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Olapeju B, Bride M, Gutman JR, Wolf K, Wabwire S, Atobrah D, Babanawo F, Akrofi OO, Atta-Obeng C, Soro BK, Touré F, Shekarau E, Hendrickson ZM. WHO antenatal care policy and prevention of malaria in pregnancy in sub-Saharan Africa. Malar J 2024; 23:218. [PMID: 39044194 PMCID: PMC11264419 DOI: 10.1186/s12936-024-05037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 07/07/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND The WHO 2016 antenatal care (ANC) policy recommends at least eight antenatal contacts during pregnancy. This study assessed ANC8 uptake following policy implementation and explored the relationship between ANC attendance and intermittent preventive treatment in pregnancy (IPTp) coverage in sub-Saharan Africa following the rollout of the World Health Organization (WHO) 2016 ANC policy, specifically, to assess differences in IPTp uptake between women attending eight versus four ANC contacts. METHODS A secondary analysis of data from 20 sub-Saharan African countries with available Demographic Health and Malaria Indicator surveys from 2018 to 2023 was performed. The key variables were the number of ANC contacts and IPTp doses received during a participant's last completed pregnancy in the past two years. Pooled crude and multivariable logistic regression models were used to explore factors associated with attendance of at least four or eight ANC contacts as well as receipt of at least three doses of IPTp during pregnancy. RESULTS Overall, only a small proportion of women (median = 3.9%) completed eight or more ANC contacts (ANC8 +). Factors significantly associated with increased odds of ANC8 + included early ANC attendance (AOR: 4.61: 95% CI 4.30-4.95), literacy (AOR: 1.20; 95% CI 1.11-1.29), and higher wealth quintile (AOR: 3.03; 95% CI 2.67-3.44). The pooled estimate across all countries showed a very slight increase in the odds of IPTp3 + among women with eight (AOR: 1.06; 95% CI 1.00-1.12) compared to those with four contacts. In all but two countries, having eight instead of four ANC contacts did not confer significantly greater odds of receiving three or more doses of IPTp (IPTp3 +), except in Ghana (AOR: 1.67; 95% CI 1.38-2.04) and Liberia (AOR: 1.43; 95% CI 1.18-1.72). CONCLUSION Eight years after the WHO ANC policy recommendation, all countries still had sub-optimal ANC8 + coverage rates. This paper is a call to action to actualize the vision of the WHO and the global malaria community of a malaria free world. Policies to improve ANC and IPTp coverage should be operationalized with clear actionable guidance and local ownership. Study findings can be used to inform multi-level policy, programmatic, and research recommendations to optimize ANC attendance and malaria in pregnancy prevention, thus improving maternal and child health outcomes, including the reduction of malaria in pregnancy.
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Affiliation(s)
- Bolanle Olapeju
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Michael Bride
- Johns Hopkins Center for Communication Programs, Baltimore, MD, USA
| | - Julie R Gutman
- Malaria Branch, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Scolastica Wabwire
- Division of Reproductive and Maternal Health, Ministry of Health, Nairobi, Kenya
| | - Deborah Atobrah
- Centre for Gender Studies and Advocacy, Institute of African Studies, University of Ghana, Accra, Ghana
| | | | | | | | | | - Fady Touré
- National Malaria Control Programme, Ministry of Health, Bamako, Mali
| | | | - Zoé M Hendrickson
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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Tesha GE, Makwaruzi S, Haws R, Mostel J, Lusasi A, Lazaro S, Mwaikambo S, Chacky F, Reaves E, Kitojo C, Serbantez N, Tetteh G, Wolf K, Oseni L. Understanding Antenatal Care Service Quality for Malaria in Pregnancy through Supportive Supervision Data in Tanzania. Am J Trop Med Hyg 2024; 110:56-65. [PMID: 38320309 PMCID: PMC10919228 DOI: 10.4269/ajtmh.23-0399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/01/2023] [Indexed: 02/08/2024] Open
Abstract
Malaria in pregnancy (MiP) is associated with maternal anemia, spontaneous abortion, and infant and maternal death. In Tanzania, MiP service data are collected through routine Malaria Services and Data Quality Improvement (MSDQI) supportive supervision rounds at antenatal care (ANC) facilities. Using structured assessment tools, the U.S. President's Malaria Initiative Impact Malaria Project reviewed two annual rounds of MSDQI data (492 facilities in 2021 and 522 facilities in 2022), including ANC records and client satisfaction interviews. We assessed coverage of key MiP care components, used logistic regression to analyze uptake of the recommended three or more doses of intermittent preventive treatment in pregnancy (IPTp3+), and assessed client satisfaction. Coverage of most MiP care components exceeded 80%; however, only 38% of women received all components. Odds of receiving IPTp3+ were much lower among late ANC initiators than among those who initiated ANC during their first trimester (odds ratio [OR], 0.46; 95% CI, 0.38-0.57). Uptake of IPTp3+ increased almost exponentially by number of ANC visits. Women with seven visits were 30 times more likely than those with three visits to receive IPTp3+ (OR, 30.71; 95% CI, 11.33-83.22). Just 54% of clients had anemia screening and only 46% received IPTp3+. Client satisfaction with services and provider communication was high (98% and 97%, respectively); only 8% of client visits exceeded 3 hours. Increased ANC visits could boost IPTp3+ coverage. Routine MSDQI supportive supervision data are useful to assess quality of care, identify service delivery gaps, and guide policies to improve quality of MiP services.
