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KC A, Rönnbäck M, Humgain U, Basnet O, Bhattarai P, Axelin A. Implementation barriers and facilitators of Moyo foetal heart rate monitor during labour in public hospitals in Nepal. Glob Health Action 2024; 17:2328894. [PMID: 38577869 PMCID: PMC11000597 DOI: 10.1080/16549716.2024.2328894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/06/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Globally, every year, approximately 1 million foetal deaths take place during the intrapartum period, fetal heart monitoring (FHRM) and timely intervention can reduce these deaths. OBJECTIVE This study evaluates the implementation barriers and facilitators of a device, Moyo for FHRM. METHODS The study adopted a qualitative study design in four hospitals in Nepal where Moyo was implemented for HRM. The study participants were labour room nurses and convenience sampling was used to select them. A total of 20 interviews were done to reach the data saturation. The interview transcripts were translated to English, and qualitative content analysis using deductive approach was applied. RESULTS Using the deductive approach, the data were organised into three categories i) changes in practice of FHRM, ii) barriers to implementing Moyo and iii) facilitators of implementing Moyo. Moyo improved adherence to intermittent FHRM as the device could handle higher caseloads compared to the previous devices. The implementation of Moyo was hindered by difficulty to organise training ondevice during non-working hours, technical issue of the device, nurse mistrust towards the device and previous experience of poor implementation to similar innovations. Facilitators for implementation included effective training on how to use Moyo, improvement in intrapartum foetal monitoring and improvement in staff morale, ease of using the device, Plan Do Study Act (PDSA) meetings to improve use of Moyo and supportive leadership. CONCLUSION The change in FHRM practice suggests that the implementation of innovative solution such as Moyo was successful with adequate facilitation, supportive staff attitude and leadership.
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Affiliation(s)
- Ashish KC
- School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Mikaela Rönnbäck
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Urja Humgain
- Research Division, Golden Community, Lalitpur, Nepal
| | - Omkar Basnet
- Research Division, Golden Community, Lalitpur, Nepal
| | | | - Anna Axelin
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Department of Nursing Science, University of Turku, Turku, Finland
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Gannon H, Chimhini G, Cortina-Borja M, Chiyaka T, Mangiza M, Fitzgerald F, Heys M, Neal SR, Chimhuya S. Risk factors of mortality in neonates with neonatal encephalopathy in a tertiary newborn care unit in Zimbabwe over a 12-month period. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000911. [PMID: 36962805 PMCID: PMC10021203 DOI: 10.1371/journal.pgph.0000911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/04/2022] [Indexed: 06/18/2023]
Abstract
Neonatal encephalopathy (NE) accounts for ~23% of the 2.4 million annual global neonatal deaths. Approximately 99% of global neonatal deaths occur in low-resource settings, however, accurate data from these low-resource settings are scarce. We reviewed risk factors of neonatal mortality in neonates admitted with neonatal encephalopathy from a tertiary neonatal unit in Zimbabwe. A retrospective review of risk factors of short-term neonatal encephalopathy mortality was conducted at Sally Mugabe Central Hospital (SMCH) (November 2018 -October 2019). Data were gathered using a tablet-based data capture and quality improvement newborn care application (Neotree). Analyses were performed on data from all admitted neonates with a diagnosis of neonatal encephalopathy, incorporating maternal, intrapartum, and neonatal risk predictors of the primary outcome: mortality. 494/2894 neonates had neonatal encephalopathy on admission and were included. Of these, 94 died giving a neonatal encephalopathy-case fatality rate (CFR) of 190 per 1000 admitted neonates. Caesarean section (odds ratio (OR) 2.95(95% confidence interval (CI) 1.39-6.25), convulsions (OR 7.13 (1.41-36.1)), lethargy (OR 3.13 (1.24-7.91)), Thompson score "11-14" (OR 2.98 (1.08-8.22)) or "15-22" (OR 17.61 (1.74-178.0)) were significantly associated with neonatal death. No maternal risk factors were associated with mortality. Nearly 1 in 5 neonates diagnosed with neonatal encephalopathy died before discharge, similar to other low-resource settings but more than in typical high-resource centres. The Thompson score, a validated, sensitive and specific tool for diagnosing neonates with neonatal encephalopathy was an appropriate predictive clinical scoring system to identify at risk neonates in this setting. On univariable analysis time-period, specifically a period of staff shortages due to industrial action, had a significant impact on neonatal encephalopathy mortality. Emergency caesarean section was associated with increased mortality, suggesting perinatal care is likely to be a key moment for future interventions.
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Affiliation(s)
- Hannah Gannon
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Unit of Child and Adolescent Health, Faculty of Medicine and Health Sciences. Primary Healthcare Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Gwendoline Chimhini
- Unit of Child and Adolescent Health, Faculty of Medicine and Health Sciences. Primary Healthcare Sciences, University of Zimbabwe, Harare, Zimbabwe
- Sally Mugabe Central Hospital Neonatal Unit, Harare, Zimbabwe
| | - Mario Cortina-Borja
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Tarisai Chiyaka
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Marcia Mangiza
- Sally Mugabe Central Hospital Neonatal Unit, Harare, Zimbabwe
| | - Felicity Fitzgerald
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Michelle Heys
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Specialist Children’s and Young People’s Services, East London NHS Foundation Trust, London, United Kingdom
| | - Samuel R. Neal
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Simbarashe Chimhuya
- Unit of Child and Adolescent Health, Faculty of Medicine and Health Sciences. Primary Healthcare Sciences, University of Zimbabwe, Harare, Zimbabwe
- Sally Mugabe Central Hospital Neonatal Unit, Harare, Zimbabwe
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Cheung KW, Bonet M, Frank KA, Oladapo OT, Hofmeyr GJ. Clinical algorithms for management of fetal heart rate abnormalities during labour. BJOG 2022. [PMID: 35415966 DOI: 10.1111/1471-0528.16731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To construct algorithms with a sequential decision analysis pathway for monitoring of the fetal heart rate and managing fetal heart rate bradycardia, late decelerations and tachycardia during labour. POPULATION Low-risk pregnant women in labour with singleton cephalic term pregnancies. SETTING Institutional births in low- and middle-income countries. SEARCH STRATEGY We sought relevant published clinical algorithms, guidelines and randomised trials/reviews by searching the Cochrane Library, PubMed and Google on the terms: "fetal AND heart AND rate AND algorithm AND (labour OR intrapartum)", up to March 2020. CASE SCENARIOS The two scenarios included were fetal heart rate bradycardia or late decelerations (potentially related to uterine rupture, placental abruption, cord prolapse, maternal hypotension, uterine hyperstimulation or unexplained) and fetal heart rate tachycardia (potentially related to maternal hyperthermia, infection, dehydration or unexplained). The algorithms provide pathways for definition, assessment, diagnosis, interventions to correct the abnormalities and ongoing monitoring leading to mode of birth, and linking to other algorithms in the series. CONCLUSIONS The algorithms provide a framework for monitoring and managing fetal heart rate bradycardia, late decelerations and tachycardia during labour. We emphasise the inherent diagnostic inaccuracy of fetal heart rate monitoring, the tendency to over-diagnose fetal compromise, the need to consider fetal heart rate information in the context of other clinical features and the need to engage in informed, shared, family-centred decision-making. We note the need for further research on methods of fetal assessment during labour including clinical fetal arousal testing and the rapid biophysical profile test. TWEETABLE ABSTRACT Decision analysis algorithms for fetal bradycardia, late decelerations and tachycardia highlight diagnostic limitations.
