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Knop MR, Nagashima-Hayashi M, Lin R, Saing CH, Ung M, Oy S, Yam ELY, Zahari M, Yi S. Impact of mHealth interventions on maternal, newborn, and child health from conception to 24 months postpartum in low- and middle-income countries: a systematic review. BMC Med 2024; 22:196. [PMID: 38750486 PMCID: PMC11095039 DOI: 10.1186/s12916-024-03417-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 05/01/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Mobile health (mHealth) technologies have been harnessed in low- and middle-income countries (LMICs) to address the intricate challenges confronting maternal, newborn, and child health (MNCH). This review aspires to scrutinize the effectiveness of mHealth interventions on MNCH outcomes during the pivotal first 1000 days of life, encompassing the period from conception through pregnancy, childbirth, and post-delivery, up to the age of 2 years. METHODS A comprehensive search was systematically conducted in May 2022 across databases, including PubMed, Cochrane Library, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), Web of Science, Scopus, PsycINFO, and Trip Pro, to unearth peer-reviewed articles published between 2000 and 2022. The inclusion criteria consisted of (i) mHealth interventions directed at MNCH; (ii) study designs, including randomized controlled trials (RCTs), RCT variations, quasi-experimental designs, controlled before-and-after studies, or interrupted time series studies); (iii) reports of outcomes pertinent to the first 1000 days concept; and (iv) inclusion of participants from LMICs. Each study was screened for quality in alignment with the Cochrane Handbook for Systematic Reviews of Interventions and the Joanne Briggs Institute Critical Appraisal tools. The included articles were then analyzed and categorized into 12 mHealth functions and outcome domain categories (antenatal, delivery, and postnatal care), followed by forest plot comparisons of effect measures. RESULTS From the initial pool of 7119 articles, we included 131 in this review, comprising 56 RCTs, 38 cluster-RCTs, and 37 quasi-experimental studies. Notably, 62% of these articles exhibited a moderate or high risk of bias. Promisingly, mHealth strategies, such as dispatching text message reminders to women and equipping healthcare providers with digital planning and scheduling tools, exhibited the capacity to augment antenatal clinic attendance and enhance the punctuality of child immunization. However, findings regarding facility-based delivery, child immunization attendance, and infant feeding practices were inconclusive. CONCLUSIONS This review suggests that mHealth interventions can improve antenatal care attendance and child immunization timeliness in LMICs. However, their impact on facility-based delivery and infant feeding practices varies. Nevertheless, the potential of mHealth to enhance MNCH services in resource-limited settings is promising. More context-specific implementation studies with rigorous evaluations are essential.
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Affiliation(s)
- Marianne Ravn Knop
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Michiko Nagashima-Hayashi
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Ruixi Lin
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Chan Hang Saing
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Mengieng Ung
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Sreymom Oy
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Esabelle Lo Yan Yam
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Marina Zahari
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Siyan Yi
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.
- KHANA Center for Population Health Research, Phnom Penh, Cambodia.
- Public Health Program, College of Education and Health Sciences, Touro University California, Vallejo, CA, USA.
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Vidler M, Kinshella MLW, Sevene E, Lewis G, von Dadelszen P, Bhutta Z. Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique. BMC Pregnancy Childbirth 2023; 23:748. [PMID: 37872504 PMCID: PMC10594808 DOI: 10.1186/s12884-023-06055-w] [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: 01/10/2023] [Accepted: 10/07/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. METHODS The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. RESULTS Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care. CONCLUSIONS There is a need to supplement the pioneering "Three Delays Framework" to include focusing on continuity of care and the "Four Critical Connection Points": (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys. TRIAL REGISTRATION NCT01911494, Date Registered 30/07/2013.
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Affiliation(s)
- Marianne Vidler
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada.
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Esperanca Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Centro de Investigação Em Saúde da Manhiça, Manhiça, Mozambique
| | | | | | - Zulfiqar Bhutta
- Department of Pediatrics, Aga Khan University, Karachi, Pakistan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
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The 2017 American College of Cardiology and American Heart Association blood pressure categories in the second half of pregnancy-a systematic review of their association with adverse pregnancy outcomes. Am J Obstet Gynecol 2023:S0002-9378(23)00017-0. [PMID: 36657559 DOI: 10.1016/j.ajog.2023.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023]
Abstract
OBJECTIVE A relationship between the 2017 American College of Cardiology and American Heart Association blood pressure thresholds and adverse pregnancy outcomes has been reported, but few studies have explored the diagnostic test properties of these cutoffs when used within pregnancy. DATA SOURCES Electronic databases were searched (2017-2021) for measurements of blood pressure in pregnancy at >20 weeks, classified according to the 2017 American College of Cardiology and American Heart Association criteria, and their relationship with pregnancy outcomes. Blood pressure was categorized as "normal" (systolic blood pressure of <120 mm Hg and diastolic blood pressure of <80 mm Hg), "elevated blood pressure" (systolic blood pressure of 120-129 mm Hg and diastolic blood pressure of <80 mm Hg), "stage 1 hypertension" (systolic blood pressure of 130-139 mm Hg and/or diastolic blood pressure of 80-89 mm Hg), and "stage 2 hypertension" (systolic blood pressure of ≥140 mm Hg and/or diastolic blood pressure of ≥90 mm Hg). STUDY ELIGIBILITY CRITERIA Studies recording blood pressure at or above 20 weeks gestation were included. METHODS Meta-analyses were used to investigate the strength of the association between blood pressure cutoffs and adverse outcomes, and the diagnostic test properties were calculated accounting for gestation. RESULTS There were 12 included studies. The American College of Cardiology or American Heart Association blood pressure categories were determined from peak blood pressures at any point from 20 weeks of gestation and at specific gestational ages (20-27, 28-32, or 33-36 weeks of gestation), as available. A higher (vs normal) blood pressure category was consistently associated with adverse outcomes. The strength of association between blood pressure categories and adverse outcomes was the greatest with "stage 2 hypertension" (blood pressure of ≥140/90 mm Hg). The results were similar when peak blood pressure was reported either at any time from 20 weeks of gestation or within gestational age groups (as above). No blood pressure category was useful as a diagnostic "rule-out test" for adverse outcomes, as all negative likelihood ratios were ≥0.2. Only "stage 2 hypertension" was useful as a "rule in-test," with positive likelihood ratios of ≥5.0, for maximum blood pressure at >20 weeks of gestation for preeclampsia and blood pressure within any gestational age groups for preeclampsia, eclampsia, stroke, maternal death, and stillbirth. CONCLUSION From 20 weeks of gestation, blood pressure thresholds of 140 mm Hg (systolic) and 90 mm Hg (diastolic) were useful in identifying women at increased risk of adverse pregnancy outcomes, irrespective of the specific gestational age at blood pressure measurement. Lowering the blood pressure threshold for abnormal blood pressure at >20 weeks of gestation would not assist clinicians in identifying women at heightened maternal or perinatal risk. No American College of Cardiology or American Heart Association blood pressure threshold can provide reassurance that women are unlikely to develop adverse outcomes.
