Community-based malaria control in Tigray, northern Ethiopia

Community-based control activities have been a major component of the Tigray regional malaria control programme since 1992. A team of 735 volunteer community health workers treat on average 60,000 clinical malaria cases monthly during the high malaria transmission season. Ensuring access for the rural population to early diagnosis and treatment has contributed to a significant decrease in death rate in under-five children at the village level from 1994 to 1996. Mapping and geographic information system (GIS) technologies have been introduced to support planning for control by assessment of community-based coverage. With further development, GIS will be used in stratification, and to assess the impact of water resources development on malaria transmission and intensity.     

Development of the Pet Bereavement Questionnaire

Abstract

The death of a pet can be a significant stressor for some people and is a known risk factor for depression. The Pet Bereavement Questionnaire (PBQ) was developed to fill the need for a brief, acceptable, well-validated instrument for use in studies of the psychological impact of losing a pet. Initial results suggest that the PBQ has good internal reliability (Cronbach's α = 0.87), as well as good construct validity, with three distinct factors reflecting grief, anger and guilt. Grief was found to correlate strongly with pet attachment. The anger and guilt scales, however, correlated with depressive symptoms. The PBQ discriminated between individuals seeking support after pet loss (who would be expected to show higher levels of bereavement) and those who simply acknowledge the recent loss of a pet. We suggest that future research into pet bereavement use this new questionnaire so that the results of different studies can be compared, normative scores can be developed and researchers in this area can use a single instrument with established construct validity. In particular, we hope the PBQ will be used in treatment outcome research to identify high-risk individuals and test the effectiveness of both existing and novel interventions. Moreover, the PBQ could also be used in clinical settings, such as tertiary care veterinary hospitals, to identify pet owners in need of clinical support services.     

Bereavement in the elderly: the role of primary care

Bereavement in the elderly is a concern to primary care physicians (PCPs) as it can lead to psychological illness such as depression. Most people are able to come to terms with their grief without any intervention, but some people are not. This case highlights the importance of early recognition of bereavement-related depressive illness in elderly people. PCPs need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the family members'' burden and suffering.     

Limnological and ecological characteristics of tropical highland reservoirs in Tigray, Northern Ethiopia

The semi-arid highlands of Northern Ethiopia (Tigray) have numerous small reservoirs that have been created by microdams in an attempt to provide water supply for irrigation and livestock drinking. Although the reservoirs have substantial added value to residents, their use as water resource is jeopardized by eutrophication and a high occurrence of blooms of toxic cyanobacteria. So far, there is no systematic information available on the limnological and aquatic ecological characteristics of these dams. We carried out a standardized survey of 32 reservoirs and assessed a wide set of morphometric, abiotic and biotic variables. The sampling was performed during two seasons, September–October 2004 (end of the wet season/start of the dry season) and April–May 2005 (towards the end of the dry season). Using multivariate analysis, we revealed dominating patterns of variable associations and compared the variability in these patterns among seasons. According to standardized PCA and RDA analyses, the most important axis of variation was mainly represented by a gradient in nutrients and altitude that was also positively associated with phytoplankton biomass, suspended matter and oxygen concentration, and negatively with water transparency. For most variables, correlations between the wet and dry season were weak, which suggests that individual reservoirs behaved rather differently in their response to seasonal changes. Nevertheless, a Mantel correlation (r = 0.32; P = 0.035) showed a weak but significant overall concordance in the variable association patterns among seasons. A number of reservoirs became very shallow or fell dry in the dry season, a process that was associated with an increase in suspended matter and conductivity and a decrease in transparency. These reservoirs contained lower amounts of fish and tended to be less eutrophic than the deeper, permanent systems, as they had lower levels of phosphorus and chlorophyll-a. With multiple regression analysis, we constructed most parsimonious models in an attempt to explain the variation in key biotic variables: phytoplankton and cyanobacteria biomass, cladoceran biomass, fish biomass and the abundance of submerged vegetation. Phytoplankton and fish biomass tended to be positively related with the concentration of total phosphorus, whereas cladoceran biomass was not associated with nutrient concentrations. The positive association of fish and phytoplankton with nutrient concentrations suggests a bottom-up control, whereas the absence of an association between zooplankton and nutrient concentrations may be indicative for top-down control. The biomass of cyanobacteria was negatively related to the biomass of cladocerans (Daphnia), which likely reflects a top-down effect. Most reservoirs were turbid. The occurrence and abundance of macrophytes tended to be positively related to water transparency and was negatively associated to TP and the amount of livestock frequenting the reservoirs. However, macrophytes were not limited to clear-water reservoirs. Handling editor: L. M. Bini     