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Affiliation(s)
- K W Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong City, Hong Kong SAR, China
| | - M Bonet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - K A Frank
- Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa
- University of Kwa-Zulu Natal, Pietermaritzburg, South Africa
| | - O T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - G J Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
- Effective Care Research Unit, University of the Witwatersrand and Water Sisulu University, Mthatha, South Africa
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Munyaw Y, Gidabayda J, Yeconia A, Guga G, Mduma E, Mdoe P. Beyond research: improved perinatal care through scale-up of a Moyo fetal heart rate monitor coupled with simulation training in northern Tanzania for helping babies breathe. BMC Pediatr 2022; 22:191. [PMID: 35410324 PMCID: PMC8996520 DOI: 10.1186/s12887-022-03249-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this project was to improve perinatal survival by introducing Moyo Fetal Heart Rate (FHR) Monitor coupled with neonatal resuscitation simulation training. METHODS The implementation was done at three district hospitals. We assessed health care workers' (HCW's) skills and perinatal death trends during implementation. Baseline data were collected from the hospitals before implementation. Newborn resuscitation (NR) skills were assessed before and after simulation training. Assessment of perinatal outcomes was done over 2 years of implementation. We used descriptive analysis; a t-test (paired and independent two-sample) and a one-way Anova test to report the findings. RESULTS A total of 107 HCW's were trained on FHR monitoring using Moyo and NR knowledge and skills using NeoNatalie simulators. The knowledge increased post-training by 13.6% (p < 0.001). Skills score was increased by 25.5 and 38.2% for OSCE A and B respectively (p < 0.001). The overall fresh stillbirths rate dropped from 9 to 5 deaths per 1000 total births and early neonatal deaths at 7 days from 5 to 3 (p < 0.05) deaths per 1000 live births over 2 years of implementation. CONCLUSION There was a significant improvement of newborn resuscitation skills among HCW's and neonatal survival at 2 years. Newborn resuscitation training coupling with Moyo FHR monitor has shown potential for improving perinatal survival. However, further evaluation is needed to explore the full potential of the package.
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Affiliation(s)
- Yuda Munyaw
- Department of Obstetrics and Gynecology, Haydom Lutheran Hospital, P.O BOX 9000, Haydom, Mbulu, Tanzania.
| | - Joshua Gidabayda
- Department of Pediatrics, Haydom Lutheran Hospital, P.O BOX 9000, Haydom, Mbulu, Tanzania
| | - Anita Yeconia
- Research Centre, Haydom Lutheran Hospital, P.O BOX 9000, Haydom, Mbulu, Tanzania
| | - Godfrey Guga
- Research Centre, Haydom Lutheran Hospital, P.O BOX 9000, Haydom, Mbulu, Tanzania
| | - Esto Mduma
- Research Centre, Haydom Lutheran Hospital, P.O BOX 9000, Haydom, Mbulu, Tanzania
| | - Paschal Mdoe
- Research Centre, Haydom Lutheran Hospital, P.O BOX 9000, Haydom, Mbulu, Tanzania
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Kamala BA, Ersdal HL, Mduma E, Moshiro R, Girnary S, Østrem OT, Linde J, Dalen I, Søyland E, Bishanga DR, Bundala FA, Makuwani AM, Richard BM, Muzzazzi PD, Kamala I, Mdoe PF. SaferBirths bundle of care protocol: a stepped-wedge cluster implementation project in 30 public health-facilities in five regions, Tanzania. BMC Health Serv Res 2021; 21:1117. [PMID: 34663296 PMCID: PMC8524841 DOI: 10.1186/s12913-021-07145-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
Background The burden of stillbirth, neonatal and maternal deaths are unacceptably high in low- and middle-income countries, especially around the time of birth. There are scarce resources and/or support implementation of evidence-based training programs. SaferBirths Bundle of Care is a well-proven package of innovative tools coupled with data-driven on-the-job training aimed at reducing perinatal and maternal deaths. The aim of this project is to determine the effect of scaling up the bundle on improving quality of intrapartum care and perinatal survival. Methods The project will follow a stepped-wedge cluster implementation design with well-established infrastructures for data collection, management, and analysis in 30 public health facilities in regions in Tanzania. Healthcare workers from selected health facilities will be trained in basic neonatal resuscitation, essential newborn care and essential maternal care. Foetal heart rate monitors (Moyo), neonatal heart rate monitors (NeoBeat) and skills trainers (NeoNatalie Live) will be introduced in the health facilities to facilitate timely identification of foetal distress during labour and improve neonatal resuscitation, respectively. Heart rate signal-data will be automatically collected by Moyo and NeoBeat, and newborn resuscitation training by NeoNatalie Live. Given an average of 4000 baby-mother pairs per year per health facility giving an estimate of 240,000 baby-mother pairs for a 2-years duration, 25% reduction in perinatal mortality at a two-sided significance level of 5%, intracluster correlation coefficient (ICC) to be 0.0013, the study power stands at 0.99. Discussion Previous reports from small-scale Safer Births Bundle implementation studies show satisfactory uptake of interventions with significant improvements in quality of care and lives saved. Better equipped and trained birth attendants are more confident and skilled in providing care. Additionally, local data-driven feedback has shown to drive continuous quality of care improvement initiatives, which is essential to increase perinatal and maternal survival. Strengths of this research project include integration of innovative tools with existing national guidelines, local data-driven decision-making and training. Limitations include the stepwise cluster implementation design that may lead to contamination of the intervention, and/or inability to address the shortage of healthcare workers and medical supplies beyond the project scope. Trial registration Name of Trial Registry: ISRCTN Registry. Trial registration number: ISRCTN30541755. Date of Registration: 12/10/2020. Type of registration: Prospectively Registered.