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Amosse F, Kinshella MLW, Boene H, Sharma S, Nhamirre Z, Tchavana C, Magee LA, von Dadelszen P, Sevene E, Vidler M, Munguambe K. The development and implementation of a community engagement strategy to improve maternal health in southern Mozambique. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001106. [PMID: 36962956 PMCID: PMC10021229 DOI: 10.1371/journal.pgph.0001106] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/03/2023] [Indexed: 02/01/2023]
Abstract
Delays to seek medical help can contribute to maternal deaths particularly in community settings at home or on the road to a health facility. Community engagement (CE) can improve care-seeking behaviours and complements community-based interventions strengthening maternal health. The purpose of this paper is to describe the process undertaken to develop and implement a large-scale community engagement strategy in rural southern Mozambique. The CE strategy was developed within the context of the "Community-Level Interventions for Pre-eclampsia" (NCT01911494) conducted between 2015-2017 in southern Mozambique. Key CE messages included pregnancy complications and their warning signs, including pre-eclampsia and eclampsia, as well as emergency readiness, birth preparedness, decision-making mechanisms, transport options and information about the trial. CE meeting logs were used to record quantitative and qualitative information on demographic data and feedback. Quantitative data was analyzed using RStudio (RStudio Inc, Boston, United States) and community feedback was qualitatively analyzed on NVivo12 (QSR International, Melbourne, Australia). CE activities reached 19,169 participants during 4,239 meetings. CE activities were reported to be well received by community members though there was a relatively lower participation of men (3565 /18.6%). The use of recognized local leaders and personnel, such as community leaders, nurses and community health workers, allowed for greater acceptance of CE activities and maximized coverage of health messages in the community setting. Our CE strategy was effective in integrating maternal health promoting activities in routine care of community health workers and nurses in the area. Understanding district differences, engaging husbands, partners, mothers-in-law and community-level decision-makers to build local support for maternal health and flexibility to tailor messages to local needs were important in developing sustainable forms of CE. Better strategies are needed to effectively engage men in maternal health promotion who were less available due to working outside of the home or neighbourhoods.
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Affiliation(s)
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Helena Boene
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Women & Children's Health, King's Collage London, London, United Kingdom
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Women & Children's Health, King's Collage London, London, United Kingdom
| | - Esperança Sevene
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Khatia Munguambe
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
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Slade LJ, Mistry HD, Bone JN, Wilson M, Blackman M, Syeda N, von Dadelszen P, Magee LA. American College of Cardiology and American Heart Association blood pressure categories-a systematic review of the relationship with adverse pregnancy outcomes in the first half of pregnancy. Am J Obstet Gynecol 2022; 228:418-429.e34. [PMID: 36241079 DOI: 10.1016/j.ajog.2022.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/02/2022] [Accepted: 10/04/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE A relationship between the 2017 American College of Cardiology and American Heart Association blood pressure thresholds and adverse pregnancy outcomes has been reported, but few studies have explored the diagnostic test properties of these cutoffs. DATA SOURCES We systematically searched electronic databases (from 2017 to 2021) for reports of blood pressure measurements in pregnancy, classified according to 2017 American College of Cardiology and American Heart Association criteria, and their relationship with pregnancy outcomes. STUDY ELIGIBILITY CRITERIA Studies recording blood pressure at <20 weeks gestation were included. METHODS Meta-analyses were used to investigate the strength of the association between blood pressure cutoffs and adverse outcomes, and the diagnostic test properties were calculated. RESULTS Of 23 studies included, there was a stepwise relationship between the American College of Cardiology and American Heart Association blood pressure category (when compared with normal blood pressure of <120/80 mmHg) and the strength of the association with preeclampsia. The category of elevated blood pressure had a risk ratio of 2.0 (95% prediction interval, 0.8-4.8), the stage 1 hypertension category had a risk ratio of 3.0 (95% prediction interval, 1.1-8.5), and the stage 2 hypertension category had a risk ratio of 7.9 (95% prediction interval, 1.8-35.1). Between-study variability was related to the magnitude of the association with stronger relationships in larger studies at low risk of bias and with unselected populations with multiple routine blood pressure measurements. None of the systolic blood pressure measurements of <120 mmHg, <130/80 mmHg, or <140/90 mmHg were useful to rule out the development of preeclampsia (all negative likelihood ratios >0.2). Only a blood pressure measurement of ≥140/90 mmHg was a good predictor for the development of preeclampsia (positive likelihood ratio, 5.95). The findings were similar for other outcomes. CONCLUSION Although a blood pressure of 120 to 140 over 80 to 90 mmHg at <20 weeks gestation is associated with a heightened risk for preeclampsia and adverse pregnancy outcomes and may assist in risk prediction in multivariable modelling, lowering the diagnostic threshold for chronic hypertension would not assist clinicians in identifying women at heightened risk.
