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Shabani J, Masanja H, Kagoye S, Minja J, Bajaria S, Mlacha Y, Msuya S, Masoud M, Simba D, Pembe AB, Makuwani AM, Ismail H, Chacha M, Kumalija C, Boerma T, Hanson C. Quality of reporting and trends of emergency obstetric and neonatal care indicators: an analysis from Tanzania district health information system data between 2016 and 2020. BMC Pregnancy Childbirth 2023; 23:716. [PMID: 37805475 PMCID: PMC10559477 DOI: 10.1186/s12884-023-06028-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/24/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Routine health facility data provides the opportunity to monitor progress in quality and uptake of health care continuously. Our study aimed to assess the reliability and usefulness of emergency obstetric care data including temporal and regional variations over the past five years in Tanzania Mainland. METHODS Data were compiled from the routine monthly district reports compiled as part of the health management information systems for 2016-2020. Key indicators for maternal and neonatal care coverage, emergency obstetric and neonatal complications, and interventions indicators were computed. Assessment on reliability and consistency of reports was conducted and compared with annual rates and proportions over time, across the 26 regions in of Tanzania Mainland and by institutional delivery coverage. RESULTS Facility reporting was near complete with 98% in 2018-2020. Estimated population coverage of institutional births increased by 10% points from 71.2% to 2016 to 81.7% in 2020 in Tanzania Mainland, driven by increased use of dispensaries and health centres compared to hospitals. This trend was more pronounced in regions with lower institutional birth rates. The Caesarean section rate remained stable at around 10% of institutional births. Trends in the occurrence of complications such as antepartum haemorrhage, premature rupture of membranes, pre-eclampsia, eclampsia or post-partum bleeding were consistent over time but at low levels (1% of institutional births). Prophylactic uterotonics were provided to nearly all births while curative uterotonics were reported to be used in less than 10% of post-partum bleeding and retained placenta cases. CONCLUSION Our results show a mixed picture in terms of usefulness of the District Health Information System(DHIS2) data. Key indicators of institutional delivery and Caesarean section rates were plausible and provide useful information on regional disparities and trends. However, obstetric complications and several interventions were underreported thus diminishing the usefulness of these data for monitoring. Further research is needed on why complications and interventions to address them are not documented reliably.
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Affiliation(s)
| | | | - Sophia Kagoye
- National Institute for Medical Research, Mwanza, Tanzania
| | | | | | | | - Sia Msuya
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania
| | | | - Daudi Simba
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Andrea B Pembe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | | | | | | | - Claudia Hanson
- London School of Hygiene & Tropical Medicine, London, UK
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2
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Egal JA, Kiruja J, Litorp H, Osman F, Erlandsson K, Klingberg‐Allvin M. Incidence and causes of severe maternal outcomes in Somaliland using the sub-Saharan Africa maternal near-miss criteria: A prospective cross-sectional study in a national referral hospital. Int J Gynaecol Obstet 2022; 159:856-864. [PMID: 35490394 PMCID: PMC9790269 DOI: 10.1002/ijgo.14236] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/21/2022] [Accepted: 04/23/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe the incidence and causes of severe maternal outcomes and the unmet need for life-saving obstetric interventions among women admitted for delivery in a referral hospital in Somaliland. METHODS A prospective cross-sectional study was conducted from April 15, 2019 to March 31, 2020, with women admitted during pregnancy or childbirth or within 42 days after delivery. Data were collected using the World Health Organization (WHO) and sub-Saharan Africa (SSA) maternal near-miss (MNM) tools. Descriptive analysis was performed by computing frequencies, proportions, and ratios. RESULTS The MNM ratios were 56 (SSA criteria) and 13 (WHO criteria) per 1000 live births. The mortality index was highest among women with medical complications (63%), followed by obstetric hemorrhage (13%), pregnancy-related infection (10%), and hypertensive disorders (7.9%) according to the SSA MNM criteria. Most women giving birth received prophylactic oxytocin for postpartum hemorrhage prevention (97%), and most laparotomies (60%) for ruptured uterus were conducted after 3 h. CONCLUSION There is a need to improve the quality of maternal health services through implementation of evidence-based obstetric interventions and continuous in-service training for healthcare providers. Using the SSA MNM criteria could facilitate such preventive measures in this setting as well as similar low-resource contexts.