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Affiliation(s)
- Benjamin A Kamala
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania. .,School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
| | - Hege L Ersdal
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Estomih Mduma
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
| | - Robert Moshiro
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania.,Department of Pediatrics, Muhimbili National Hospital, Dar es Salaam, Tanzania.,Paediatric Association of Tanzania, Dar es Salaam, Tanzania
| | | | | | - Jørgen Linde
- Obstetric Department, Stavanger University Hospital, Stavanger, Norway
| | - Ingvild Dalen
- Obstetric Department, Stavanger University Hospital, Stavanger, Norway
| | | | - Dunstan R Bishanga
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Felix Ambrose Bundala
- Reproductive and Child Health Section, Ministry of Health Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Ahmad M Makuwani
- Reproductive and Child Health Section, Ministry of Health Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Boniphace Marwa Richard
- Department of Health, President's Office- Regional Authority and Local Government, Dodoma, Tanzania
| | | | - Ivony Kamala
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania.,Tanzania Midwifery Association (TAMA), Dar es Salaam, Tanzania
| | - Paschal F Mdoe
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
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Al Wattar BH, Honess E, Bunnewell S, Welton NJ, Quenby S, Khan KS, Zamora J, Thangaratinam S. Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis. CMAJ 2021; 193:E468-E477. [PMID: 33824144 PMCID: PMC8049638 DOI: 10.1503/cmaj.202538] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND: Cesarean delivery is the most common surgical procedure worldwide. Intrapartum fetal surveillance is routinely offered to improve neonatal outcomes, but the effects of different methods on the risk of emergency cesarean deliveries remains uncertain. We conducted a systematic review and network meta-analysis to evaluate the effectiveness of different types of fetal surveillance. METHODS: We searched MEDLINE, Embase and CENTRAL until June 1, 2020, for randomized trials evaluating any intrapartum fetal surveillance method. We performed a network meta-analysis within a frequentist framework. We assessed the quality and network inconsistency of trials. We reported primarily on intrapartum emergency cesarean deliveries and other secondary maternal and neonatal outcomes using risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS: We included 33 trials (118 863 patients) evaluating intermittent auscultation with Pinard stethoscope/handheld Doppler (IA), cardiotocography (CTG), computerized cardiotocography (cCTG), CTG with fetal scalp lactate (CTG-lactate), CTG with fetal scalp pH analysis (CTG-FBS), CTG with fetal pulse oximetry (FPO-CTG), CTG with fetal heart electrocardiogram (CTG-STAN) and their combinations. Intermittent auscultation reduced the risk of emergency cesarean deliveries compared with other types of surveillance (IA v. CTG: RR 0.83, 95% CI 0.72–0.97; IA v. CTG-FBS: RR 0.71, 95% CI 0.63–0.80; IA v.CTG-lactate: RR 0.77, 95% CI 0.64–0.92; IA v. FPO-CTG: RR 0.75, 95% CI 0.65–0.87; IA v.FPO-CTG-FBS: RR 0.81, 95% CI 0.67–0.99; cCTG-FBS v. IA: RR 1.21, 95% CI 1.04–1.42), except STAN-CTG-FBS (RR 1.17, 95% CI 0.98–1.40). There was a similar reduction observed for emergency cesarean deliveries for fetal distress. None of the evaluated methods was associated with a reduced risk of neonatal acidemia, neonatal unit admissions, Apgar scores or perinatal death. INTERPRETATION: Compared with other types of fetal surveillance, intermittent auscultation seems to reduce emergency cesarean deliveries in labour without increasing adverse neonatal and maternal outcomes.
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Affiliation(s)
- Bassel H Al Wattar
- Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK
| | - Emma Honess
- Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK
| | - Sarah Bunnewell
- Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK
| | - Nicky J Welton
- Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK
| | - Siobhan Quenby
- Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK
| | - Khalid S Khan
- Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK
| | - Javier Zamora
- Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK
| | - Shakila Thangaratinam
- Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK
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Oommen H, Ranjan K, Murugesan S, Gore A, Sonthalia S, Ninan P, Bernitz S, Sorbye I, Lukasse M. Implementation of the Moyo fetal heart rate monitor in district hospitals in Bihar, India: a feasibility study. BMJ Open 2021; 11:e041071. [PMID: 33558349 PMCID: PMC7871681 DOI: 10.1136/bmjopen-2020-041071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Globally, half of all stillbirths occur during birth. Detection of fetal distress with fetal heart rate monitoring (FHRM), followed by appropriate and timely management, might reduce fresh stillbirths and neonatal morbidity. This study aimed to investigate the barriers and facilitators for the implementation of Moyo FHRM use in Bihar state, and secondarily, the feasibility of collecting reliable obstetrical and neonatal outcome data to assess the effect of implementation. SETTING CARE Bihar and the hospital management at four district hospitals (DHs) in Bihar state, each with 6500 to 15 000 deliveries a year, agreed to testing the implementation of Moyo FHRM through a process of meetings, training sessions and collecting data. At each hospital, a clinical training expert was trained to train others, while a clinical assessment facilitator collected data. METHODOLOGY Observational notes were taken at all training sessions and meetings. Individual interviews (n=4) were conducted with clinical training experts (CTEs) on training experiences and barriers and facilitators for Moyo FHRM implementation. The CTEs recoded field notes in diaries. Descriptive analyses performed on pre-implementation and post-implementation data (n=521) assessed quality and completeness. RESULTS Main barriers to implementation of Moyo FHRM were health system and cultural challenges involving (1) existing practices, (2) insufficient human resources, (3) action delays and (4) cultural and local challenges. Another barrier was insufficient involvement of doctors. Facilitators for implementation were easy use of the Moyo FHRM device and adequate training for staff.Electronic collection of obstetrical data worked well but had substantial missing data. CONCLUSION Health system and cultural challenges are a major constraint to Moyo FHRM implementation in low-resource settings. Improvements at all levels of infrastructure, practices and skills will be critical in busy DHs in Bihar. Full-scale implementation needs doctor-led leadership and ownership. Obstetrical data collection for the purpose of scientific analysis needs to be improved.