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Affiliation(s)
- Laura J Slade
- Department of Obstetrics and Gynaecology, Women's and Children's Hospital, Adelaide, Australia.
| | - Hiten D Mistry
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Jeffrey N Bone
- British Columbia Children's Hospital Research Institute, The University of British Columbia, Vancouver, Canada; Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, Canada
| | - Milly Wilson
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Maya Blackman
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Nuhaat Syeda
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
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Mbuthia GW, Magutah K, Pellowski J. Approaches and outcomes of community health worker's interventions for hypertension management and control in low-income and middle-income countries: systematic review. BMJ Open 2022; 12:e053455. [PMID: 35365519 PMCID: PMC8977767 DOI: 10.1136/bmjopen-2021-053455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To critically appraise the scope, content and outcomes of community health worker (CHW) interventions designed to reduce blood pressure (BP) in low-income and middle-income countries (LMICs). METHOD We performed a database search (PUBMED, EMBASE, CINAHL, PsycINFO, OpenGrey, Cochrane Central Trials Register and Cochrane Database of Systematic Reviews) to identify studies in LMICs from 2000 to 2020. Eligible studies were interventional studies published in English and reporting CHW interventions for management of BP in LMICs. Two independent reviewers screened the titles, abstracts and full texts of publications for eligibility and inclusion. Relevant information was extracted from these studies using a tailored template. Risk of bias was assessed using the Cochrane collaboration risk of bias tool. Qualitative synthesis of results was done through general summary of the characteristics and findings of each study. We also analysed the patterns of interventions and their outcomes across the studies. Results were presented in form of narrative and tables. RESULTS Of the 1557 articles identified, 14 met the predefined criteria. Of these, 12 were cluster randomised trials whereas two were pretest/post-test studies. The CHW interventions were mainly community-based and focused on behaviour change for promoting BP control among hypertensive patients as well as healthy individuals. The interventions had positive effects in the BP reduction, linkage to care, treatment adherence and in reducing cardivascular-disease risk level. DISCUSSION AND CONCLUSION The current review is limited in that, a meta-analysis to show the overall effect of CHW interventions in the management of hypertension was not possible due to the diversity of the interventions, and outcomes of the studies included in the review. Summarised outcomes of individual studies showed CHW enhanced the control and management of hypertension. Further studies are needed to indicate the impact and cost-effectiveness of CHW-led interventions in the control and management of hypertension in LMICs.
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Affiliation(s)
- Grace Wambura Mbuthia
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Karani Magutah
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Jennifer Pellowski
- International Health Institute, School of Public Health, Brown University, Providence, Rhode Island, USA
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Avoka CK, McArthur E, Banke-Thomas A. Interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub-Saharan Africa: A systematic review. Trop Med Int Health 2022; 27:494-509. [PMID: 35322914 PMCID: PMC9321161 DOI: 10.1111/tmi.13747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective The objective of the study was to review the evidence on interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub‐Saharan Africa (SSA). Methods A systematic search of PubMed, Embase, Cochrane Register and CINAHL Plus was conducted to identify studies on obstetric emergency referral in SSA. Studies were included based on pre‐defined eligibility criteria. Details of reported referral interventions were extracted and categorised. The Joanna Biggs Institute Critical Appraisal checklists were used for quality assessment of included studies. A formal narrative synthesis approach was used to summarise findings guided by the WHO's referral system flow. Results A total of 14 studies were included, with seven deemed high quality. Overall, 7 studies reported referral decision‐making interventions including training programmes for health facility and community health workers, use of a triage checklist and focused obstetric ultrasound, which resulted in improved knowledge and practice of recognising danger signs for referral. 9 studies reported on referral communication using mobile phones and referral letters/notes, resulting in increased communication between facilities despite telecommunication network failures. Referral decision making and communication interventions achieved a perceived reduction in maternal mortality. 2 studies focused on referral feedback, which improved collaboration between health facilities. Conclusion There is limited evidence on how well referral interventions work in sub‐Saharan Africa, and limited consensus regarding the framework underpinning the expected change. This review has led to the proposition of a logic model that can serve as the base for future evaluations which robustly expose the (in)efficiency of referral interventions.