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Affiliation(s)
- Jama Ali Egal
- College of Medicine and Health ScienceUniversity of HargeisaHargeisaSomaliland,Institution of Health and WelfareDalarna UniversityDalarnaSweden
| | - Jonah Kiruja
- College of Medicine and Health ScienceUniversity of HargeisaHargeisaSomaliland,Institution of Health and WelfareDalarna UniversityDalarnaSweden
| | - Helena Litorp
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden,Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Fatumo Osman
- Institution of Health and WelfareDalarna UniversityDalarnaSweden,Department of Public Health and Caring ScienceUppsala UniversityUppsalaSweden
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3
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Firoz T, Trigo Romero CL, Leung C, Souza JP, Tunçalp Ö. Global and regional estimates of maternal near miss: a systematic review, meta-analysis and experiences with application. BMJ Glob Health 2022; 7:bmjgh-2021-007077. [PMID: 35387768 PMCID: PMC8987675 DOI: 10.1136/bmjgh-2021-007077] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 12/17/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Maternal near miss (MNM) is a useful means to examine quality of obstetric care. Since the introduction of the WHO MNM criteria in 2011, it has been tested and validated, and is being used globally. We sought to systematically review all available studies using the WHO MNM criteria to develop global and regional estimates of MNM frequency and examine its application across settings. Methods We conducted a systematic review by implementing a comprehensive literature search from 2011 to 2018 in six databases with no language restrictions. The predefined data collection tool included sections on study characteristics, frequency of near-miss cases and study quality. Meta-analysis was performed by regional groupings. Reported adaptations, modifications and remarks about application were extracted. Results 7292 articles were screened by title and abstract, and 264 articles were retrieved for full text review for the meta-analysis. An additional 230 articles were screened for experiences with application of the WHO MNM criteria. Sixty studies with near-miss data from 56 countries were included in the meta-analysis. The pooled global near-miss estimate was 1.4% (95% CI 0.4% to 2.5%) with regional variation in MNM frequency. Of the 20 studies that made adaptations to the criteria, 19 were from low-resource settings where lab-based criteria were adapted due to resource limitations. Conclusions The WHO MNM criteria have enabled the comparison of global and sub-national estimates of MNM frequency. There has been good uptake in low-resource countries but contextual adaptations are necessary.
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Affiliation(s)
- Tabassum Firoz
- Yale New Haven Health, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Carla Lionela Trigo Romero
- Department of Social Medicine, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, Brazil
| | - Clarus Leung
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - João Paulo Souza
- Department of Social Medicine, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, Brazil
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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4
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Drechsel KC, Adu-Bonsaffoh K, Olde Loohuis KM, Srofenyoh EK, Boateng D, Browne JL. Maternal near-miss and mortality associated with hypertensive disorders of pregnancy remote from term: A multicenter observational study in Ghana. AJOG GLOBAL REPORTS 2022; 2:100045. [PMID: 36275498 PMCID: PMC9564034 DOI: 10.1016/j.xagr.2021.100045] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Maternal death rates remain high in many low- and middle-income countries. Hypertensive disorders of pregnancy account for 18% of maternal mortality in Ghana. The maternal near-miss approach was designed to evaluate severe (acute) complications in pregnancy, which is useful to detect potential areas for clinical care improvement. OBJECTIVE This study aimed (1) to determine the incidence of severe maternal complications, maternal near-miss cases, and mortality cases associated with hypertensive disorders of pregnancy remote from term and (2) to assess the health system's performance indicators for the management of hypertensive disorders of pregnancy remote from term in middle-income country referral hospitals. STUDY DESIGN This study was nested in the ongoing Severe Preeclampsia adverse Outcome Triage study, a multicenter observational cohort study, and included women recruited from December 1, 2017, to May 31, 2020, from 5 referral hospitals in Ghana. Women aged >16 years, admitted to the hospital with hypertensive disorders of pregnancy, with gestational age between 26 and 34 weeks were eligible. Near miss was defined according to the World Health Organization and sub-Saharan African near-miss criteria. Descriptive statistics of pregnancy and maternal and perinatal outcomes up to 6 weeks after delivery of women with severe maternal outcomes were presented for maternal deaths and maternal near-miss casigurees and compared with that of women without severe maternal outcomes. The health