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Affiliation(s)
- Hanna Oommen
- Department of Obstetrics and Gynecology, South Norwegian Hospital SSHF, Kristiansand, Agder, Norway
- Faculty of Life Science and Education, University of South Wales, Pontypridd, Rhondda Cynon Taff, UK
| | - Kunal Ranjan
- Solutions for Sustainable Development, CARE India, Patna, Bihar, India
| | - Sudha Murugesan
- Solutions for Sustainable Development, CARE India, Patna, Bihar, India
| | - Aboli Gore
- Solutions for Sustainable Development, CARE India, Patna, Bihar, India
| | - Sunil Sonthalia
- Solutions for Sustainable Development, CARE India, Patna, Bihar, India
| | - Pradeep Ninan
- Paediatric Surgery, Madhipura Christian Hospital, Madhipura, Bihar, India
| | - Stine Bernitz
- Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Akershus, Norway
| | - Ingvil Sorbye
- Department of Obstetrics and Gynecology, Oslo University Hospital HF, Oslo, Norway
| | - Mirjam Lukasse
- Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Akershus, Norway
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Kongsberg, Buskerud, Norway
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8
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Valderrama CE, Ketabi N, Marzbanrad F, Rohloff P, Clifford GD. A review of fetal cardiac monitoring, with a focus on low- and middle-income countries. Physiol Meas 2020; 41:11TR01. [PMID: 33105122 PMCID: PMC9216228 DOI: 10.1088/1361-6579/abc4c7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There is limited evidence regarding the utility of fetal monitoring during pregnancy, particularly during labor and delivery. Developed countries rely on consensus ‘best practices’ of obstetrics and gynecology professional societies to guide their protocols and policies. Protocols are often driven by the desire to be as safe as possible and avoid litigation, regardless of the cost of downstream treatment. In high-resource settings, there may be a justification for this approach. In low-resource settings, in particular, interventions can be costly and lead to adverse outcomes in subsequent pregnancies. Therefore, it is essential to consider the evidence and cost of different fetal monitoring approaches, particularly in the context of treatment and care in low-to-middle income countries. This article reviews the standard methods used for fetal monitoring, with particular emphasis on fetal cardiac assessment, which is a reliable indicator of fetal well-being. An overview of fetal monitoring practices in low-to-middle income counties, including perinatal care access challenges, is also presented. Finally, an overview of how mobile technology may help reduce barriers to perinatal care access in low-resource settings is provided.
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Affiliation(s)
- Camilo E Valderrama
- Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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9
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Perlman JM, Velaphi S, Massawe A, Clarke R, Merali HS, Ersdal H. Achieving Country-Wide Scale for Helping Babies Breathe and Helping Babies Survive. Pediatrics 2020; 146:S194-S207. [PMID: 33004641 DOI: 10.1542/peds.2020-016915k] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 11/24/2022] Open
Abstract
Helping Babies Breathe (HBB) was piloted in 2009 as a program targeted to reduce neonatal mortality (NM). The program has morphed into a suite of programs termed Helping Babies Survive that includes Essential Care for Every Baby. Since 2010, the HBB and Helping Babies Survive training programs have been taught to >850 000 providers in 80 countries. Initial HBB training is associated with a significant improvement in knowledge and skills. However, at refresher training, there is a knowledge-skill gap evident, with a falloff in skills. Accumulating evidence supports the role for frequent refresher resuscitation training in facilitating skills retention. Beyond skill acquisition, HBB has been associated with a significant reduction in early NM (<24 hours) and fresh stillbirth rates. To evaluate the large-scale impact of the growth of skilled birth attendants, we analyzed NM rates in sub-Saharan Africa (n = 11) and Nepal (as areas of growing HBB implementation). All have revealed a consistent reduction in NM at 28 days between 2009 and 2018; a mean reduction of 5.34%. The number of skilled birth attendants, an indirect measure of HBB sustained rollout, reveals significant correlation with NM, fresh stillbirth, and perinatal mortality rates, highlighting HBB's success and the need for continued efforts to train frontline providers. A novel live newborn resuscitation trainer as well as a novel app (HBB Prompt) have been developed, increasing knowledge and skills while providing simulation-based repeated practice. Ongoing challenges in sustaining resources (financial and other) for newborn programming emphasize the need for innovative implementation strategies and training tools.