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Affiliation(s)
- Cephas K Avoka
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, London, UK.,LSE Health, London School of Economics and Political Science, London, UK
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Kinshella MLW, Boene H, Sevene E, Valá A, Sharma S, Vidler M, Magee LA, von Dadelszen P, Munguambe K, Payne BA. How Gender Influenced the Experience of Using a mHealth Intervention in Rural Mozambique: Secondary Qualitative Analysis of Community Health Worker Survey Data. Front Glob Womens Health 2022; 3:661000. [PMID: 35284909 PMCID: PMC8907823 DOI: 10.3389/fgwh.2022.661000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background The mixed-gender community health worker (CHW) program in Mozambique is a window into the different experiences that male and female CHWs may face in their work. The objective of this study is to investigate how gender influenced the experiences of community health workers using the PIERS on the Move (POM) mHealth app in Mozambique. Methods This is a secondary analysis by gender of health care workers involved in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial (NCT01911494). A structured survey with 10 open-ended questions was used to elicit CHW experiences using the POM app. Data collection took place in 2017 after completion of the CLIP trial. This analysis examined emergent themes to consider how experiences may have been shaped by health worker gender. Results Of the 43 CHWs who used the POM app, there were 31 (72%) women and 12 (28%) men. Gender differences emerged in descriptions of how using POM increased their value and respect by pregnant women and community members. Fifty-eight percent of female CHWs (18/31) said that POM positively influenced their status in the community in comparison to 33% of their male counterparts (4/12). While the small sample sizes, particularly of male CHWs who used POM, preclude conclusions, these findings were supported by qualitative results. Female CHWs tended to elaborate more about community perceptions of their increased value and status as health care providers than male CHWs. Conclusion CHWs work within existing gender norms. While gender norms are perceived to support the comfort of women to speak to another woman about their maternal and child health issues, gender norms also work against female CHWs as their professionalism may be questioned more than for their male counterparts. CHW's narratives suggested that the mHealth intervention was valued beyond the technology itself because it also added symbolic clinical value and demonstrated a tangible investment in their professional capacities, which may have been especially appreciated by the female CHWs.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Helena Boene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Anifa Valá
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Laura A. Magee
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Beth A. Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Beth A. Payne
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Boene H, Valá A, Kinshella MLW, La M, Sharma S, Vidler M, Magee LA, von Dadelszen P, Sevene E, Munguambe K, Payne BA. Implementation of the PIERS on the Move mHealth Application From the Perspective of Community Health Workers and Nurses in Rural Mozambique. Front Glob Womens Health 2021; 2:659582. [PMID: 34816216 PMCID: PMC8593977 DOI: 10.3389/fgwh.2021.659582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background:mHealth is increasingly regarded as having the potential to support service delivery by health workers in low-resource settings. PIERS on the Move (POM) is a mobile health application developed to support community health workers identification and management of women at risk of adverse outcomes from pre-eclampsia. The objective of this study was to evaluate the impact of using POM in Mozambique on community health care workers' knowledge and self-efficacy related to caring for women with pre-eclampsia, and their perception of usefulness of the tool to inform implementation. Method: An evaluation was conducted for health care workers in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial from 2014 to 2016 in Maputo and Gaza provinces (NCT01911494). A structured survey was designed using themes from the Technology Acceptance Model, which describes the likelihood of adopting the technology based on perceived usefulness and perceived ease of use. Surveys were conducted in Portuguese and translated verbatim to English for analysis. Preliminary analysis of open-ended responses was conducted to develop a coding framework for full qualitative analysis, which was completed using NVivo12 (QSR International, Melbourne, Australia). Results: Overall, 118 community health workers (44 intervention; 74 control) and 55 nurses (23 intervention; 32 control) were surveyed regarding their experiences. Many community health workers found the POM app easy to use (80%; 35/44), useful in guiding their activities (68%; 30/44) and pregnant women received their counseling more seriously because of the POM app (75%; 33/44). Almost a third CHWs reported some challenges using the POM app (30%; 13/44), including battery depletion after a full day's activity. Community health workers reported increases in knowledge about pre-eclampsia and other pregnancy complications and increases in confidence, comfort and capacity to advise women on health conditions and deliver services. Nurses recognized the increased capacity of community health workers and were more confident in their clinical and technological skills to identify women at risk of obstetric complications. Conclusions: Many of the community health workers reported that POM improved knowledge, self-efficacy and strengthened relationships with the communities they serve and local nurses. This helped to strengthen the link between community and health facility. However, findings highlight the need to consider program and systematic challenges to implementation.
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Affiliation(s)
- Helena Boene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Anifa Valá
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Michelle La
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique.,Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique.,Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Beth A Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
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Hoodbhoy Z, Sheikh SS, Qureshi R, Memon J, Raza F, Kinshella MLW, Bone JN, Vidler M, Sharma S, Payne BA, Magee LA, von Dadelszen P, Bhutta ZA. Role of community engagement in maternal health in rural Pakistan: Findings from the CLIP randomized trial. J Glob Health 2021; 11:04045. [PMID: 34326995 PMCID: PMC8285765 DOI: 10.7189/jogh.11.04045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Community-based strategies to promote maternal health can help raise awareness of pregnancy danger signs and preparations for emergencies. The objective of this study was to assess change in birth preparedness and complication readiness (BPCR) and pregnant women’s knowledge about pre-eclampsia as part of community engagement (CE) activities in rural Pakistan during the Community Level Interventions for Pre-eclampsia (CLIP) Trial. Methods The CLIP Trial was a cluster randomized controlled trial that aimed to reduce maternal and perinatal morbidity and mortality using CE strategies alongside mobile health-supported care by community health care providers. CE activities engaged pregnant women at their homes and male stakeholders through village meetings in Hyderabad and Matiari in Sindh, Pakistan. These sessions covered pregnancy complications, particularly pre-eclampsia/eclampsia, BPCR and details of the CLIP intervention package. BPCR was assessed using questions related to transport arrangement, permission for care, emergency funds, and choice of facility birth attendant for delivery during quarterly household surveys. Outcomes were assessed via multilevel logistic regression with adjustment for relevant confounders with effects summarized as odds ratios and 95% confidence intervals. Results There were 15 137 home-based CE sessions with pregnant women and families (n = 46 614) and 695 village meetings with male stakeholders (n = 7784) over two years. The composite outcomes for BPCR and pre-eclampsia knowledge did not differ significantly between trial arms. However, CE activities were associated with improved pre-eclampsia knowledge in some areas. Specifically, pregnant women in the intervention clusters were twice as likely to know that seizures could be a complication of pregnancy (odds ratio (OR) = 2.17, 95% confidence interval (CI) = 1.11, 4.23) and 2.5 times more likely to know that high blood pressure is potentially life-threatening during pregnancy (OR = 2.52, 95% CI = 1.31, 4.83) vs control clusters. Conclusions The findings suggested that a CE strategy for male and female community stakeholders increased some measures of knowledge regarding complications of pre-eclampsia in low-resource settings. However, the effect of this intervention on long-term health outcomes needs further study. Trial registration Clinical Trials.gov – INCT01911494.
