This week in the BMJ
Volume 331, Number 7519, Issue of 1 Oct 2005Misoprostol helps anaemic women in childbirth
Misoprostol helps anaemic women in childbirth
Routine use of misoprostol as a sublingual tablet may reduce postpartum morbidity and mortality in developing countries, where many pregnant women are anaemic. In a randomised double blind placebo controlled trial of 661 women in Guinea-Bissau, Høj and colleagues (p 723) found that 600 µg misoprostol significantly reduced the incidence of severe postpartum haemorrhage. Compared with women randomised to placebo, women who received the drug lost less blood and had a smaller decrease in haemoglobin concentration.
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What works for malaria
Guidelines for treating children with uncomplicated malaria changed in Zambia in 2002 in line with the best available evidence, but the change has not yet translated into adequate use at the point of care. A cross sectional study by Zurovac and colleagues (p 734) shows how artemether-lumefantrine, which should be the first choice of treatment for children weighing 10 kg or more, is not being prescribed even when available.
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In a cluster randomised trial, Chandramohan and colleagues (p 727) showed that sulfadoxine-pyrimethamine can prevent malaria and anaemia in infants up to 15 months old. These children may also have a higher risk of high parasite density malaria after treatment is stopped, however.
Educational outreach improves TB control
An educational outreach programme that trains nurse practitioners to diagnose and treat tuberculosis seems to be a promising solution for improving quality of care without extra staff in resource poor countries. A pragmatic cluster randomised controlled trial by Fairall and colleagues (p 750) included 1999 patients presenting with cough or difficult breathing to 40 South African primary care clinics staffed by nurses. Nurses in the intervention arm diagnosed more tuberculosis and prescribed more corticosteroids, while antibiotic prescribing did not significantly differ between the arms.
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User fees should be dropped in sub-Saharan Africa
Removing user fees—charges for health care at the point of use—could save an estimated 233 000 lives a year in children aged under 5 in 20 African countries. This is an estimation of a modelling study by James and colleagues (p747), who argue that the abolition could be done at a relatively low cost while greatly improving people's access to health care.
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On p 762, Gilson and McIntyre support the call for removal of user fees, but warn that the action—if approved—might backfire if not planned and managed with care.
Approaches for improving health in Africa need rethinking
Current international approaches to poverty and health in Africa will at best have a limited effect and may even be counterproductive, argue Sanders and colleagues (p 755). They discuss the current initiatives and propose an alternative approach that focuses on social mobilisation and increasing the numbers and capacity of workers in primary care. But also, crucially, the international community must create favourable economic conditions through making trade fairer, limiting the arms trade, battling corruption, and ensuring that delivery of aid is improved.
Women's empowerment may improve HIV prevention
Systematic efforts to increase women's economic, social, and political empowerment must be supported as key components of a comprehensive strategy to fight AIDS in sub-Saharan Africa, where women account for 57% of adults with AIDS, argue Kim and Watts (p 769). In some countries, a woman only recently ceased to become a property of her husband's family after his death. Also, refusing sex, inquiring about other partners, or suggesting condom use is known to trigger intimate partner violence. Broader social forces stand in the way of ensuring adequate HIV prevention, say the authors. On p 708, Simwaka and colleagues say the millenium development goals will not be achieved until urgent action is taken to improve sex equality.
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