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Affiliation(s)
- Jeffrey M Perlman
- Weill Cornell Medicine and New York-Presbyterian Komansky Children's Hospital, New York, New York;
| | - Sithembiso Velaphi
- Department of Pediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Augustine Massawe
- Department of Pediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Robert Clarke
- Maternal and Newborn Care, Latter-day Saint Charities Affiliate Faculty and Department of Public Health, College of Life Sciences, Brigham Young University, Provo, Utah
| | - Hasan S Merali
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Canada; and
| | - Hege Ersdal
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
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10
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Mdoe P, Yeconia A, Buu F, Kusulla S, Blacy L, Guga G, Mduma E, Kidanto H. Midwives' and Women's Perception on Moyo Fetal Heart Rate Monitor for Intrapartum Fetal Heart Rate Monitoring; A Cross-Sectional Study. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2020; 13:87-92. [PMID: 32256129 PMCID: PMC7092687 DOI: 10.2147/mder.s241741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/13/2020] [Indexed: 11/23/2022] Open
Abstract
Background The annual global neonatal mortality stands at 2.5 million deaths, 1 million of them dying within the first day of life. An additional 2.6 million are stillborn globally, the majority of them due to intrapartum events. Optimal fetal heart rate (FHR) monitoring has the potential to timely detect fetuses at risk and, if coupled with timely obstetric responses may save more newborns. Moyo is a new Doppler with nine crystals capable of monitoring FHR both intermittently and continuously. Aim To assess women's and midwives' opinions on the use of Moyo for intrapartum FHR monitoring. Methods We conducted a cross-sectional study using a structured questionnaire to assess women's and midwives' perception. Women who gave birth at the hospital who used Moyo were interviewed using a questionnaire immediately before discharge from the hospital. Twenty-eight midwives who have been using Moyo for more than 6 months were also interviewed using a structured questionnaire. Data were analyzed using excel and result presented in figures. Results In total 113 postpartum women who were monitored using Moyo were interviewed before discharge. Out of these, 46 (40.7%) were first-time mothers and the rest were multipara. In total, 95 women (84.1%) used Moyo and other devices for FHR monitoring, 81 (72%) said Moyo was better than Fetoscopes and handheld Doppler, two-third 75 (66.4%) felt that Moyo was comfortable and 93 (82.3%) would like Moyo to be used on them in the future. Out of 28 midwives, 11 (39.3%) used Moyo continuous only, 3 (10.7%) used Moyo intermittently only and 14 (50.0%) used both intermittent and continuous. Thirteen (46.4%) midwives prefer to use Moyo both intermittent and continuous. Sixteen (55.6%) said Moyo was effective, 21 (75%) felt comfortable to use Moyo, and 13 (46.4%) said Moyo was easy to use. Conclusion The majority of midwives and women who used Moyo felt that Moyo was comfortable for intrapartum FHR monitoring. Moyo can be used both intermittently and continuously depending on the user's preferences.
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Affiliation(s)
- Paschal Mdoe
- Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Anita Yeconia
- Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Fanuel Buu
- Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Simeon Kusulla
- Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Ladislaus Blacy
- Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Godfrey Guga
- Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Estomih Mduma
- Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Hussein Kidanto
- Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania
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11
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Scale-Up of Doppler to Improve Intrapartum Fetal Heart Rate Monitoring in Tanzania: A Qualitative Assessment of National and Regional/District Level Implementation Factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17061931. [PMID: 32188037 PMCID: PMC7142453 DOI: 10.3390/ijerph17061931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 02/26/2020] [Accepted: 03/05/2020] [Indexed: 12/18/2022]
Abstract
High-quality intrapartum care, including intermittent monitoring of fetal heart rates (FHR) to detect and manage abnormalities, is recommended by WHO and the Government of Tanzania (GoT) and creates potential to save newborn lives in Tanzania. Handheld Doppler devices have been investigated in several low-resource countries as an alternative to Pinard stethoscope and are more sensitive to detecting accelerations and decelerations of the fetal heart as compared to Pinard. This study assessed perspectives of high-level Tanzanian policymakers on facilitators and barriers to scaling up use of the hand-held Doppler for assessing FHR during labor and delivery. From November 2018-August 2019, nine high-level policymakers and subject matter experts were interviewed using a semi-structured questionnaire, with theoretical domains drawn from Proctor's implementation outcomes framework. Interviewees largely saw use of Doppler to improve intrapartum FHR monitoring as aligning with national priorities, though they noted competing demands for resources. They felt that GoT should fund Doppler, but prioritization and budgeting should be driven from district level. Recommended ways forward included learning from scale up of Helping Babies Breathe rollout, making training approaches effective, using clinical mentoring, and establishing systematic monitoring of outcomes. To be most effective, introduction of Doppler must be concurrent with improving case management practices for abnormal intrapartum FHR. WHO's guidance on scale-up, as well as implementation science frameworks, should be considered to guide implementation and evaluation.
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12
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Housseine N, Punt MC, Mohamed AG, Said SM, Maaløe N, Zuithoff NPA, Meguid T, Franx A, Grobbee DE, Browne JL, Rijken MJ. Quality of intrapartum care: direct observations in a low-resource tertiary hospital. Reprod Health 2020; 17:36. [PMID: 32171296 PMCID: PMC7071714 DOI: 10.1186/s12978-020-0849-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 01/02/2020] [Indexed: 11/16/2022] Open
Abstract
Background The majority of the world’s perinatal deaths occur in low- and middle-income countries. A substantial proportion occurs intrapartum and is avoidable with better care. At a low-resource tertiary hospital, this study assessed the quality of intrapartum care and adherence to locally-tailored clinical guidelines. Methods A non-participatory, structured, direct observation study was held at Mnazi Mmoja Hospital, Zanzibar, Tanzania, between October and November 2016. Women in active labour were followed and structure, processes of labour care and outcomes of care systematically recorded. Descriptive analyses were performed on the labour observations and compared to local guidelines and supplemented by qualitative findings. A Poisson regression analysis assessed factors affecting foetal heart rate monitoring (FHRM) guidelines adherence. Results 161 labouring women were observed. The nurse/midwife-to-labouring-women ratio of 1:4, resulted in doctors providing a significant part of intrapartum monitoring. Care during labour and two-thirds of deliveries was provided in a one-room labour ward with shared beds. Screening for privacy and communication of examination findings were done in 50 and 34%, respectively. For the majority, there was delayed recognition of labour progress and insufficient support in second stage of labour. While FHRM was generally performed suboptimally with a median interval of 105 (interquartile range 57–160) minutes, occurrence of an intrapartum risk event (non-reassuring FHR, oxytocin use or poor progress) increased assessment frequency significantly (rate ratio 1.32 (CI 1.09–1.58)). Conclusions Neither international nor locally-adapted standards of intrapartum routine care were optimally achieved. This was most likely due to a grossly inadequate capacity of birth attendants; without whom innovative interventions at birth are unlikely to succeed. This calls for international and local stakeholders to address the root causes of unsafe intrafacility care in low-resource settings, including the number of skilled birth attendants required for safe and respectful births.