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Affiliation(s)
- Zahra Hoodbhoy
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sana Sadiq Sheikh
- Department of Obstetrics and Gynecology, The Aga Khan University, Karachi, Pakistan
| | - Rahat Qureshi
- Department of Obstetrics and Gynecology, The Aga Khan University, Karachi, Pakistan
| | - Javed Memon
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Farrukh Raza
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey N Bone
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Sumedha Sharma
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Beth A Payne
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Magee
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, London, UK
| | - Peter von Dadelszen
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, London, UK
| | - Zulfiqar A Bhutta
- Center of Excellence in Women & Child Health, The Aga Khan University, Pakistan and East Africa, Karachi, Pakistan.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
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11
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Sevene E, Boene H, Vidler M, Valá A, Macuacua S, Augusto O, Fernandes Q, Bique C, Macete E, Sidat M, von Dadelszen P, Munguambe K. Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique. Reprod Health 2021; 18:145. [PMID: 34229709 PMCID: PMC8259411 DOI: 10.1186/s12978-021-01192-x] [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: 03/16/2020] [Accepted: 06/24/2021] [Indexed: 11/21/2022] Open
Abstract
Background Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals. Method The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals. Results Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility. Conclusions This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level. Maternal mortality is an important public health problem in Mozambique. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. We conducted a study to describe the feasibility of task-sharing the screening and initiation of management for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and to document healthcare facility preparedness to respond to referrals. The study was done to inform a future intervention trial known as the Community-Level Interventions for Pre-eclampsia (CLIP) study. We interviewed community health workers, women, various community groups, health care providers, and policymakers and assessed health facilities in Maputo and Gaza provinces, Mozambique. Our results showed that community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they were not trained or equipped to provide obstetric emergencies care prior to referral. Nurses at primary health facilities were supportive of task-sharing with community health workers; however, some barriers mentioned include a lack of equipment, shortage of supervisors, and irregular drug availability. Local stakeholders emphasized the need for comprehensive training and supervision of community health workers to take on new tasks. Task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia was deemed feasible at the community level in southern Mozambique, but still, to be addressed some health system level barriers to the management of pregnancies complications.
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Affiliation(s)
- Esperança Sevene
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique. .,Department of Physiologic Science, Clinical Pharmacology, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique.
| | - Helena Boene
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and The Child and Family Research Unit, University of British Columbia, Vancouver, BC, Canada
| | - Anifa Valá
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Salésio Macuacua
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Orvalho Augusto
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.,Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Cassimo Bique
- Ministério da Saúde, Maputo, Mozambique.,Hospital Central de Maputo, Maputo, Mozambique
| | - Eusébio Macete
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.,Ministério da Saúde, Maputo, Mozambique
| | - Mohsin Sidat
- Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Khátia Munguambe
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.,Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
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12
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Blood pressure thresholds in pregnancy for identifying maternal and infant risk: a secondary analysis of Community-Level Interventions for Pre-eclampsia (CLIP) trial data. LANCET GLOBAL HEALTH 2021; 9:e1119-e1128. [PMID: 34237265 PMCID: PMC8295039 DOI: 10.1016/s2214-109x(21)00219-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/15/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
Background Blood pressure measurement is a marker of antenatal care quality. In well resourced settings, lower blood pressure cutoffs for hypertension are associated with adverse pregnancy outcomes. We aimed to study the associations between blood pressure thresholds and adverse outcomes and the diagnostic test properties of these blood pressure cutoffs in low-resource settings. Methods We did a secondary analysis of data from 22 intervention clusters in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials (NCT01911494) in India (n=6), Mozambique (n=6), and Pakistan (n=10). We included pregnant women aged 15–49 years (12–49 years in Mozambique), identified in their community by trained community health workers, who had data on blood pressure measurements and outcomes. The trial was unmasked. Maximum blood pressure was categorised as: normal blood pressure (systolic blood pressure [sBP] <120 mm Hg and diastolic blood pressure [dBP] <80 mm Hg), elevated blood pressure (sBP 120–129 mm Hg and dBP <80 mm Hg), stage 1 hypertension (sBP 130–139 mm Hg or dBP 80–89 mm Hg, or both), non-severe stage 2 hypertension (sBP 140–159 mm Hg or dBP 90–109 mm Hg, or both), or severe stage 2 hypertension (sBP ≥160 mm Hg or dBP ≥110 mm Hg, or both). We classified women according to the maximum blood pressure category reached across all visits for the primary analyses. The primary outcome was a maternal, fetal, or neonatal mortality or morbidity composite. We estimated dose-response relationships between blood pressure category and adverse outcomes, as well as diagnostic test properties. Findings Between Nov 1, 2014, and Feb 28, 2017, 21 069 women (6067 in India, 4163 in Mozambique, and 10 839 in Pakistan) contributed 103 679 blood pressure measurements across the three CLIP trials. Only women with non-severe or severe stage 2 hypertension, as discrete diagnostic categories, experienced more adverse outcomes than women with normal blood pressure (risk ratios 1·29–5·88). Using blood pressure categories as diagnostic thresholds (women with blood pressure within the category or any higher category vs those with blood pressure in any lower category), dose-response relationships were observed between increasing thresholds and adverse outcomes, but likelihood ratios were informative only for severe stage 2 hypertension and maternal CNS events (likelihood ratio 6·36 [95% CI 3·65–11·07]) and perinatal death (5·07 [3·64–7·07]), particularly stillbirth (8·53 [5·63–12·92]). Interpretation In low-resource settings, neither elevated blood pressure nor stage 1 hypertension were associated with maternal, fetal, or neonatal mortality or morbidity adverse composite outcomes. Only the threshold for severe stage 2 hypertension met diagnostic test performance standards. Current diagnostic thresholds for hypertension in pregnancy should be retained. Funding University of British Columbia, the Bill & Melinda Gates Foundation.