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Affiliation(s)
- Goodluck Elias Tesha
- U.S. President’s Malaria Initiative Impact Malaria Project, Dar es Salaam, Tanzania
| | - Stella Makwaruzi
- U.S. President’s Malaria Initiative Impact Malaria Project, Dar es Salaam, Tanzania
| | - Rachel Haws
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jadmin Mostel
- U.S. President’s Malaria Initiative Impact Malaria Project, Washington, District of Columbia
| | - Abdallah Lusasi
- Ministry of Health, National Malaria Control Program, Dodoma, Tanzania
| | - Samwel Lazaro
- Ministry of Health, National Malaria Control Program, Dodoma, Tanzania
| | | | - Frank Chacky
- Ministry of Health, National Malaria Control Program, Dodoma, Tanzania
| | - Erik Reaves
- U.S. President’s Malaria Initiative, U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | - Chonge Kitojo
- U.S. President’s Malaria Initiative, United States Agency for International Development, Dar es Salaam, Tanzania
| | - Naomi Serbantez
- U.S. President’s Malaria Initiative, United States Agency for International Development, Dar es Salaam, Tanzania
| | - Gladys Tetteh
- U.S. President’s Malaria Initiative Impact Malaria Project, Washington, District of Columbia
| | - Katherine Wolf
- U.S. President’s Malaria Initiative Impact Malaria Project, Washington, District of Columbia
| | - Lolade Oseni
- U.S. President’s Malaria Initiative Impact Malaria Project, Washington, District of Columbia
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Cormick G, Moraa H, Zahroh RI, Allotey J, Rocha T, Peña-Rosas JP, Qureshi ZP, Hofmeyr GJ, Mistry H, Smits L, Vogel JP, Palacios A, Gwako GN, Abalos E, Larbi KK, Carroli G, Riley R, Snell KI, Thorson A, Young T, Betran AP, Thangaratinam S, Bohren MA. Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review. BMJ Open 2023; 13:e070677. [PMID: 38135336 DOI: 10.1136/bmjopen-2022-070677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVES Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia. DESIGN Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach. DATA SOURCES MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022. ELIGIBILITY CRITERIA We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators. RESULTS Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium. CONCLUSION Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions. PROSPERO REGISTRATION NUMBER CRD42021239143.
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Affiliation(s)
- Gabriela Cormick
- Centro de Investigaciones en Epidemiología y Salud Pública (Consejo Nacional de Investigaciones Científicas y Técnicas- CONICET), Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
- Universidad Nacional de La Matanza, San Justo, Provincia de Buenos Aires, Argentina
| | | | - Rana Islamiah Zahroh
- Gender and Women's Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Allotey
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Centre (BRC), University Hospitals Birmingham, Birmingham, UK
| | - Thaís Rocha
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | | | - G Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand Faculty of Health Sciences, East London, Eastern Cape, South Africa
- University of Botswana, Gaborone, Botswana
| | - Hema Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Luc Smits
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands
| | - Joshua Peter Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Alfredo Palacios
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Centre for Health Economics, University of York, York, UK
| | | | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | | | - Guillermo Carroli
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Santa Fe, Argentina
| | - Richard Riley
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | - Anna Thorson
- Human Reproduction Program/World Health Organization (Geneva), Geneva, Switzerland
| | - Taryn Young
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Dept. of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Ana Pilar Betran
- 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, Geneve, Switzerland
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Centre (BRC), University Hospitals Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Meghan A Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Tamrat T, Setiyawati YD, Barreix M, Gayatri M, Rinjani SO, Pasaribu MP, Geissbuhler A, Shankar AH, Tunçalp Ö. Exploring perceptions and operational considerations for use of a smartphone application to self-monitor blood pressure in pregnancy in Lombok, Indonesia: protocol for a qualitative study. BMJ Open 2023; 13:e073875. [PMID: 38110387 DOI: 10.1136/bmjopen-2023-073875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal deaths globally and require close monitoring of blood pressure (BP) to mitigate potential adverse effects. Despite the recognised need for research on self-monitoring of blood pressure (SMBP) among pregnant populations, there are very few studies focused on low and middle income contexts, which carry the greatest burden of HDPs. The study aims to understand the perceptions, barriers, and operational considerations for using a smartphone software application to perform SMBP by pregnant women in Lombok, Indonesia. METHODS AND ANALYSIS This study includes a combination of focus group discussions, in-depth interviews and workshop observations. Pregnant women will also be provided with a research version of the smartphone BP application to use in their home and subsequently provide feedback on their experiences. The study will include pregnant women with current or past HDP, their partners and the healthcare workers involved in the provision of antenatal care services within the catchment area of six primary healthcare centres. Data obtained from the interviews and observations will undergo thematic analyses using a combination of both inductive and deductive approaches. ETHICS AND DISSEMINATION The study was approved by the World Health Organization (WHO) and Human Reproduction Programme (HRP) Research Project Review Panel and WHO Ethical Review Committee (A65932) as well as the Health Research Ethics Committee, Faculty of Medicine, Universitas Mataram in Indonesia (004/UN18/F7/ETIK/2023).Findings will be disseminated through research publications and communicated to the Lombok district health offices. The analyses from this study will also inform the design of a subsequent impact evaluation.