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Affiliation(s)
- Natasha Housseine
- Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands. .,Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Huispost nr. STR 6.131, P.O. Box 85500, 3508, Utrecht, Netherlands. .,Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania.
| | - Marieke C Punt
- Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Ali Gharib Mohamed
- School of Health and Medical Science, State University of Zanzibar (SUZA), Zanzibar, Tanzania
| | - Said Mzee Said
- School of Health and Medical Science, State University of Zanzibar (SUZA), Zanzibar, Tanzania
| | - Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolaas P A Zuithoff
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Huispost nr. STR 6.131, P.O. Box 85500, 3508, Utrecht, Netherlands
| | - Tarek Meguid
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania.,School of Health and Medical Science, State University of Zanzibar (SUZA), Zanzibar, Tanzania
| | - Arie Franx
- Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Diederick E Grobbee
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Huispost nr. STR 6.131, P.O. Box 85500, 3508, Utrecht, Netherlands
| | - Joyce L Browne
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Huispost nr. STR 6.131, P.O. Box 85500, 3508, Utrecht, Netherlands
| | - Marcus J Rijken
- Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands.,Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Huispost nr. STR 6.131, P.O. Box 85500, 3508, Utrecht, Netherlands
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13
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Plotkin M, Kamala B, Ricca J, Fogarty L, Currie S, Kidanto H, Wheeler SB. Systematic review of Doppler for detecting intrapartum fetal heart abnormalities and measuring perinatal mortality in low- and middle-income countries. Int J Gynaecol Obstet 2020; 148:145-156. [PMID: 31646629 PMCID: PMC7004154 DOI: 10.1002/ijgo.13014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/16/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Using Doppler to improve detection of intrapartum fetal heart rate (FHR) abnormalities coupled with appropriate, timely intrapartum care in low- and middle-income countries (LMIC) can save lives. OBJECTIVE To review studies using Doppler to improve detection of intrapartum FHR abnormalities and intrapartum care quality in LMIC health facilities. SEARCH STRATEGY PubMed, Web of Science, Embase, Global Health, and Scopus were searched from inception to October 2018 by combining terms for Doppler, perinatal outcomes, and FHR monitoring. SELECTION CRITERIA Selected studies compared Doppler and Pinard stethoscope for detecting/monitoring intrapartum FHR, or described provider and maternal preferences for FHR monitoring in LMIC settings. DATA COLLECTION AND ANALYSIS Two team members independently screened and collected data. Risk of bias was assessed by Cochrane EPOC criteria. RESULTS Eleven studies from eight countries were included. Doppler was superior at detecting abnormal intrapartum FHR as compared with Pinard stethoscope, but was not associated with improved perinatal outcomes. Using Doppler on admission helped to accurately measure perinatal deaths occurring after facility admission. CONCLUSION Studies and program learning are needed to translate improved detection of FHR abnormalities to improved case management in LMICs. Doppler should be used to calculate a facility indicator of intrapartum care quality. PROSPERO registration: CRD42019121924.
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Affiliation(s)
- Marya Plotkin
- USAID's Maternal and Child Survival Program/JhpiegoWashingtonDCUSA
| | - Benjamin Kamala
- Faculty of Health SciencesUniversity of StavangerStavangerNorway
| | - Jim Ricca
- USAID's Maternal and Child Survival Program/JhpiegoWashingtonDCUSA
| | | | - Sheena Currie
- USAID's Maternal and Child Survival Program/JhpiegoWashingtonDCUSA
| | | | - Stephanie B. Wheeler
- Department of Health Policy and ManagementGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Moshiro R, Perlman JM, Mdoe P, Kidanto H, Kvaløy JT, Ersdal HL. Potential causes of early death among admitted newborns in a rural Tanzanian hospital. PLoS One 2019; 14:e0222935. [PMID: 31577806 PMCID: PMC6774517 DOI: 10.1371/journal.pone.0222935] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Approximately 40,000 newborns die each year in Tanzania. Regional differences in outcome are common. Reviewing current local data, as well as defining potential causal pathways leading to death are urgently needed, before targeted interventions can be implemented. OBJECTIVE To describe the clinical characteristics and potential causal pathways contributing to newborn death and determine the presumed causes of newborn mortality within seven days, in a rural hospital setting. METHODS Prospective observational study of admitted newborns born October 2014-July 2017. Information about labour/delivery and newborn management/care were recorded on data collection forms. Causes of deaths were predominantly based on clinical diagnosis. RESULTS 671 were admitted to a neonatal area. Reasons included prematurity n = 213 (32%), respiratory issues n = 209 (31%), meconium stained amniotic fluid with respiratory issues n = 115 (17%) and observation for < 24 hours n = 97 (14%). Death occurred in 124 infants. Presumed causes were birth asphyxia (BA) n = 59 (48%), prematurity n = 19 (15%), presumed sepsis n = 19 (15%), meconium aspiration syndrome (MAS) n = 13 (10%) and congenital abnormalities n = 14 (11%). More newborns who died versus survivors had oxygen saturation <60% on admission (37/113 vs 32/258; p≤0.001) respectively. Moderate hypothermia on admission was common i.e. deaths 35.1 (34.6-36.0) vs survivors 35.5 (35.0-36.0)°C (p≤0.001). Term newborns who died versus survivors were fourfold more likely to have received positive pressure ventilation after birth i.e. 4.57 (1.22-17.03) (p<0.02). CONCLUSION Intrapartum-related complications (BA, MAS), prematurity, and presumed sepsis were the leading causes of death. Intrapartum hypoxia, prematurity and attendant complications and presumed sepsis, are major pathways leading to death. Severe hypoxia and hypothermia upon admission are additional contributing factors. Strategies to identify fetuses at risk during labour e.g. improved fetal heart rate monitoring, coupled with timely interventions, and implementation of WHO interventions for preterm newborns, may reduce mortality in this low resource setting.