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13
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Bone JN, Khowaja AR, Vidler M, Payne BA, Bellad MB, Goudar SS, Mallapur AA, Munguambe K, Qureshi RN, Sacoor C, Sevene E, Frederix GWJ, Bhutta ZA, Mitton C, Magee LA, von Dadelszen P. Economic and cost-effectiveness analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials in India, Pakistan and Mozambique. BMJ Glob Health 2021; 6:bmjgh-2020-004123. [PMID: 34031134 PMCID: PMC8149358 DOI: 10.1136/bmjgh-2020-004123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 12/11/2022] Open
Abstract
Background The Community-Level Interventions for Pre-eclampsia (CLIP) trials (NCT01911494) in India, Pakistan and Mozambique (February 2014–2017) involved community engagement and task sharing with community health workers for triage and initial treatment of pregnancy hypertension. Maternal and perinatal mortality was less frequent among women who received ≥8 CLIP contacts. The aim of this analysis was to assess the incremental costs and cost-effectiveness of the CLIP intervention overall in comparison to standard of care, and by PIERS (Pre-eclampsia Integrated Estimate of RiSk) On the Move (POM) mobile health application visit frequency. Methods Included were all women enrolled in the three CLIP trials who had delivered with known outcomes by trial end. According to the number of POM-guided home contacts received (0, 1–3, 4–7, ≥8), costs were collected from annual budgets and spending receipts, with inclusion of family opportunity costs in Pakistan. A decision tree model was built to determine the cost-effectiveness of the intervention (vs usual care), based on the primary clinical endpoint of years of life lost (YLL) for mothers and infants. A probabilistic sensitivity analysis was used to assess uncertainty in the cost and clinical outcomes. Results The incremental per pregnancy cost of the intervention was US$12.66 (India), US$11.51 (Pakistan) and US$13.26 (Mozambique). As implemented, the intervention was not cost-effective due largely to minimal differences in YLL between arms. However, among women who received ≥8 CLIP contacts (four in Pakistan), the probability of health system and family (Pakistan) cost-effectiveness was ≥80% (all countries). Conclusion The intervention was likely to be cost-effective for women receiving ≥8 contacts in Mozambique and India, and ≥4 in Pakistan, supporting WHO guidance on antenatal contact frequency. Trial registration number NCT01911494.
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Affiliation(s)
- Jeffrey N Bone
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Asif R Khowaja
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Beth A Payne
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mrutyunjaya B Bellad
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Shivaprasad S Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Ashalata A Mallapur
- S Nijalingappa Medical College and HSK Hospital and Research Centre, Bagalkot, Karnataka, India
| | - Khatia Munguambe
- Centro de Investigação em Saúde de Manhiça, Manhiça, Maputo, Mozambique
| | - Rahat N Qureshi
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
| | - Charfudin Sacoor
- Centro de Investigação em Saúde de Manhiça, Manhiça, Maputo, Mozambique
| | - Esperanca Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Maputo, Mozambique.,Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Zulfiqar A Bhutta
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Craig Mitton
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada.,Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada .,Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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14
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Joiner A, Lee A, Chowa P, Kharel R, Kumar L, Caruzzo NM, Ramirez T, Reynolds L, Sakita F, Van Vleet L, von Isenburg M, Yaffee AQ, Staton C, Vissoci JRN. Access to care solutions in healthcare for obstetric care in Africa: A systematic review. PLoS One 2021; 16:e0252583. [PMID: 34086753 PMCID: PMC8177460 DOI: 10.1371/journal.pone.0252583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/18/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context. METHODS The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach. FINDINGS A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention. INTERPRETATION Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.