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Affiliation(s)
- Tigest Tamrat
- 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
- University of Geneva, Geneva, Switzerland
| | | | - Maria Barreix
- 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
| | - Mergy Gayatri
- Summit Institute for Development, Mataram, Indonesia
- Brawijaya University, Malang, Indonesia
| | | | | | | | - Anuraj H Shankar
- Summit Institute for Development, Mataram, Indonesia
- Oxford University Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | - 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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Kuliya-Gwarzo A, Tancred T, Gordon D, Bates I, Raven J. Maternal anaemia care in Kano state, Nigeria: an exploratory qualitative study of experiences of uptake and provision. F1000Res 2023; 12:288. [PMID: 38434670 PMCID: PMC10905168 DOI: 10.12688/f1000research.130980.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 03/05/2024] Open
Abstract
Background Maternal anaemia (anaemia in pregnancy, childbirth, and the postpartum period) remains a persistent challenge, particularly in Kano State, Nigeria, which has the highest prevalence of maternal anaemia globally, at 72%. Methods We conducted a qualitative study in Murtala Muhammad Specialist Hospital in Kano State, Nigeria. We aimed to identify factors constraining uptake and provision of maternal anaemia care, exploring perspectives across different stakeholders. We carried out 10 key informant interviews with policymakers and hospital managers, 28 in-depth interviews with healthcare providers and pregnant women using antenatal services and four focus group discussions with pregnant women's husbands and mothers-in-law. Data were analysed thematically. Results Issues with provision include a lack of provider training and guidelines specific to maternal anaemia and blood transfusion, insufficient staff to meet increasing demand, and inadequate resources. Issues with uptake include the inability to afford informal user fees, distrust in health services and the blood transfusion process, and a lack of understanding of the causes, consequences, and treatment for anaemia, resulting in poor uptake of care and adherence to treatment. Conclusions This study recommends the implementation of standardized guidelines and training sessions to better support healthcare providers in offering quality services and increasing funding allocated to supporting maternal anaemia care. Education initiatives for service users and the public are also recommended to build public trust in health services and to improve understanding of maternal anaemia.
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Affiliation(s)
| | - Tara Tancred
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Daniel Gordon
- Physiotherapy, Brunel University, London, UB8 3PH, UK
| | - Imelda Bates
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Joanna Raven
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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Festo C, Vannevel V, Ali H, Tamrat T, Mollel GJ, Hlongwane T, Fahmida KA, Alland K, Barreix M, Mehrtash H, Silva R, Thwin SS, Mehl G, Labrique AB, Masanja H, Tunçalp Ӧ. Accuracy of a smartphone application for blood pressure estimation in Bangladesh, South Africa, and Tanzania. NPJ Digit Med 2023; 6:69. [PMID: 37069209 PMCID: PMC10107587 DOI: 10.1038/s41746-023-00804-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/13/2023] [Indexed: 04/19/2023] Open
Abstract
Undetected and unmonitored hypertension carries substantial mortality and morbidity, especially during pregnancy. We assessed the accuracy of OptiBPTM, a smartphone application for estimating blood pressure (BP), across diverse settings. The study was conducted in community settings: Gaibandha, Bangladesh and Ifakara, Tanzania for general populations, and Kalafong Provincial Tertiary Hospital, South Africa for pregnant populations. Based on guidance from the International Organization for Standardization (ISO) 81,060-2:2018 for non-invasive BP devices and global consensus statement, we compared BP measurements taken by two independent trained nurses on a standard auscultatory cuff to the BP measurements taken by a research version of OptiBPTM called CamBP. For ISO criterion 1, the mean error was 0.5 ± 5.8 mm Hg for the systolic blood pressure (SBP) and 0.1 ± 3.9 mmHg for the diastolic blood pressure (DBP) in South Africa; 0.8 ± 7.0 mmHg for the SBP and -0.4 ± 4.0 mmHg for the DBP in Tanzania; 3.3 ± 7.4 mmHg for the SBP and -0.4 ± 4.3 mmHg for the DBP in Bangladesh. For ISO criterion 2, the average standard deviation of the mean error per subject was 4.9 mmHg for the SBP and 3.4 mmHg for the DBP in South Africa; 6.3 mmHg for the SBP and 3.6 mmHg for the DBP in Tanzania; 6.4 mmHg for the SBP and 3.8 mmHg for the DBP in Bangladesh. OptiBPTM demonstrated accuracy against ISO standards in study populations, including pregnant populations, except in Bangladesh for SBP (criterion 2). Further research is needed to improve performance across different populations and integration within health systems.
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Affiliation(s)
- Charles Festo
- Ifakara Health Institute, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Valerie Vannevel
- South African Medical Research Council Maternal and Infant Health Care Strategies Unit, Pretoria, South Africa
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
- Department of Obstetrics and Gynaecology, Kalafong Provincial Tertiary Hospital, Pretoria, South Africa
| | - Hasmot Ali
- The JiVitA Maternal and Child Health and Nutrition Research Project, Nasirabad, Keranipara, Rangpur, 5400, Bangladesh
| | - Tigest Tamrat
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Getrud J Mollel
- Ifakara Health Institute, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Tsakane Hlongwane
- South African Medical Research Council Maternal and Infant Health Care Strategies Unit, Pretoria, South Africa
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
- Department of Obstetrics and Gynaecology, Kalafong Provincial Tertiary Hospital, Pretoria, South Africa
| | - Kaniz A Fahmida
- The JiVitA Maternal and Child Health and Nutrition Research Project, Nasirabad, Keranipara, Rangpur, 5400, Bangladesh
| | - Kelsey Alland
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - María Barreix
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Ronaldo Silva
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Soe Soe Thwin
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Garrett Mehl
- Department of Digital Health and Innovations, World Health Organization, Geneva, Switzerland
| | - Alain B Labrique
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Digital Health and Innovations, World Health Organization, Geneva, Switzerland
| | - Honorati Masanja
- Ifakara Health Institute, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Ӧzge Tunçalp
- UNDP/UNFPA/UNICEF/World Bank Special Program 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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Maluleke K, Musekiwa A, Kgarosi K, Gregor EM, Dlangalala T, Nkambule S, Mashamba-Thompson T. A Scoping Review of Supply Chain Management Systems for Point of Care Diagnostic Services: Optimising COVID-19 Testing Capacity in Resource-Limited Settings. Diagnostics (Basel) 2021; 11:diagnostics11122299. [PMID: 34943536 PMCID: PMC8700402 DOI: 10.3390/diagnostics11122299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/14/2021] [Accepted: 11/17/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Point of care (POC) testing has enabled rapid coronavirus disease 2019 (COVID-19) diagnosis in resource-limited settings with limited laboratory infrastructure and high disease burden. However, the accessibility of the tests is not optimal in these settings. This scoping review mapped evidence on supply chain management (SCM) systems for POC diagnostic services to reveal evidence that can help guide future research and inform the improved implementation of SARS-CoV-2 POC diagnostics in resource-limited settings. Methodology: This scoping review was guided by an adapted version of the Arksey and O’Malley methodological framework. We searched the following electronic databases: Medline Ovid, Medline EBSCO, Scopus, PubMed, PsychInfo, Web of Science and EBSCOHost. We also searched grey literature in the form of dissertations/theses, conference proceedings, websites of international organisations such as the World Health Organisation and government reports. A search summary table was used to test the efficacy of the search strategy. The quality of the included studies was appraised using the mixed method appraisal tool (MMAT) version 2018. Results: We retrieved 1206 articles (databases n = 1192, grey literature n = 14). Of these, 31 articles were included following abstract and full-text screening. Fifteen were primary studies conducted in LMICs, and 16 were reviews. The following themes emerged from the included articles: availability and accessibility of POC diagnostic services; reasons for stockouts of POC diagnostic tests (procurement, storage, distribution, inventory management and quality assurance) and human resources capacity in POC diagnostic services. Of the 31 eligible articles, 15 underwent methodological quality appraisal with scores between 90% and 100%. Conclusions: Our findings revealed limited published research on SCM systems for POC diagnostic services globally. We recommend primary studies aimed at investigating the barriers and enablers of SCM systems for POC diagnostic services for highly infectious pathogens such SARS-CoV-2 in high disease-burdened settings with limited laboratory infrastructures.