system's maternal and perinatal performance indicators were calculated. RESULTS Overall, 447 women with hypertensive disorders of pregnancy were included in the analyses with a mean maternal age of 32 (±5.8) years and mean gestational age at recruitment of 30.5 (±2.4) weeks. Of these patients, 46 (10%) had gestational hypertension, 338 (76%) had preeclampsia, and 63 (14%) had eclampsia. There were 148 near-miss cases (33.1%) and 12 maternal deaths (2.7%). Severe maternal outcomes constituted complications from severe preeclampsia (80/160 [50%]) and eclampsia (63/160 [39.4%]). Concerning organ dysfunction, hematologic and respiratory dysfunctions constituted 59/160 [38.6%] and 23/160 [14.8%] respectively. Nearly all women had a cesarean delivery (347/447 [84%] and 140/160 [93%] in the severe maternal outcome group) and delivered prematurely (83%, with 178/379 [93%] at <32 weeks of gestation). Stillbirth and neonatal deaths occurred in 63 of 455 women (14%) and 81 of 392 women (19%), respectively, constituting a stillbirth ratio of 161 per 1000 live births and neonatal mortality rate of 207 per 1000 live births as there were 392 live births in this cohort. Overall, the intensive care unit admission rate was 12.7% (n=52/409); moreover, 45 of 52 women (86.5%) admitted to the intensive care unit had severe maternal outcomes. The maternal death ratio was 3100 per 100,000 live births, the maternal near-miss–to–mortality ratio was 12.3, and the mortality index was 8%. CONCLUSION Maternal near miss and maternal and perinatal mortalities were common in women with hypertensive disorders of pregnancy remote from term in referral hospitals in Ghana. Providing appropriate patient-centered and multidisciplinary quality care for these women is crucial in improving pregnancy outcomes. Context-tailored interventions should be considered in the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings. Further research on interventions to improve timely referral and reduce in-hospital delays in care provision is recommended to facilitate emergency care services for women with hypertensive emergencies.
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Affiliation(s)
- Katja C.E. Drechsel
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (Drs Drechsel, Adu-Bonsaffoh, Olde Loohuis, Boateng, and Browne)
| | - Kwame Adu-Bonsaffoh
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (Drs Drechsel, Adu-Bonsaffoh, Olde Loohuis, Boateng, and Browne)
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana (Dr Adu-Bonsaffoh)
- Department of Obstetrics and Gynaecology, Korle-Bu Teaching Hospital, Accra, Ghana (Dr Adu-Bonsaffoh)
- Corresponding author: Kwame Adu-Bonsaffoh, MD.
| | - Klaartje M. Olde Loohuis
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (Drs Drechsel, Adu-Bonsaffoh, Olde Loohuis, Boateng, and Browne)
| | - Emmanuel K. Srofenyoh
- Department of Obstetrics and Gynecology, Greater Accra Regional Hospital, Ghana Health Service, Accra, Ghana (Dr Srofenyoh)
| | - Daniel Boateng
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (Drs Drechsel, Adu-Bonsaffoh, Olde Loohuis, Boateng, and Browne)
| | - Joyce L. Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (Drs Drechsel, Adu-Bonsaffoh, Olde Loohuis, Boateng, and Browne)
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Jayaratnam S, Franklin R, de Costa C. A scoping review of maternal near miss assessment in Australia, New Zealand, South-East Asia and the South Pacific region: How, what, why and where to? Aust N Z J Obstet Gynaecol 2021; 62:198-213. [PMID: 34791649 DOI: 10.1111/ajo.13457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/05/2021] [Accepted: 10/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe maternal morbidity or maternal near miss (MNM) events can have significant consequences for individuals, their families and society and the study of these events may inform practices to reduce future adverse pregnancy outcomes. AIMS To review the scope of MNM studies undertaken in Australia, New Zealand, South-East Asia and the South Pacific region. MATERIALS AND METHODS A systematic search of four online databases (MEDLINE, EMBASE, SCOPUS and CINAHL) and the World Health Organization Library was conducted to identify all relevant studies published between 1 January 2011 and 31 December 2020. The studies were reviewed and included if they assessed MNM using a composite outcome or a predefined set of indicators. RESULTS The literature search yielded 143 articles of which 49 are included in this review. There were substantial differences in the monitoring approach to MNM in the Australasian region. Overall rates of MNM in the region ranged from two to 100/1000 births and the most common aetiologies identified were direct obstetric causes such as postpartum haemorrhage, pre-eclampsia and sepsis. Multidisciplinary review indicated a substantial number of MNM cases were preventable or amenable to improved management, mostly from a provider perspective. CONCLUSIONS Assessment of MNM is an important part of the evaluation of maternity care provision. Reaching a consensus on indicators and how best to collect information will allow a more discerning assessment of MNM including longer-term health outcomes, aspects of preventability and financial implications for health services.