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Affiliation(s)
- Robert Moshiro
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Jeffrey M. Perlman
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States of America
| | - Paschal Mdoe
- Department of Obstetrics and Gynecology, Haydom Lutheran Hospital, Manyara, Tanzania
| | - Hussein Kidanto
- School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
- Research Department, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- Research Department, Stavanger University Hospital, Stavanger, Norway
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - Hege L. Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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15
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Mduma E, Kvaløy JT, Soreide E, Svensen E, Mdoe P, Perlman J, Johnson C, Kidanto HL, Ersdal HL. Frequent refresher training on newborn resuscitation and potential impact on perinatal outcome over time in a rural Tanzanian hospital: an observational study. BMJ Open 2019; 9:e030572. [PMID: 31562152 PMCID: PMC6773328 DOI: 10.1136/bmjopen-2019-030572] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Globally, perinatal mortality remains high, especially in sub-Saharan countries, mainly because of inadequate obstetric and newborn care. Helping Babies Breathe (HBB) resuscitation training as part of a continuous quality improvement (CQI) programme may improve outcomes. The aim of this study was to describe observed changes in perinatal survival during a 6-year period, while adjusting for relevant perinatal risk factors. SETTING Delivery rooms and operating theatre in a rural referral hospital in northern-central Tanzania providing comprehensive obstetric and basic newborn care 24 hours a day. The hospital serves approximately 2 million people comprising low social-economic status. PARTICIPANTS All newborns (n=31 122) born in the hospital from February 2010 through January 2017; 4893 were born in the 1-year baseline period (February 2010 through January 2011), 26 229 in the following CQI period. INTERVENTIONS The HBB CQI project, including frequent HBB training, was implemented from February 2011. This is a quality assessment analysis of prospectively collected observational data including patient, process and outcome measures of every delivery. Logistic regression modelling was used to construct risk-adjusted variable life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes in perinatal survival (primary outcome). RESULTS During the 6-year CQI period, the unadjusted number of extra lives saved according to the VLAD plot was 150 despite more women admitted with pregnancy and labour complications and more caesarean deliveries. After adjusting for these risk factors, the risk-adjusted VLAD plot indicated that an estimated 250 extra lives were saved. The risk-adjusted CUSUM plot confirmed a persistent and steady increase in perinatal survival. CONCLUSIONS The risk-adjusted statistical process control methods indicate significant improvement in perinatal survival after initiation of the HBB CQI project with continuous focus on newborn resuscitation training during the period, despite a concomitant increase in high-risk deliveries. Risk-adjusted VLAD and CUSUM are useful methods to quantify, illustrate and demonstrate persistent changes in outcome over time.
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Affiliation(s)
- Estomih Mduma
- Haydom Lutheran Hospital, Haydom, Tanzania
- Department of Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Jan Terje Kvaløy
- Research, Stavanger University Hospital, Stavanger, Norway
- Department of Mathematics and Physics, University of Stavanger Department of Mathematics and Natural Science, Stavanger, Norway
| | - Eldar Soreide
- Critical Care and Anaesthesiology Research Group, Department of Clinical Medicine, Stavanger University Hospital, Stavanger, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | | | - Paschal Mdoe
- Haydom Lutheran Hospital, Haydom, Tanzania
- Faculty of Social Science, University of Stavanger, Stavanger, Norway
| | - Jeffrey Perlman
- Pediatrics, Weill Cornell Medical College, New York Presbyterian Hospital, New York City, New York, USA
| | - Caroline Johnson
- Department of Mathematics and Natural Science, University of Stavanger, Stavanger, Norway
| | - Hussein Lessio Kidanto
- School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
- Helse Stavanger HF, Stavanger, Norway
| | - Hege Langli Ersdal
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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16
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Rivenes Lafontan S, Kidanto HL, Ersdal HL, Mbekenga CK, Sundby J. Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania. BMC Pregnancy Childbirth 2019; 19:165. [PMID: 31077139 PMCID: PMC6511185 DOI: 10.1186/s12884-019-2286-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 04/12/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Regular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania. METHODS A qualitative design was used to collect data. Five focus group discussions and 10 semi-structured in-depth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis. RESULTS The participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate. CONCLUSION The electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device's functions, its limitations and its procedures for use are well understood by users.
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Affiliation(s)
- Sara Rivenes Lafontan
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway
| | - Hussein L. Kidanto
- Medical College, East Africa, Aga Khan University, Dar es Salaam, Tanzania
- Department of Research, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway
| | - Hege L. Ersdal
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway
| | - Columba K. Mbekenga
- School of Nursing and Midwifery, Aga Khan University, Dar es Salaam, Tanzania
| | - Johanne Sundby
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway
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17
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Kamala B, Kidanto H, Dalen I, Ngarina M, Abeid M, Perlman J, Ersdal H. Effectiveness of a Novel Continuous Doppler (Moyo) Versus Intermittent Doppler in Intrapartum Detection of Abnormal Foetal Heart Rate: A Randomised Controlled Study in Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E315. [PMID: 30678354 PMCID: PMC6388236 DOI: 10.3390/ijerph16030315] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 01/25/2023]
Abstract
Background: Intrapartum foetal heart rate (FHR) monitoring is crucial for identification of hypoxic foetuses and subsequent interventions. We compared continuous monitoring using a novel nine-crystal FHR monitor (Moyo) versus intermittent single crystal Doppler (Doppler) for the detection of abnormal FHR. Methods: An unmasked randomised controlled study was conducted in a tertiary hospital in Tanzania (ClinicalTrials.gov Identifier: NCT02790554). A total of 2973 low-risk singleton pregnant women in the first stage of labour admitted with normal FHR were randomised to either Moyo (n = 1479) or Doppler (1494) arms. The primary outcome was the proportion of abnormal FHR detection. Secondary outcomes were time intervals in labour, delivery mode, Apgar scores, and perinatal outcomes. Results: Moyo detected abnormal FHR more often (13.3%) compared to Doppler (9.8%) (p = 0.002). Time intervals from admission to detection of abnormal FHR were 15% shorter in Moyo (p = 0.12) and from the detection of abnormal FHR to delivery was 36% longer in Moyo (p = 0.007) compared to the Doppler arm. Time from last FHR to delivery was 12% shorter with Moyo (p = 0.006) compared to Doppler. Caesarean section rates were higher with the Moyo device compared to Doppler (p = 0.001). Low Apgar scores (<7) at the 1st and 5th min were comparable between groups (p = 0.555 and p = 0.800). Perinatal outcomes (fresh stillbirths and 24-h neonatal deaths) were comparable at delivery (p = 0.497) and 24-h post-delivery (p = 0.345). Conclusions: Abnormal FHR detection rates were higher with Moyo compared to Doppler. Moyo detected abnormal FHR earlier than Doppler, but time from detection to delivery was longer. Studies powered to detect differences in perinatal outcomes with timely responses are recommended.
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Affiliation(s)
- Benjamin Kamala
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway.
- Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.
| | - Hussein Kidanto
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway.