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Affiliation(s)
- Anjni Joiner
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Austin Lee
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Phindile Chowa
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ramu Kharel
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Lekshmi Kumar
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Nayara Malheiros Caruzzo
- Physical Education Department, State University of Maringá, Maringá, PR, United States of America
| | - Thais Ramirez
- Duke Global Health Institute, Durham, NC, United States of America
| | - Lindy Reynolds
- University of Alabama School of Public Health, Birmingham, AL, United States of America
| | - Francis Sakita
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Lee Van Vleet
- Durham County Emergency Services, Durham, NC, United States of America
| | - Megan von Isenburg
- Medical Center Library, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Anna Quay Yaffee
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Catherine Staton
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
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15
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Adepoju AA, Vidler M, Akadri AA, Jaiyesimi E, Nwankpa CC, Odubena OO, Sharma S, Li L, Tu D, Drebit S, Payne B, Akeju DO, Bhutta Z, Magee LA, Nathan HL, Shennan AH, Sotunsa J, Adetoro OO, von Dadelszen P, Dada OA, Soyinka O. The ability and safety of community-based health workers to safely initiate lifesaving therapies for pre-eclampsia in Ogun State, Nigeria: An analysis of 260 community treatments with MgSO 4 and/or methyldopa. Pregnancy Hypertens 2021; 25:179-184. [PMID: 34175582 DOI: 10.1016/j.preghy.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/31/2020] [Accepted: 05/08/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate community-based health workers' ability to identify cases of hypertension in pregnancy, safely deliver methyldopa and magnesium sulphate and make referrals when appropriate. STUDY DESIGN This was part of Nigeria Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial (NCT01911494). Community-based Health Workers (CHW) recruited pregnant women from five Local Government Areas (clusters) and used mobile health aid for clinical assessment of pre-eclampsia. MAIN OUTCOME MEASURES The primary outcome was the number of adverse events that occurred after the administration of magnesium sulphate and/or methyldopa to pregnant women by CHWs. FINDINGS Of 8790 women receiving mobile health-guided care, community-based health workers in Nigeria provided 309 women with hypertension (4.2% of delivered women), and safely administered 142 doses of intramuscular magnesium sulphate. Community Heath Extension Workers (CHEWs) and nurses gave fifty-two and sixty-seven doses of intramuscular magnesium sulphate respectively, twenty-three doses were given by other health care workers (midwives, community health officers, health assistants). The high rate of administration by nurses can be explained by turf protection as well as their seniority within the health system. Also, CHEWs and nurses gave 124 doses of oral methyldopa and 126 urgent referrals were completed. There were no complications related to administration of treatment or referral. INTERPRETATION These findings demonstrate the ability of community-based health workers to safely administer methyldopa and intramuscular magnesium sulphate. The use of task-sharing, therefore, could drastically reduce the three delays (triage, transport and treatment) associated with high maternal mortality and morbidity in rural communities in low- and middle-income countries.
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Affiliation(s)
- Akinmade A Adepoju
- Centre for Research in Reproductive Health, Sagamu, Ogun State, Nigeria.
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339 West 28th Avenue, Vancouver, British Columbia V5Z 4H4, Canada
| | - Adebayo A Akadri
- Department of Obstetrics and Gynaecology, Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria
| | - Ebun Jaiyesimi
- Centre for Research in Reproductive Health, Sagamu, Ogun State, Nigeria
| | - Chimaobi C Nwankpa
- Department of Obstetrics and Gynaecology, Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria
| | - Oluwafayokemi O Odubena
- Department of Obstetrics and Gynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-341 West 28th Avenue, Vancouver, British Columbia V5Z 4H4, Canada
| | - Larry Li
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-337 West 28th Avenue, Vancouver, British Columbia V5Z 4H4, Canada
| | - Domena Tu
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339 West 28th Avenue, Vancouver, British Columbia V5Z 4H4, Canada
| | - Sharla Drebit
- BC Emergency Medicine Network, Department of Emergency Medicine, University of British Columbia, Rm 11235 11th Floor, 2775 Laurel St, Vancouver, British Columbia V5Z 1M9, Canada
| | - Beth Payne
- School of Population and Public Health, University of British Columbia, Women's Health Research Institute, Rm H203 - West 28th Avenue, Vancouver, British Columbia V5Z 4H4, Canada
| | - David O Akeju
- Department of Sociology, University of Lagos, Lagos, Nigeria
| | - Zulfiqar Bhutta
- Program for Global Pediatric Research, Hospital for Sick Children, Toronto, Canada; Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Hannah L Nathan
- Department to Women and Children's Health, King's College London, London, UK
| | - Andrew H Shennan
- Department to Women and Children's Health, King's College London, London, UK
| | - John Sotunsa
- Department of Obstetrics and Gynaecology, Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria
| | | | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Olukayode A Dada
- Centre for Research in Reproductive Health, Sagamu, Ogun State, Nigeria
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von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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17
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Magee LA, Bone J, Owasil SB, Singer J, Lee T, Bellad MB, Goudar SS, Logan AG, Macuacua SE, Mallapur AA, Nathan HL, Qureshi RN, Sevene E, Shennan AH, Valá A, Vidler M, Bhutta ZA, von Dadelszen P. Pregnancy Outcomes and Blood Pressure Visit-to-Visit Variability and Level in Three Less-Developed Countries. Hypertension 2021; 77:1714-1722. [PMID: 33775120 PMCID: PMC8284372 DOI: 10.1161/hypertensionaha.120.16851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine (L.A.M., H.L.N., A.H.S., P.v.D.), King's College London, United Kingdom.,Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute (L.A.M., J.B., M.V., P.v.D.)