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Affiliation(s)
- Kuhlula Maluleke
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa; (A.M.); (T.D.)
- Correspondence:
| | - Alfred Musekiwa
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa; (A.M.); (T.D.)
| | - Kabelo Kgarosi
- Department of Library Services, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa;
| | - Emily Mac Gregor
- School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa;
| | - Thobeka Dlangalala
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa; (A.M.); (T.D.)
| | - Sphamandla Nkambule
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban 4000, South Africa;
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Giblin L, Vousden N, Nathan H, Gidiri F, Goudar S, Charantimath U, Sandall J, Seed PT, Chappell LC, Shennan AH. Effect of the CRADLE vital signs alert device intervention on referrals for obstetric haemorrhage in low-middle income countries: a secondary analysis of a stepped- wedge cluster-randomised control trial. BMC Pregnancy Childbirth 2021; 21:317. [PMID: 33882864 PMCID: PMC8061003 DOI: 10.1186/s12884-021-03796-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Obstetric haemorrhage is the leading cause of maternal death worldwide, 99% of which occur in low and middle income countries. The majority of deaths and adverse events are associated with delays in identifying compromise and escalating care. Management of severely compromised pregnant women may require transfer to tertiary centres for specialised treatment, therefore early recognition is vital for efficient management. The CRADLE vital signs alert device accurately measures blood pressure and heart rate, calculates the shock index (heart rate divided by systolic blood pressure) and alerts the user to compromise through a traffic light system reflecting previously validated shock index thresholds. METHODS This is a planned secondary analysis of data from the CRADLE-3 trial from ten clusters across Africa, India and Haiti where the device and training package were randomly introduced. Referral data were prospectively collected for a 4-week period before, and a 4-week period 3 months after implementation. Referrals from primary or secondary care facilities to higher level care for any cause were recorded. The denominator was the number of women seen for maternity care in these facilities. RESULTS Between April 1 2016 and Nov 30th, 2017 536,223 women attended maternity care facilities. Overall, 3.7% (n = 2784/74,828) of women seen in peripheral maternity facilities were referred to higher level care in the control period compared to 4.4% (n = 3212/73,371) in the intervention period (OR 0.89; 0.39-2.05) (data for nine sites that were able to collect denominator). Of these 0.29% (n = 212) pre-intervention and 0.16% (n = 120) post-intervention were referred to higher-level facilities for maternal haemorrhage. Although overall referrals did not significantly reduce there was a significant reduction in referrals for obstetric haemorrhage (OR 0.56 (0.39-0.65) following introduction of the device with homogeneity (i-squared 26.1) between sites. There was no increase in any bleeding-related morbidity (maternal death or emergency hysterectomy). CONCLUSIONS Referrals for obstetric haemorrhage reduced following implementation of the CRADLE Vital Signs Alert Device, occurring without an increase in maternal death or emergency hysterectomy. This demonstrates the potential benefit of shock index in management pathways for obstetric haemorrhage and targeting limited resources in low- middle- income settings. TRIAL REGISTRATION This study is registered with the ISRCTN registry, number ISRCTN41244132 (02/02/2016).
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Affiliation(s)
- Lucie Giblin
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Nicola Vousden
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Hannah Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shivaprasad Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Umesh Charantimath
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK.
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9
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A cross-sectional study of the role of men and the knowledge of danger signs during pregnancy in southern Mozambique. BMC Pregnancy Childbirth 2020; 20:572. [PMID: 32993554 PMCID: PMC7526108 DOI: 10.1186/s12884-020-03265-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 09/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background The role of the male partner and wider family in maternal health, especially in case of emergencies, has been receiving increasing attention over the last decade. Qualitative research has highlighted that women depend on others to access high quality maternity care. Currently little is known about these factors in relation to maternal health in Mozambique. Methods A cross sectional household survey was conducted with men and women in southern Mozambique about decision making, financial support and knowledge of danger signs. A multivariable logistic model was used to identify factors associated with knowledge of danger signs and Cohen’s kappa for agreement among couples. Results A total of 775 men and women from Marracuene and Manhica districts were interviewed. Maternal health care decisions were frequently made jointly by the couple (32–49%) and financial support was mainly provided by the man (46–80%). Parental and parent-in-law involvement in decision making and financial support was minimal (0–3%). The average number of danger signs respondents knew was 2.05 and no significant difference (p = 0.294) was found between men and women. Communication with the partner was a significant predictor for higher knowledge of danger signs for both men (p = 0.01) and women (p = 0.03). There was very low agreement within couples regarding decision making (p = 0.04), financial support (p = 0.01) and presence at antenatal care consultations (p = 0.001). Results suggest women and men have a high willingness for more male participation in antenatal care, although their understanding of what constitutes this participation is not clear. Conclusion The study findings highlight the important role men play in decision making and financial support for maternal health care issues. Strengthening male involvement in antenatal care services, by investing in counselling and receiving couples, could help accelerate gains in maternal health in Mozambique. Maternal health care studies should collect more data from men directly as men and women often report different views and behavior regarding maternal health care issues and male involvement.