Pet Loss,Complicated Grief,and Post-Traumatic Stress Disorder in Hawaii

We examined the impact of pet/animal death on Complicated Grief (CG) and Post-Traumatic Stress Disorder (PTSD) in relation to demographic variables amongst a diverse population of racial and ethnic groups in Hawaii. Three hundred and fifty-five participants (142 solicited by mail, 213 volunteer college students) completed a 37-item questionnaire, the Inventory of Complicated Grief Revised Short Form (ICG-R-SF) and the PTSD Check-list (PCL), and we assessed relationships between demographic variables such as pet ownership with CG and PTSD scores, to gauge potential at-risk populations. While Filipino populations presented increased, if subclinical, CG and/or PTSD scores, no primary racial/ethnic identity correlated with significant scores, based on the DSM-IV-TR criteria. Individuals who scored higher on questions related to empathy with animals, such as adopting strays, feeling like their pet can sense their mood, integration of animals into the family unit, and feeling over-protective of their pet correlated with higher CG and PTSD scores. We found that 3.8% of participants met the cutoff score for CG and 5.7% met the cutoff score for PTSD, following the death of a pet/animal. There is a need for multicultural awareness regarding both human–pet/animal relationships and bereavement.     

Malaria, schistosomiasis, and intestinal helminths in relation to microdams in Tigray, northern Ethiopia.

A survey was undertaken in Tigray, Northern Ethiopia, to assess the prevalence of malaria, schistosomiasis, and intestinal helminths in relation to microdams. The survey took place from March to June 1995, during the dry season, at 41 microdams. At each site the village nearest the dam (within thirty minutes walk) was selected, ten households were randomly chosen, and all family members were examined for malaria and intestinal parasites. The overall study sample was 2271 people, of all age groups. Plasmodium falciparum infection was documented in four villages (at 10% of microdams); prevalence was 1.2% (range 0-20% by village). Larvae of Anopheles gambiae s.l. were found at one microdam. Infection with intestinal schistosomiasis was documented in 20 villages (at 49% of microdams), and one third of those infected had moderate to heavy infections. Biomphalaria species, the intermediate host snails of Schistosoma mansoni, were found at 16 microdams (39%), and snails infected by mammalian cercariae were found in one locality. Infections with soil-transmitted nematodes were prevalent: hookworm was detected in more than two thirds of the villages, and Ascaris lumbricoides and Trichuris trichiura were present in almost half of the villages. Out of 2078 stool examinations, the prevalence of S. mansoni infection was 7.2% (range 0-48% by village), of A. lumbricoides 2.3% (range 0-31%), of T. trichiura 2.4% (range 0-21%), and of hookworm 8.9% (range 0-78%). The prevalence of malaria, S. mansoni and hookworm was higher at altitudes below 2000 metres above sea level. S. mansoni was more prevalent in microdams built more than 5 years before the survey, while T. trichiura was more prevalent at recently constructed microdams. The widespread distribution of schistosomiasis and intestinal helminths, and the presence of malaria infection during the dry season confirm that microdams create favourable conditions for the transmission of these parasitic diseases. Health safeguards must be incorporated into the planning, construction, and operation of microdams and irrigation systems in order to prevent or reduce these diseases. In areas with high prevalence, control activities should be intensified.     