- School of Medicine, Aga Khan University, P.O. Box 38129, Dar es Salaam, Tanzania.
| | - Ingvild Dalen
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway.
| | - Matilda Ngarina
- Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.
| | - Muzdalifat Abeid
- School of Medicine, Aga Khan University, P.O. Box 38129, Dar es Salaam, Tanzania.
| | - Jeffrey Perlman
- Department of Paediatrics, Weill Cornell Medicine, New York, NY 10065, USA.
| | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway.
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, 4011 Stavanger, Norway.
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Moshiro R, Mdoe P, Perlman JM. A Global View of Neonatal Asphyxia and Resuscitation. Front Pediatr 2019; 7:489. [PMID: 31850287 PMCID: PMC6902004 DOI: 10.3389/fped.2019.00489] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/07/2019] [Indexed: 01/31/2023] Open
Abstract
Birth asphyxia (BA), assumed to be related to intrapartum related hypoxia-ischemia, accounts for one million neonatal deaths annually. In the low resource setting BA is usually defined as a failure to initiate or sustain spontaneous breathing at birth. In the resource replete setting BA is a biochemical definition related to impaired gas exchange, due to interruption of placental blood flow (PBF). An umbilical arterial pH <7.00 referred to as severe fetal acidemia, reflects a degree of acidosis, where potential risk of adverse neurologic sequelae is increased. However, even with this degree of acidemia, the likelihood of mortality or adverse neurologic sequelae remains low. The aim is to focus on the definition of BA in the low resource setting, and compare it to the diagnosis in the resource replete setting, highlighting the importance of interruption of placental blood flow as it relates to morbidity and mortality. With asphyxia, the fetus aims to redistribute cardiac output to protect more vital organs e.g., brain, myocardium, and adrenal gland at the expense of decreased flow to organs such as kidney or intestine. In an experimental newborn model, animals subjected to asphyxia immediately develop primary apnea with bradycardia sustained blood pressure and normal pH. Recovery of respirations follows basic interventions, i.e. stimulation coupled with reversal of asphyxia. However, if asphyxia is sustained, secondary apnea manifests with bradycardia, hypotension, and pH <7.00. More intensive resuscitation including bag mask ventilation ± intubation ± cardio-pulmonary resuscitation may be necessary for correction upon reversal of asphyxia. Identification of a severely acidemic state (cord arterial pH < 7.00) in the newborn, may help to differentiate the truly asphyxiated intrapartum related cases that result in mortality, from those cases where mortality is related to delay in or ineffective basic resuscitation.
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Affiliation(s)
- Robert Moshiro
- Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Paschal Mdoe
- Department of Obstetrics and Gynecology, Haydom Lutheran Hospital, Manyara, Tanzania
| | - Jeffrey M Perlman
- Division of Newborn Medicine, Department of Pediatrics, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States
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Kamala BA, Ersdal HL, Dalen I, Abeid MS, Ngarina MM, Perlman JM, Kidanto HL. Implementation of a novel continuous fetal Doppler (Moyo) improves quality of intrapartum fetal heart rate monitoring in a resource-limited tertiary hospital in Tanzania: An observational study. PLoS One 2018; 13:e0205698. [PMID: 30308040 PMCID: PMC6181403 DOI: 10.1371/journal.pone.0205698] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/28/2018] [Indexed: 01/04/2023] Open
Abstract
Background Intrapartum Fetal Heart Rate (FHR) monitoring is crucial for the early detection of abnormal FHR, facilitating timely obstetric interventions and thus the potential reduction of adverse perinatal outcomes. We explored midwifery practices of intrapartum FHR monitoring pre and post implementation of a novel continuous automatic Doppler device (the Moyo). Methodology A pre/post observational study among low-risk pregnancies at a tertiary hospital was conducted from March to December 2016. In the pre-implementation period, intermittent monitoring was conducted with a Pinard stethoscope (March to June 2016, n = 1640 women). In the post-implementation period, Moyo was used for continuous FHR monitoring (July-December 2016, n = 2442 women). The primary outcome was detection of abnormal FHR defined as absent, FHR<120or FHR>160bpm. The secondary outcomes were rates of assessment/documentation of FHR, obstetric time intervals and intrauterine resuscitations. Chi-square test, Fishers exact test, t-test and Mann-Whitney U test were used in bivariate analysis whereas binary and multinomial logistic regression were used for multivariate. Results Moyo use was associated with greater detection of abnormal FHR (8.0%) compared with Pinard (1.6%) (p<0.001). There were higher rates of non-assessment/documentation of FHR pre- (45.7%) compared to post-implementation (2.2%) (p<0.001). At pre-implementation, 8% of deliveries had FHR documented as often as ≤ 60 minutes, compared to 51% post-implementation (p<0.001). Implementation of continuous FHR monitoring was associated with a shorter time interval from the last FHR assessment to delivery i.e. median (IQR) of 60 (30,100) to 45 (21,85) minutes (p<0.001); and shorter time interval between each FHR assessment i.e. from 150 (86,299) minutes to 60 (41,86) minutes (p<0.001). Caesarean section rates increased from 2.6 to 5.4%, and vacuum deliveries from 2.2 to 5.8% (both p<0.001). Perinatal outcomes i.e. fresh stillbirths and early neonatal deaths were similar between time periods. The study was limited by both lack of randomization and involvement of low-risk pregnant women with fewer adverse perinatal outcomes than would be expected in a high-risk population. Conclusion Implementation of the Moyo device, which continuously measures FHR, was associated with improved quality in FHR monitoring practices and the detection of abnormal FHR. These improvements led to more frequent and timely obstetric responses. Follow-up studies in a high-risk population focused on a more targeted description of the FHR abnormalities and the impact of intrauterine resuscitation is a critical next step in determining the effect on reducing perinatal mortality.
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Affiliation(s)
- Benjamin A. Kamala
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- * E-mail: ,
| | - Hege L. Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Ingvild Dalen
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Muzdalifat S. Abeid
- Department of Obstetrics and Gynecology, Temeke Regional Referral Hospital, Dar es Salaam, Tanzania
- School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
| | - Matilda M. Ngarina
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Jeffrey M. Perlman
- Department of Pediatrics, Weill Medical College, New York, New York, United States of America
| | - Hussein L. Kidanto
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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