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10
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Widmer M, Bonet M, Betrán AP. Would you like to participate in this trial? The practice of informed consent in intrapartum research in the last 30 years. PLoS One 2020; 15:e0228063. [PMID: 31978100 PMCID: PMC6980544 DOI: 10.1371/journal.pone.0228063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/07/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Informed consent is the cornerstone of the ethical conduct and protection of the rights and wellbeing of participants in clinical research. Therefore, it is important to identify the most appropriate moments for the participants to be informed and to give consent, so that they are able to make a responsible and autonomous decision. However, the optimal timing of consent in clinical research during the intrapartum period remains controversial, and currently, there is no clear guidance. OBJECTIVE We aimed to describe practices of informed consent in intrapartum care clinical research in the last three decades, as reported in uterotonics for postpartum haemorrhage prevention trials. METHODS This is a secondary analysis of the studies included in the Cochrane review entitled "Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis" published in 2018. All the reports included in the Cochrane network meta-analysis were eligible for inclusion in this analysis, except for those reported in languages other than English, French or Spanish. We extracted and synthesized data on the time each of the components of the informed consent process occurred. RESULTS We assessed data from 192 studies, out of 196 studies included in the Cochrane review. The majority of studies (59.9%, 115 studies) reported that women were informed about the study, without specifying the timing. When reported, most studies informed women at admission to the facility for childbirth. Most of the studies reported that consent was sought, but only 59.9% reported the timing, which in most of the cases, was at admission for childbirth. Among these, 32 studies obtained consent in the active phase of labour, 17 in the latent phase and in 10 studies the labour status was unknown. Women were consented antenatally in 6 studies and in 8 studies the consent was obtained indistinctly during antenatal care or at admission. Most of the studies did not specified who was the person who sought the informed consent. CONCLUSION Practices of informed consent in trials on use of uterotonics for prevention of postpartum haemorrhage showed variability and substandard reporting. Informed consent sought at admission for childbirth was the most frequent approach implemented in these trials.
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Affiliation(s)
- Mariana Widmer
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - Mercedes Bonet
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - Ana Pilar Betrán
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
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11
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Miller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry Res 2020; 283:112452. [PMID: 31255320 PMCID: PMC6923620 DOI: 10.1016/j.psychres.2019.06.027] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 01/22/2023]
Abstract
Implementation science is focused on maximizing the adoption, appropriate use, and sustainability of effective clinical practices in real world clinical settings. Many implementation science questions can be feasibly answered by fully experimental designs, typically in the form of randomized controlled trials (RCTs). Implementation-focused RCTs, however, usually differ from traditional efficacy- or effectiveness-oriented RCTs on key parameters. Other implementation science questions are more suited to quasi-experimental designs, which are intended to estimate the effect of an intervention in the absence of randomization. These designs include pre-post designs with a non-equivalent control group, interrupted time series (ITS), and stepped wedges, the last of which require all participants to receive the intervention, but in a staggered fashion. In this article we review the use of experimental designs in implementation science, including recent methodological advances for implementation studies. We also review the use of quasi-experimental designs in implementation science, and discuss the strengths and weaknesses of these approaches. This article is therefore meant to be a practical guide for researchers who are interested in selecting the most appropriate study design to answer relevant implementation science questions, and thereby increase the rate at which effective clinical practices are adopted, spread, and sustained.
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Affiliation(s)
- Christopher J. Miller
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA,Corresponding Author: ; (p) 857-364-5688 (fax) 857-364-6140
| | - Shawna N. Smith
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA,Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Marianne Pugatch
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, MA, USA
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12
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Nkamba DM, Ditekemena J, Wembodinga G, Bernard P, Tshefu A, Robert A. Proportion of pregnant women screened for hypertensive disorders in pregnancy and its associated factors within antenatal clinics of Kinshasa, Democratic Republic of Congo. BMC Pregnancy Childbirth 2019; 19:297. [PMID: 31416427 PMCID: PMC6694649 DOI: 10.1186/s12884-019-2435-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/29/2019] [Indexed: 11/25/2022] Open
Abstract
Background Screening for hypertensive disorders in pregnancy (HDP) is clinically important for identifying women at high risk, and planning early preventative interventions to improve pregnancy outcomes. Several studies in developing countries show that pregnant women are seldom screened for HDP. We conducted a study in Kinshasa, DR Congo, in order to assess the proportion of pregnant women screened for HDP, and to identify factors associated with the screening. Methods We conducted a facility-based cross-sectional study in a random sample of 580 pregnant women attending the first antenatal visit. Data collection consisted of a review of antenatal records, observations at the antenatal care services, and interviews. A pregnant woman was considered as screened for HDP if she had received the tree following services: blood pressure measurement, urine testing for proteinuria, and HDP risk assessment. Multivariable logistic regression, with generalized estimating equations, was used to identify factors associated with the screening for HDP. Results Of the 580 pregnant women, 155 (26.7%) were screened for HDP, 555 (95.7%) had their blood pressure checked, 347(59.8%) were assessed for risk factors of HDP, and 156 (26.9%) were tested for proteinuria. After multivariable analysis, screening for HDP was significantly higher in parous women (AOR = 2.09; 95% CI, 1.11–3.99; P = 0.023), in women with a gestational age of at least 20 weeks (AOR = 5.50; 95% CI, 2.86–10.89; P = 0.002), in women attending in a private clinic (AOR = 3.49; 95% CI, 1.07–11.34; P = 0.038), or in a hospital (AOR = 3.24; 95% CI, 1.24–8.47; P = 0.017), and when no additional payment was required for proteinuria testing at the clinic (AOR = 2.39; 95% CI, 1.14–5.02; P = 0.021). Conclusion Our results show that screening for HDP during the first antenatal visit in Kinshasa is not universal. The factors associated with screening included maternal as well as clinics’ characteristics. More effort should be made both at maternal and clinic levels to improve the screening for HDP in Kinshasa.