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Affiliation(s)
- Skandarupan Jayaratnam
- Mater Mothers' Hospital, Brisbane, Queensland, Australia.,JCU College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Richard Franklin
- College of Public Health, Medical and Vet Sciences, James Cook University, Townsville, Queensland, Australia
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6
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Escobar M, Mosquera C, Hincapie MA, Nasner D, Carvajal JA, Maya J, De Mucio B, Sosa CG, Rojas JA. Diagnostic performance of two different maternal near-miss approaches in a High Obstetric Risk Unit. Women Health 2021; 61:723-736. [PMID: 34328063 DOI: 10.1080/03630242.2021.1959492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Maternal near-miss (MNM) is a maternal quality care indicator. The World Health Organization (WHO) defines it as a state in which a woman nearly dies but survives due to a complication during pregnancy, birth, or puerperium. The Latin American Federation of Obstetrics and Gynecology (FLASOG) and the Colombian National Health Institute (INS) established recommendations for the event's epidemiological surveillance; nonetheless, the operational definitions of the cases are different. This retrospective study examined the approaches of FLASOG and INS versus the WHO approach (gold standard) for the assessment of MNM in a high obstetric risk unit. Patients admitted with at least one criterion of the WHO, FLASOG, or INS approach for the definition of MNM from March 2016 to March 2017 were included. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were evaluated, as well as the Receiver Operating Characteristics (ROC) curve of the FLASOG and INS. MNM classification compared to WHO system as reference. The results highlight that the WHO classification establishes very high boundaries for some of the diagnostic criteria and the lack of standardization of the MNM criteria among the different proposals in Latin America hinders the applicability in Colombia and other countries with a similar situation.
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Affiliation(s)
- María Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Claudia Mosquera
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | | | - Daniela Nasner
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
| | - Javier Andrés Carvajal
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Juliana Maya
- Facultad de Ciencias de Salud, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Bremen De Mucio
- Latin American Center for Perinatology, Women and Reproductive Health, Pan American Health Organization/World Health Organization, Montevideo, Uruguay
| | - Claudio Gerardo Sosa
- Department of Obstetrics and Gynecology, School of Medicine, University of Uruguay, Montevideo, Uruguay
| | - José Antonio Rojas
- Intensive Care in Obstetric Research Group (GRICIO), Department of Obstetrics and Gynecology, University of Cartagena, Cartagena, Colombia
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7
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Atuhairwe S, Gemzell-Danielsson K, Byamugisha J, Kaharuza F, Tumwesigye NM, Hanson C. Abortion-related near-miss morbidity and mortality in 43 health facilities with differences in readiness to provide abortion care in Uganda. BMJ Glob Health 2021; 6:bmjgh-2020-003274. [PMID: 33547174 PMCID: PMC7871269 DOI: 10.1136/bmjgh-2020-003274] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction With a view to inform policy for improved postabortion care, we describe abortion-related near-miss and mortality by sociodemographic risk factors and management options by pregnancy trimester in Uganda. Methods This secondary data analysis used an adapted WHO near-miss methodology to collect cross-sectional maternal near-miss and abortion complications data at 43 health facilities in Central and Eastern Uganda in 2016–2017. We computed abortion severe morbidity, near-miss and mortality ratios per 100 000 live births, and described the proportion of cases that worsened to an abortion near-miss or death, stratified by geographical region and trimester. We tested for association between independent variables and abortion near-miss, and obtained prevalence ratios for association between second trimester near-miss and independent demographic and management indicators. We assessed health facility readiness for postabortion care provision in Central and Eastern regions. Results Of 3315 recorded severe abortion morbidity cases, 1507 were near-misses. Severe abortion morbidity, near-miss and mortality ratios were 2063, 938 and 23 per 100 000 live births, respectively. Abortion-related mortality ratios were 11 and 57 per 100 000 in Central and Eastern regions, respectively. Abortion near-miss cases were significantly associated with referral (p<0.001). Second trimester had greater abortion mortality than first trimester. Eastern region had greater abortion-related morbidity and mortality than Central region with facilities in the former characterised by inferior readiness to provide postabortion care. Conclusions Uganda has a major abortion near-miss morbidity and mortality; with mortality higher in the second trimester. Life-saving commodities are lacking especially in Eastern region compromising facility readiness for postabortion care provision.
