths across 20 districts, translating to INT$ 9.4 per livebirth covered. ICERs were estimated at INT$ 1,272 per neonatal death averted or INT$ 41 per life year saved. Net benefit estimates ranged from INT$ 1,046 million to INT$ 3,254 million, and benefit-cost ratios from 71 to 218. Our study suggests that participatory women’s groups scaled up by the public health system are highly cost-effective in improving neonatal survival and have a very favourable return on investment. The intervention can be scaled up in similar settings within India and other countries.
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