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Affiliation(s)
- Dalau Mukadi Nkamba
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo. .,Institut de Recherche Expérimentale et Clinique (IREC), Pôle d'Epidémiologie et Biostatistique (EPID), Université catholique de Louvain (UCLouvain), Brussels, Belgium.
| | - John Ditekemena
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Gilbert Wembodinga
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pierre Bernard
- Institut de Recherche Expérimentale et Clinique (IREC), Département d'obstétrique, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Annie Robert
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle d'Epidémiologie et Biostatistique (EPID), Université catholique de Louvain (UCLouvain), Brussels, Belgium
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13
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Gong E, Dula J, Alberto C, de Albuquerque A, Steenland M, Fernandes Q, Cuco RM, Sequeira S, Chicumbe S, Gudo ES, McConnell M. Client experiences with antenatal care waiting times in southern Mozambique. BMC Health Serv Res 2019; 19:538. [PMID: 31370854 PMCID: PMC6670125 DOI: 10.1186/s12913-019-4369-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/24/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Antenatal care (ANC) provides a range of critical health services during pregnancy that can improve maternal and neonatal health outcomes. In Mozambique, only half of women receive four or more ANC visits, which are provided for free at public health centers by maternal and child health (MCH) nurses. Waiting time has been shown to contribute to negative client experiences, which may be a driver of low maternity care utilization. A recent pilot study of a program to schedule ANC visits demonstrated that scheduling care reduces waiting time and results in higher rates of complete ANC. This study aims to explore client experiences with waiting time for ANC in standard practice and care and after the introduction of appointment scheduling. METHODS This study uses a series of qualitative interviews to unpack client experiences with ANC waiting time with and without scheduled care, in order to better understand the impact of waiting time on client experiences. Thirty-eight interviews were collected in May to June 2017 at three pilot study clinics in southern Mozambique, with a focus on two paired intervention and comparison facilities sharing similar facility characteristics. Data were analyzed using inductive thematic analysis methods using NVivo software. RESULTS Clients described strong motivations to seek ANC, pointing to the need to address convenience of care, and highlighted direct and indirect costs of seeking care that were exacerbated by long waiting times. Direct costs include time and transport costs of going to the clinic, while indirect costs include being unable to fulfill household and work obligations. Other barriers to complete ANC utilization of four or more visits include transport costs, negative provider experiences, and delayed ANC initiation, which limit the potential number of clinic contacts. CONCLUSIONS Findings demonstrate that the scheduling intervention improves the client experience of seeking care by allowing women to both seek ANC and fulfill other productive obligations. Innovation in healthcare delivery should consider adapting models that minimize waiting times.
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Affiliation(s)
- Estelle Gong
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA USA
| | - Janeth Dula
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Carla Alberto
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | | | - Maria Steenland
- Population Studies and Training Center, Brown University, Providence, RI USA
| | - Quinhas Fernandes
- National Directorate of Public Health, Ministry of Health, Maputo, Mozambique
| | - Rosa Marlene Cuco
- National Directorate of Public Health, Ministry of Health, Maputo, Mozambique
| | - Sandra Sequeira
- Department of International Development, London School of Economics, London, UK
| | - Sérgio Chicumbe
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Eduardo Samo Gudo
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA USA
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14
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Vousden N, Lawley E, Seed PT, Gidiri MF, Charantimath U, Makonyola G, Brown A, Yadeta L, Best R, Chinkoyo S, Vwalika B, Nakimuli A, Ditai J, Greene G, Chappell LC, Sandall J, Shennan AH. Exploring the effect of implementation and context on a stepped-wedge randomised controlled trial of a vital sign triage device in routine maternity care in low-resource settings. Implement Sci 2019; 14:38. [PMID: 30999963 PMCID: PMC6471783 DOI: 10.1186/s13012-019-0885-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Interventions aimed at reducing maternal mortality are increasingly complex. Understanding how complex interventions are delivered, to whom, and how they work is key in ensuring their rapid scale-up. We delivered a vital signs triage intervention into routine maternity care in eight low- and middle-income countries with the aim of reducing a composite outcome of morbidity and mortality. This was a pragmatic, hybrid effectiveness-implementation stepped-wedge randomised controlled trial. In this study, we present the results of the mixed-methods process evaluation. The aim was to describe implementation and local context and integrate results to determine whether differences in the effect of the intervention across sites could be explained. METHODS The duration and content of implementation, uptake of the intervention and its impact on clinical management were recorded. These were integrated with interviews (n = 36) and focus groups (n = 19) at 3 months and 6-9 months after implementation. In order to determine the effect of implementation on effectiveness, measures were ranked and averaged across implementation domains to create a composite implementation strength score and then correlated with the primary outcome. RESULTS Overall, 61.1% (n = 2747) of health care providers were trained in the intervention (range 16.5% to 89.2%) over a mean of 10.8 days. Uptake and acceptability of the intervention was good. All clusters demonstrated improved availability of vital signs equipment. There was an increase in the proportion of women having their blood pressure measured in pregnancy following the intervention (79.2% vs. 97.6%; OR 1.30 (1.29-1.31)) and no significant change in referral rates (3.7% vs. 4.4% OR 0.89; (0.39-2.05)). Availability of resources and acceptable, effective referral systems influenced health care provider interaction with the intervention. There was no correlation between process measures within or between domains, or between the composite score and the primary outcome. CONCLUSIONS This process evaluation has successfully described the quantity and quality of implementation. Variation in implementation and context did not explain differences in the effectiveness of the intervention on maternal mortality and morbidity. We suggest future trials should prioritise in-depth evaluation of local context and clinical pathways. TRIAL REGISTRATION Trial registration: ISRCTN41244132 . Registered on 2 Feb 2016.