Factors associated with uptake of post-abortion family planning in Shire town,Tigray, Ethiopia

Objectives

Post-abortion contraceptive service is pivotal for the prevention of unwanted pregnancy and alleviation of its complication. Worldwide half of the pregnancy is unplanned, whereas unwanted pregnancy ends up with abortion. This study assessed post-abortion contraceptive uptake and associated factors among abortion service users at health institution in Shire town, North Ethiopia. Institutional based cross-sectional study was conducted from December 15/2016 to March 15, 2017, in Shire town. Data were collected using systematic random sampling technique. Bivariate and multivariable analyses were done to determine the association of each independent variable with the dependent variable.

Results

Overall post-abortion contraceptive utilization in this study was 61.5%. Married [AOR 2.59, 95% CI (1.16, 5.65)], completed College education [AOR 5.69, 95% CI (1.61, 20.11)], previous contraceptive used [AOR 3.62, 95% CI (1.77, 7.40)], counseling of family planning [AOR 3.53 95% CI (1.69, 7.37)], grand multipara [AOR 7.91, 95% CI (1.66, 37.74)] and public health institution [AOR 5.95, 95% CI (3.03, 11.72)] were significantly associated with the post-abortion contraceptive utilization. In this study, post-abortion contraceptive utilization was about two-third. Being married, had been completing a college education, had been receiving family planning counseling, previous contraceptive usage, abortion care service at public health institution, and being grand multiparty were determinants of post-abortion contraceptive utilization.

     

Analysis of household's energy consumption,forest degradation and plantation requirements in Eastern Tigray,Northern Ethiopia

This study examines the link between household's energy consumption, forest degradation and plantation requirements in Eastern Tigray. Data on household's fuelwood, cow‐dung, kerosene and electricity consumption in the study sites were collected from 557 urban and 114 rural households. Deforestation rate was estimated following FAO and Woody Biomass Inventory Strategy Planning Project (WBISPP's) conversion factors. The study showed that household's fuelwood consumption in urban areas (mean = 2.5 kg/day) was about 52% lower as compared to the rural villages (mean = 3.8 kg/day). The estimated area abandoned annually in the vicinity of urban areas as the result of urban fuelwood consumption varies from 217 ha around Maichew town to 12047 ha around Mekelle City. The estimated area abandoned in rural areas annually as the result of tree cutting for fuelwood also varies from 6.5 ha around Sinkata to 127 ha around Dergajen village. It is therefore recommended that an estimated annual tree plantation of area ranging from 286 ha around Maichew town to 21,684 ha around Mekelle city is required. Moreover, an estimated annual tree plantation of area ranging from 16 ha around Sinkata village to 229 ha around the Dergajen village is required taking the existing population into account.     

Restoration of native vegetation following exclosure establishment on communal grazing lands in Tigray,Ethiopia

Questions: Is plant species richness, diversity and above‐ground standing biomass enhanced after establishing exclosures on communal grazing lands? What factors influence the effectiveness of exclosures to restore degraded native vegetation in Tigray, Ethiopia? Location: Northern Ethiopia. Methods: We used a space‐for‐time substitution approach to detect changes in plant species richness, diversity and above‐ground standing biomass after conversion of communal grazing lands to exclosures. We selected replicated (n=3) 5‐, 10‐, 15‐ and 20‐year‐old exclosures and paired each exclosure with an adjacent communal grazing land to ensure that soil and terrain conditions were as similar as possible among each pair. Results: All exclosures displayed higher plant species richness, diversity and biomass than the communal grazing lands. Differences in plant species richness and biomass between an exclosure age and adjacent communal grazing land were higher in oldest than in youngest exclosures. In exclosures, much of the variability in plant species composition and biomass was explained by a combination of edaphic (total nitrogen, phosphorus, texture and soil pH) and site (precipitation and altitude) variables (R²=0.72–0.82). Edaphic and site variables also explained much of the variability in plant species composition in communal grazing lands (R²=0.76–0.82). Our study shows that all exclosures are at an early stage of succession. The increase in economically important indigenous shrub and tree species with exclosure age suggests that, with time, a valuable afromontane forest may develop. Conclusions: Establishment of exclosures on communal grazing lands is a viable option to restore degraded native vegetation. However, before expanding exclosures, the ecological consequences of additional exclosures should be investigated as further expansion of exclosures could increase grazing pressure on remaining grazing areas. Furthermore, consideration of edaphic and site variables will help optimize selection of areas for establishment of exclosures and enhance natural regeneration in exclosures in the future.     