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute (L.A.M., J.B., M.V., P.v.D.)
| | - Salwa Banoo Owasil
- GKT School of Biomedical Sciences (S.B.O.), King's College London, United Kingdom
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (J.S., T.L.), University of British Columbia, Vancouver, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (J.S., T.L.), University of British Columbia, Vancouver, Canada
| | - Mrutunjaya B Bellad
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India (M.B.B., S.S.G.)
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India (M.B.B., S.S.G.)
| | | | - Salésio E Macuacua
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique (S.E.M., E.S., A.V.)
| | - Ashalata A Mallapur
- S Nijalingappa Medical College, Hanagal Shree Kumareshwar Hospital and Research Centre, Bagalkote, Karnataka, India (A.A.M.)
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine (L.A.M., H.L.N., A.H.S., P.v.D.), King's College London, United Kingdom
| | - Rahat N Qureshi
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan (R.N.Q., Z.A.B.)
| | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique (S.E.M., E.S., A.V.).,Department of Physiological Sciences, Clinical Pharmacology, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique (E.S.)
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine (L.A.M., H.L.N., A.H.S., P.v.D.), King's College London, United Kingdom
| | - Anifa Valá
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique (S.E.M., E.S., A.V.)
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute (L.A.M., J.B., M.V., P.v.D.)
| | - Zulfiqar A Bhutta
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan (R.N.Q., Z.A.B.).,Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada (Z.A.B.)
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine (L.A.M., H.L.N., A.H.S., P.v.D.), King's College London, United Kingdom.,Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute (L.A.M., J.B., M.V., P.v.D.)
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18
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von Dadelszen P, Bhutta ZA, Sharma S, Bone J, Singer J, Wong H, Bellad MB, Goudar SS, Lee T, Li J, Mallapur AA, Munguambe K, Payne BA, Qureshi RN, Sacoor C, Sevene E, Vidler M, Magee LA. The Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials in Mozambique, Pakistan, and India: an individual participant-level meta-analysis. Lancet 2020; 396:553-563. [PMID: 32828187 PMCID: PMC7445426 DOI: 10.1016/s0140-6736(20)31128-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 11/18/2019] [Accepted: 05/01/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND To overcome the three delays in triage, transport and treatment that underlie adverse pregnancy outcomes, we aimed to reduce all-cause adverse outcomes with community-level interventions targeting women with pregnancy hypertension in three low-income countries. METHODS In this individual participant-level meta-analysis, we de-identified and pooled data from the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trials in Mozambique, Pakistan, and India, which were run in 2014-17. Consenting pregnant women, aged 12-49 years, were recruited in their homes. Clusters, defined by local administrative units, were randomly assigned (1:1) to intervention or control groups. The control groups continued local standard of care. The intervention comprised community engagement and existing community health worker-led mobile health-supported early detection, initial treatment, and hospital referral of women with hypertension. For this meta-analysis, as for the original studies, the primary outcome was a composite of maternal or perinatal outcome (either maternal, fetal, or neonatal death, or severe morbidity for the mother or baby), assessed by unmasked trial surveillance personnel. For this analysis, we included all consenting participants who were followed up with completed pregnancies at trial end. We analysed the outcome data with multilevel modelling and present data with the summary statistic of adjusted odds ratios (ORs) with 95% CIs (fixed effects for maternal age, parity, maternal education, and random effects for country and cluster). This meta-analysis is registered with PROSPERO, CRD42018102564. FINDINGS Overall, 44 clusters (69 330 pregnant women) were randomly assigned to intervention (22 clusters [36 008 pregnancies]) or control (22 clusters [33 322 pregnancies]) groups. 32 290 (89·7%) pregnancies in the intervention group and 29 698 (89·1%) in the control group were followed up successfully. Median maternal age of included women was 26 years (IQR 22-30). In the intervention clusters, 6990 group and 16 691 home-based community engagement sessions and 138 347 community health worker-led visits to 20 819 (57·8%) of 36 008 women (of whom 11 095 [53·3%] had a visit every 4 weeks) occurred. Blood pressure and dipstick proteinuria were assessed per protocol. Few women were eligible for methyldopa for severe hypertension (181 [1%] of 20 819) or intramuscular magnesium sulfate for pre-eclampsia (198 [1%]), of whom most accepted treatment (162 [89·5%] of 181 for severe hypertension and 133 [67·2%] of 198 for pre-eclampsia). 1255 (6%) were referred to a comprehensive emergency obstetric care facility, of whom 864 (82%) accepted the referral. The primary outcome was similar in the intervention (7871 [24%] of 32 290 pregnancies) and control clusters (6516 [22%] of 29 698; adjusted OR 1·17, 95% CI 0·90-1·51; p=0·24). No intervention-related serious adverse events occurred, and few adverse effects occurred after in-community treatment with methyldopa (one [2%] of 51; India only) and none occurred after in-community treatment with magnesium sulfate or during transport to facility. INTERPRETATION The CLIP intervention did not reduce adverse pregnancy outcomes. Future community-level interventions should expand the community health worker workforce, assess general (rather than condition-specific) messaging, and include health system strengthening. FUNDING University of British Columbia, a grantee of the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada.
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Hubert Wong
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Mrutyunjaya B Bellad
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Tang Lee
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Jing Li
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Ashalata A Mallapur
- S Nijalingappa Medical College, Hanagal Shree Kumareshwar Hospital and Research Centre, Bagalkote, Karnataka, India
| | - Khátia Munguambe
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique; Department of Physiological Sciences, Clinical Pharmacology, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Beth A Payne
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Rahat N Qureshi
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Esperança Sevene
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Department of Physiological Sciences, Clinical Pharmacology, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
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