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Affiliation(s)
- Nicola Vousden
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Elodie Lawley
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Paul T. Seed
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Muchabayiwa Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Umesh Charantimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka 590010 India
| | - Grace Makonyola
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG UK
| | - Adrian Brown
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG UK
| | - Lomi Yadeta
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG UK
| | - Rebecca Best
- Welbodi Partnership, Ola During Childrens Hospital, Freetown, Sierra Leone
| | - Sebastian Chinkoyo
- Department of Obstetrics and Gynaecology, Ndola Teaching Hospital, Ndola, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia, Lusaka, Zambia
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, Mulago Hospital, Makerere University, Kampala, Uganda
| | - James Ditai
- Sanyu Africa Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Grace Greene
- Hope Health Action, Hopital Convention Baptiste d’Haiti, Cap Haitien, Haiti
| | - Lucy C. Chappell
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Jane Sandall
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Andrew H. Shennan
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
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15
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Althabe F, Chomba E, Tshefu AK, Banda E, Belizán M, Bergel E, Berrueta M, Bertrand J, Bose C, Cafferata ML, Carlo WA, Ciganda A, Donnay F, García Elorrio E, Gibbons L, Klein K, Liljestrand J, Lusamba PD, Mavila AK, Mazzoni A, Nkamba DM, Mwanakalanga FH, Mwapule Tembo A, Mwenechanya M, Pyne-Mercier L, Spira C, Wetshikoy JD, Xiong X, Buekens P. A multifaceted intervention to improve syphilis screening and treatment in pregnant women in Kinshasa, Democratic Republic of the Congo and in Lusaka, Zambia: a cluster randomised controlled trial. LANCET GLOBAL HEALTH 2019; 7:e655-e663. [PMID: 30910531 PMCID: PMC6465956 DOI: 10.1016/s2214-109x(19)30075-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/19/2018] [Accepted: 01/16/2019] [Indexed: 11/11/2022]
Abstract
Background Despite international recommendations, coverage of syphilis testing in pregnant women and treatment of those found seropositive remains limited in sub-Saharan Africa. We assessed whether combining the provision of supplies with a behavioural intervention was more effective than providing supplies only, to improve syphilis screening and treatment during antenatal care. Methods In this 18-month, cluster randomised controlled trial, we randomly assigned (1:1) 26 urban antenatal care clinics in Kinshasa, Democratic Republic of the Congo, and Lusaka, Zambia, to receive a behavioural intervention (opinion leader selection, academic detailing visits, reminders, audits and feedback, and supportive supervision) plus supplies for syphilis testing and treatment (intervention group) or to receive supplies only (control group). The primary outcomes were proportion of pregnant women who had syphilis screening out of the total who attended the clinic; and the proportion of women who had treatment with benzathine benzylpenicillin out of those who tested positive for syphilis at their first antenatal care visit. This trial is registered at ClinicalTrials.gov, number NCT02353117. Findings The 18-month study period was Feb 1, 2016, to July 14, 2017. 18 357 women were enrolled at the 13 intervention clinics and 17 679 women were enrolled at the 13 control clinics at their first antenatal care visit. Syphilis screening was done in a median of 99·9% (IQR 99·0–100·0) of women in the intervention clinics and 93·8% (85·0–98·9) in the control clinics (absolute difference 6·1% [95% CI 1·1–14·1]; p=0·00092). Syphilis treatment at the first visit was done in a median of 100% (IQR 99·7–100·0) of seropositive women in intervention clinics and 43·2% (2·6–83·2) of seropositive women in control clinics (absolute difference 56·8% [12·8–99·0]; p=0·0028). Interpretation A behavioural intervention, together with the provision of supplies, can lead to more than 95% of women being screened and treated for syphilis. The sole provision of supplies is sufficient to reach such levels of screening coverage but is not sufficient to ensure high levels of treatment. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Fernando Althabe
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina; UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Elwyn Chomba
- University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ernest Banda
- University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - María Belizán
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Eduardo Bergel
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Mabel Berrueta
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
| | - Jane Bertrand
- Tulane University School of Public Health and Tropical Medicine, Los Angeles, CA, USA
| | - Carl Bose
- University of North Carolina (UNC) School of Medicine, UNC Hospitals, Chapel Hill, NC, USA
| | | | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alvaro Ciganda
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - France Donnay
- Tulane University School of Public Health and Tropical Medicine, Los Angeles, CA, USA
| | | | - Luz Gibbons
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Karen Klein
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | | | - Paul D Lusamba
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Arlette K Mavila
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Agustina Mazzoni
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Dalau M Nkamba
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | | | | | | | - Cintia Spira
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Jean D Wetshikoy
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Xu Xiong
- Tulane University School of Public Health and Tropical Medicine, Los Angeles, CA, USA
| | - Pierre Buekens
- Tulane University School of Public Health and Tropical Medicine, Los Angeles, CA, USA
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16