Humus Form Development during Forest Restoration in Exclosures of the Tigray Highlands, Northern Ethiopia

Forest restoration in protected exclosures has become a common practice to fight land degradation in the highlands of northern Ethiopia. Insights into ecosystem processes governing restoration in these formerly degraded areas are gained through the study of humus forms and factors influencing humus formation during vegetation recovery. Humus forms of 135 sample plots located in different land use types were morphologically described. The subsequent classification into six humus form types was based on principal component analysis and cluster analysis. Where areas are closed for a longer time, humus profiles are commonly more developed and higher organic matter accumulation is noticed as well as increased nutrient stocks. The combined effects of seasonal drought conditions and low fresh litter quality account for an overall slow decomposition, which explains the high importance of litter input for organic matter accumulation. Based on a correlation analysis, vegetation cover, litter production, litter quality, soil nutrient content, soil moisture, and topography were identified as important factors influencing humus formation. It is inferred that humus formation leads to improvements in soil fertility and structure, microclimate development, and soil protection and therefore forms part of the restoration processes taking place in exclosures.     

Establishment and management of woody seedlings in gullies in a semi-arid environment (Tigray, Ethiopia)

In the north Ethiopian highlands, gully erosion is a significant land degradation process. Although the protective role of vegetation has been demonstrated in many studies, efforts previously made in using woody species for erosion control in the research area are limited, and when applied, survival of the planted seedlings was very low. Lack of experience and fundamental knowledge on species autecology and traits are two important bottlenecks. This study therefore aims at better understanding seedling establishment and growth in a context of tree plantings, with the view to further control gully erosion in a semi-arid environment. To this end survival, growth and development of seedlings of Acacia etbaica Schweinf., Sesbania sesban (L.) Merr. and Dodonaea angustifolia L.f. were monitored during 26 months in a field trial under different site conditions and treatments. The experiment was established at two sites characterized by topographic and edaphic conditions (Vertisol and sandy colluvium) representative for the study area. At each site, seedlings were subjected to different treatments of watering, sheltering and planting position (gully floor, sidewall and shoulder), and a large set of plant growth variables was regularly monitored. Height and biomass growth was fastest for Sesbania, even if affected by different pests. Regardless of the species, plants growing in the (nutrient-rich) Vertisol site had a higher survival rate and an overall better development. Shelter protection significantly increased survival and resulted in taller seedlings. Notwithstanding these general trends, treatment effects were often varying over time and strongly influenced by specific edaphic conditions. Generally, Acacia performed best on gully shoulder and wall, Sesbania on the gully floor and Dodonaea on shoulder positions. Recommendations for planting practice and follow-up research are discussed.     

Ethnobotanical study of medicinal plants in Ganta Afeshum District,Eastern Zone of Tigray,Northern Ethiopia

Background

Starting from the ancient time, the people of Ethiopia use medicinal plants as traditional medicine to heal different human and livestock ailments. This ethnobotanical study of medicinal plants was carried out in Ganta Afeshum District, Eastern Zone of Tigray, Northern Ethiopia, to identify medicinal plant species used by the local community to treat various human and livestock ailments.

Methods

A total of 78 informants (54 men and 24 women) were selected to collect ethnobotanical information from four study sites. Among the 78 informants, 20 key informants were selected purposefully; the other 58 informants were selected randomly by lottery method. Ethnobotanical data were collected using semi-structured interviews, field observations, guided field walks, and group discussions and were analyzed by preference ranking, paired comparison, direct matrix ranking, informant consensus factor, fidelity level (FL), use-value, independent samples t test, and Pearson correlation coefficients.