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Affiliation(s)
- Susan Atuhairwe
- Department of Obstetrics and Gynaecology, Makerere University CHS, Kampala, Uganda .,Reproductive Endocrinology and Infertility, Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | | | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University CHS, Kampala, Uganda
| | - Frank Kaharuza
- Association of Obstetricians and Gynaecologists of Uganda, Kampala, Uganda
| | | | - Claudia Hanson
- Public Health Sciences, Karolinska Institute, Stockholm, Sweden.,Dept of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
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8
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Hanson C, Atuhairwe S, Lucy Atim J, Marrone G, Morris JL, Kaharuza F. Effects of the Helping Mothers Survive Bleeding after Birth training on near miss morbidity and mortality in Uganda: A cluster-randomized trial. Int J Gynaecol Obstet 2020; 152:386-394. [PMID: 32981091 PMCID: PMC7894512 DOI: 10.1002/ijgo.13395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 12/26/2022]
Abstract
Objective To assess the effect of Helping Mothers Survive Bleeding after Birth training on postpartum hemorrhage (PPH) near miss and case fatality rates in Uganda. Methods Training was evaluated using a cluster‐randomized design between June 2016 and September 2017 in 18 typical rural districts (clusters) in Eastern and Central Uganda of which nine districts were randomly assigned to the intervention. The main outcome was PPH near miss defined using the World Health Organization’s disease and management‐based approach. Interrupted time series analysis was performed to estimate the difference in the change of outcomes. Results Outcomes of 58 000 and 95 455 deliveries during the 6‐month baseline and 10‐month endline periods, respectively, were included. A reduction of PPH near misses was observed in the intervention compared to the comparison districts (difference‐in‐difference of slopes 4.19, 95% CI, –7.64 to –0.74); P<0.05). There was an increase in overall reported near miss cases (difference‐in‐difference 1.24, 95% CI, 0.37–2.10; P<0.001) and an increase in PPH case fatality rate (difference‐in‐difference 2.13, 95% CI, 0.14–4.12; P<0.05). Conclusion This pragmatic cluster‐randomized trial conducted in typical rural districts of Uganda indicated a reduction of severe PPH cases while case fatality did not improve, suggesting that this basic training needs to be complemented by additional measures for sustained mortality reduction. Trial registration: PACTR201604001582128.
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Affiliation(s)
- Claudia Hanson
- Department of Global Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Susan Atuhairwe
- Directorate of Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda.,Association of Obstetricians and Gynaecologists of Uganda, Kampala, Uganda
| | - Joyce Lucy Atim
- Mbale Regional Referral Hospital, Mbale, Uganda.,Uganda Nurses and Midwives Union, Kampala, Uganda
| | - Gaetano Marrone
- Department of Global Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Jessica L Morris
- FIGO (International Federation of Gynecology and Obstetrics), London, UK
| | - Frank Kaharuza
- Association of Obstetricians and Gynaecologists of Uganda, Kampala, Uganda.,Makerere University School of Public Health, Kampala, Uganda
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