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Objectives:To describe important details of the design and operational features of the Mwanza sexually transmitted diseases (STD) control programme. To assess the feasibility of the intervention, the distribution of STD syndromes observed, the clinical eVectiveness of syndromic STD case management, the utilisation of STD services by the population, and the quality of syndromic STD services delivered at rural health units. Methods:The intervention was integrated into rural primary healthcare (PHC) units. It comprised improved STD case management using the syndromic approach, facilitated by a regional programme oYce which ensured the training of health workers, a reliable supply of eVective drugs, and regular support supervision. Five studies were performed to evaluate operational performance: (i) a survey of register books to collect data on patients presenting with STDs and reproductive tract infections (RTIs) to rural health units with improved STD services, (ii) a survey of register books from health units in communities without improved services, (iii) a survey of register books from referral clinics, (iv) a home based cross sectional study of STD patients who did not return to the intervention health units for follow up, (v) a cross sectional survey of reported STD treatment seeking behaviour in a random cohort of 8845 adults served by rural health units. Results: During the 2 years of the Mwanza trial, 12 895 STD syndromes were treated at the 25 intervention health units. The most common syndromes were urethral discharge (67%) and genital ulcers (26%) in men and vaginal discharge (50%), lower abdominal tenderness (33%), and genital ulcers (13%) in women. Clinical treatment eVectiveness was high in patients from whom complete follow up data were available, reaching between 81% and 98% after first line treatment and 97%-99% after first, second, and third line treatment. Only 26% of patients referred to higher levels of health care had presented to their referral institutions. During the trial period, data from the cohort showed that 12.8% of men and 8.6% of women in the intervention communities experienced at least one STD syndrome. Based on various approaches, utilisation of the improved health units by symptomatic STD patients in these communities was estimated at between 50% and 75%. During the first 6 months of intervention attendance at intervention units increased by 53%. Thereafter, the average attendance rate was about 25% higher than in comparison communities. Home visits to 367 non-returners revealed that 89% had been free of symptoms after treatment, but 28% became symptomatic again within 3 months of treatment. 100% of these patients reported that they had received treatment, but only 74% had been examined, only 57% had been given health education, and only 30% were oVered condoms. Patients did not fully recall which treatment they had been given, but possibly only 63% had been treated exactly according to guidelines. Conclusions: This study demonstrated that it is feasible to integrate eVective S...

Objective To assess maternal mortality.Design Prospective community-based survey, a sisterhood method survey and hospital data. SettingThe study was performed in communities in a rural area in Northwestern Tanzania and the local district hospital. ResultsFour hundred and forty-seven pregnant women in the community survey were followed up as far as six weeks after delivery; there were 2865 respondents in the sisterhood survey; the hospital study involved 7526 deliveries. Maternal morality ratios derived from the prospective community-based survey, the sisterhood method survey and hospital data analysis were 241, 297, and 845 per 100000 live births, respectively. ConclusionsHospital data tend to overestimate maternal mortality in these communities. The sisterhood method is easier and more convenient than a prospective community-based study.

Objective: To compare perinatal mortality* stratified for risk level, in home births attended by a relative or traditional birth atten dant without formal training with births attended by trained personnel in a dispensary or hospital. Study design: A prospective community based study in five villages in Northwestern Tanzania during 1990, involving 222 women delivering at home and 199 in a dispensary or hospital. Results: Twenty-two of the 29 (76%) perinatal deaths occurred in home births. Perinatal mortality, stratified for risk level, was three times higher in home births than it was in births in dispensaries or in hospital (Mantel-Haenszel odds ratio, 3.29; 95% Cl, 1.28-9.22). Conclusions: This study re-emphasises that all births should be attended by adequately trained personnel. More effective strategies are needed to convince women with high risk pregnancies to deliver in hospital. Emergency referral services are required to deal with unexpected complications arising in low risk births at home.

In this prospective community-based study, a symphysis-fundal height chart was constructed, derived from 403 measurements in 83 women, in a local rural population. Using the recommended Cardiff chart, 132 measurements (32,9%) were below the 10th centile line, while only two measurements were above the 90th centile line. This may indicate that a high percentage of the Tanza nian fetus are growth retarded or genetically small. The relative importance of each of these remains unknown. Use of the Cardiff chart in rural Tanzania could result in unnecessary referrals, which is undesirable in view of both the women involved and strained resources. Therefore, the use of a symphysis fundal height chart, based on measurements in the local population, is recommended.