Results

A total of 173 medicinal plants were collected and identified that were distributed across 77 families and 156 genera. The family Fabaceae stood first by contributing 17 (9.8%) species followed by Lamiaceae and Solanaceae with 9 (5.2%) species each. Rhamnus prinoides was reported for the treatment of many of the described diseases. One hundred sixteen (67.1%) medicinal plant species were collected from natural vegetation, 34 (19.7) were from home gardens, 13 (7.5%) from farmland, and 10 (5.8%) were from natural vegetation and home gardens. The most widely used life form was herbs (69 species, 39.9%) followed by shrubs (58 species, 33.5%). The most commonly used part of the medicinal plants was the leaves followed by roots. The plants were prepared by grinding, powdering, squeezing, roasting, and burning and were administered through oral, dermal, nasal, anal, ocular, and vaginal, and on the surface of the teeth. The most commonly used applications were by drinking, smearing, eating, fumigation, and chewing. There was no difference between men and women informants, showing that the two sexes had similar knowledge in the use of traditional medicinal plants. Educational level and medicinal plant knowledge of informants were negatively correlated; whereas age and medicinal plant knowledge of informants were positively correlated.

Conclusions

Ganta Afeshum District is relatively rich in diversity of medicinal plant resources accompanied with a rich indigenous knowledge within the local communities to harvest and effectively use to prevent different human and livestock ailments. However, nowadays, deforestation, agricultural expansion, overgrazing, drought, and overexploitation are threatening these properties. Therefore, people of the study area should apply complementary conservation approaches (in situ and ex situ) for sustainable use of these resources and to prevent species extinction.

     

When a pet dies: Religious issues,euthanasia and strategies for coping with bereavement

Abstract

Sixty-eight people from a variety of religious backgrounds and who had experienced the death of a companion animal were interviewed. Questions covered their personal experience of their pet's death, the role that their religion played in this experience and factors affecting how well they coped with the death. Individuals varied widely in their emotional response to the death of their pet. Demographic variables were relatively weak predictors of the distress experienced, the strongest predictor of distress being whether or not the animal was euthanized. Religion did not affect the level of distress that participants reported or the veterinary treatment, including euthanasia, that they considered appropriate. Nevertheless, 56 percent of participants believed in an afterlife for their pet and generally found this belief comforting. Having someone to talk to, and being included in decision-making were also reported to be helpful.     

Risk Factors for Maternal Mortality in Rural Tigray,Northern Ethiopia: A Case-Control Study

Background

Maternal mortality continues to have devastating impacts in many societies, where it constitutes a leading cause of death, and thus remains a core issue in international development. Nevertheless, individual determinants of maternal mortality are often unclear and subject to local variation. This study aims to characterise individual risk factors for maternal mortality in Tigray, Ethiopia.

Methods

A community-based case-control study was conducted, with 62 cases and 248 controls from six randomly-selected rural districts. All maternal deaths between May 2012 and September 2013 were recruited as cases and a random sample of mothers who delivered in the same communities within the same time period were taken as controls. Multiple logistic regression was used to identify independent determinants of maternal mortality.

Results

Four independent individual risk factors, significantly associated with maternal death, emerged. Women who were not members of the voluntary Women’s Development Army were more likely to experience maternal death (OR 2.07, 95% CI 1.04–4.11), as were women whose husbands or partners had below-median scores for involvement during pregnancy (OR 2.19, 95% CI 1.14–4.18). Women with a pre-existing history of other illness were also at increased risk (OR 5.58, 95% CI 2.17–14.30), as were those who had never used contraceptives (OR 2.58, 95% CI 1.37–4.85). Previous pregnancy complications, a below-median number of antenatal care visits and a woman’s lack of involvement in health care decision making were significant bivariable risks that were not significant in the multivariable model.

Conclusions

The findings suggest that interventions aimed at reducing maternal mortality need to focus on encouraging membership of the Women’s Development Army, enhancing husbands’ involvement in maternal health services, improving linkages between maternity care and other disease-specific programmes and ensuring that women with previous illnesses or non-users of contraceptive services are identified and followed-up as being at increased risk during pregnancy and childbirth.     

An ethnobotanical study of medicinal plants used in Kilte Awulaelo District,Tigray Region of Ethiopia

Background

The Ethiopian people have been dependent on traditional medicine, mainly medicinal plants, from time immemorial for control of human and animal health problems, and they still remain to be largely dependent on the practice. The purpose of the current study was to conduct ethnobotanical study to document medicinal plants used to treat diseases of human and domestic animals in Kilte Awulaelo District in the Tigray Region of Ethiopia.

Methods

Ethnobotanical data were collected between July and September 2011 through semi-structured interviews, ranking exercises and field observations. For the interviews, 72 knowledgeable informants were sampled using purposive sampling method. For the different ranking exercises, key informants were identified with the help of elders and local administrators from informants that were already involved in the interviews.

Results

The study revealed 114 medicinal plant species belonging to 100 genera and 53 families. The plants were used to treat 47 human and 19 livestock diseases. Of the species, the majority (74%) were obtained from the wild. Herbs were the most utilized plants, accounting for 44% of the species, followed by shrubs (29%). Leaf was the most commonly used plant part accounting for 42.98% of the plants, followed by roots (25.73%). Preference ranking exercise on selected plants used against abdominal pain indicated the highest preference of people for Solanum marginatum. Direct matrix ranking showed Cordia africana as the most preferred multipurpose plant in the community. Preference ranking of selected scarce medicinal plants indicated Myrica salicifolia as the most scarce species, followed by Boscia salicifolia and Acokanthera schimperi. According to priority ranking, drought was identified as the most destructive factor of medicinal plants, followed by overgrazing and firewood collection.

Conclusion

Medicinal plants are still playing significant role in the management of various human and livestock diseases in the study area with herbs taking the lead in the number of plants used in the preparation of remedies, which may be an indication of their relatively better abundance as compared to other life forms. Recurrent drought was reported to have seriously threatened medicinal plant resources in the District. Awareness is thus needed be raised among local people on sustainable utilization and management of plant resources. Ex situ and in situ conservation measures should be taken to protect the medicinal plants of the District from further destruction and special attention should be given to the medicinal plants that were indicated by preference ranking exercise as the most threatened ones.

     

Pet Loss and Representations of Death,Attachment, Depression,and Euthanasia

Studies that have examined pet loss hypothesize that attachment, representations of death, and the belief in an afterlife for animals may influence owners’ bereavement and depressive outcomes. The following instruments were administered to 159 Italian participants recruited through snowball sampling: the Lexington Attachment to Pets Scale (LAPS), the Pet Bereavement Questionnaire (PBQ), the Testoni Death Representation Scale (TDRS), and Beck’s Depression Inventory II (BDI-II). Questions concerning pet euthanasia-related issues and the relationship between owners and veterinarians were also submitted to the participants. A path model was conducted, showing that the representation of death and the attachment to a pet had a direct effect on pet grief, which in turn had a direct effect on depression. The results show a positive correlation between the LAPS and PBQ factors, particularly with the PBQ factor Grief. The LAPS factors positively correlated with the TDRS representation of Death as a Passage and negatively correlated with the TDRS representation of Death as Annihilation. The LAPS People Substituting factor positively correlated with the total score and the Cognitive-Affective factor of the BDI-II. The PBQ factors positively correlated with the BDI-II, whereas only the TDRS Death as Annihilation factor positively correlated with the BDI-II. Belief in a transcendent dimension was associated with higher scores on the PBQ Guilt factor and the TDRS factors of Death as a Passage and Death as Change, whereas these beliefs were associated with lower scores on the TDRS factor Death as Annihilation.

The results indicated that the sensitivity of the veterinarian and a veterinarian who helps owners make conscious and informed decisions for their pet and choose the right time to perform euthanasia are important variables in the management of pet loss. However, these factors are not sufficient and psychological support should be improved to help owners better cope with grief.     

Health Extension Workers' and Mothers' Attitudes to Maternal Health Service Utilization and Acceptance in Adwa Woreda,Tigray Region,Ethiopia

Background

The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs’ and mother’s attitudes to maternal health services in Adwa Woreda, Tigray Region.

Methods

In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women’s social status and mobility; and women’s perceptions of skilled birth attendant’s care. All data were analyzed thematically.

Findings

There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women’s Development Groups (WDGs), and referral by ambulance to health facilities either before a woman’s Expected Due Date (EDD) or if labour started at home.

Conclusion

With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women’s groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.