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Vousden N, Lawley E, Nathan HL, Seed PT, Gidiri MF, Goudar S, Sandall J, Chappell LC, Shennan AH. Effect of a novel vital sign device on maternal mortality and morbidity in low-resource settings: a pragmatic, stepped-wedge, cluster-randomised controlled trial. Lancet Glob Health 2019; 7:e347-e356. [PMID: 30784635 PMCID: PMC6379820 DOI: 10.1016/s2214-109x(18)30526-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/19/2018] [Accepted: 11/07/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND In 2015, an estimated 303 000 women died in pregnancy and childbirth. Obstetric haemorrhage, sepsis, and hypertensive disorders of pregnancy account for more than 50% of maternal deaths worldwide. There are effective treatments for these pregnancy complications, but they require early detection by measurement of vital signs and timely administration to save lives. The primary aim of this trial was to determine whether implementation of the CRADLE Vital Sign Alert and an education package into community and facility maternity care in low-resource settings could reduce a composite of all-cause maternal mortality or major morbidity (eclampsia and hysterectomy). METHODS We did a pragmatic, stepped-wedge, cluster-randomised controlled trial in ten clusters across Africa, India, and Haiti, introducing the device into routine maternity care. Each cluster contained at least one secondary or tertiary hospital and their main referral facilities. Clusters crossed over from existing routine care to the CRADLE intervention in one of nine steps at 2-monthly intervals, with CRADLE devices replacing existing equipment at the randomly allocated timepoint. A computer-generated randomly allocated sequence determined the order in which the clusters received the intervention. Because of the nature of the intervention, this trial was not masked. Data were gathered monthly, with 20 time periods of 1 month. The primary composite outcome was at least one of eclampsia, emergency hysterectomy, and maternal death. This study is registered with the ISRCTN registry, number ISRCTN41244132. FINDINGS Between April 1, 2016, and Nov 30, 2017, among 536 223 deliveries, the primary outcome occurred in 4067 women, with 998 maternal deaths, 2692 eclampsia cases, and 681 hysterectomies. There was an 8% decrease in the primary outcome from 79·4 per 10 000 deliveries pre-intervention to 72·8 per 10 000 deliveries post-intervention (odds ratio [OR] 0·92, 95% CI 0·86-0·97; p=0·0056). After planned adjustments for variation in event rates between and within clusters over time, the unexpected degree of variability meant we were unable to judge the benefit or harms of the intervention (OR 1·22, 95% CI 0·73-2·06; p=0·45). INTERPRETATION There was an absolute 8% reduction in primary outcome during the trial, with no change in resources or staffing, but this reduction could not be directly attributed to the intervention due to variability. We encountered unanticipated methodological challenges with this trial design, which can provide valuable learning for future research and inform the trial design of future international stepped-wedge trials. FUNDING Newton Fund Global Research Programme: UK Medical Research Council; Department of Biotechnology, Ministry of Science & Technology, Government of India; and UK Department of International Development.
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Affiliation(s)
- Nicola Vousden
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Elodie Lawley
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Muchabayiwa Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shivaprasad Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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17
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Hanson C, Munjanja S, Binagwaho A, Vwalika B, Pembe AB, Jacinto E, Chilinda GK, Donahoe KB, Wanyonyi SZ, Waiswa P, Gidiri MF, Benova L. National policies and care provision in pregnancy and childbirth for twins in Eastern and Southern Africa: A mixed-methods multi-country study. PLoS Med 2019; 16:e1002749. [PMID: 30779738 PMCID: PMC6380547 DOI: 10.1371/journal.pmed.1002749] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/22/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND High-risk pregnancies, such as twin pregnancies, deserve particular attention as mortality is very high in this group. With a view to inform policy and national guidelines development for the Sustainable Development Goals, we reviewed national training materials, guidelines, and policies underpinning the provision of care in relation to twin pregnancies and assessed care provided to twins in 8 Eastern and Southern African countries: Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS AND FINDINGS We located policies and guidelines by reviewing national repositories and by contacting experts to systematically map country-level maternal and newborn training materials, guidelines, and policies. We extracted recommendations for care for twins spanning ante-, intra-, and postpartum care that typically should be offered during twin pregnancies and childbirth. We compared care provided for mothers of twins to that provided for mothers of singletons during the ante-, intra-, and postpartum period and computed neonatal mortality rates using the most recent Demographic and Health Surveys (DHS) data for each country. There was a paucity of guidance on care specifically for twin or multiple pregnancies: None of the countries provided clear guidance on additional number of antenatal care visits or specific antenatal content, while 7 of the 8 countries recommended twins to be delivered in a comprehensive emergency obstetric and neonatal care facility. These results were mirrored by DHS results of 73,462 live births (of which 1,360 were twin) indicating that twin pregnancies did not receive more frequent or intensified antenatal care. The percentage of twin deliveries in hospitals varied from 25.3% in Mozambique to 63.0% in Kenya, and women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals compared to women with singleton live births; this difference was significant in 5 of the 8 countries (t test p < 0.05). The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% in Rwanda. The newborn mortality rate among twins, adjusted for maternal age and parity, was 4.6 to 7.2 times higher for twins compared to singletons in all 8 countries. CONCLUSIONS Despite the limited sample size and the limited number of clinically relevant services evaluated, our study provided evidence that mothers of twins receive insufficient care and that mortality in twin newborns is very high in Eastern and Southern Africa. Most countries have insufficient guidelines for the care of twins. While our data do not allow us to make a causal link between insufficient guidelines and insufficient care, they call for an assessment and reconceptualisation of policies to reduce the unacceptably high mortality in twins in Eastern and Southern Africa.
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Affiliation(s)
- Claudia Hanson
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
- Department of Public Health Sciences–Global Health, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Stephen Munjanja
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Andrea B. Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Elsa Jacinto
- Women’s and Children’s Health Department, National Directorate for Public Health, Ministry of Health, Maputo, Mozambique
| | - George K. Chilinda
- Department of Obstetrics and Gynaecology, Medical College, Blantyre, Malawi
| | | | - Sikolia Z. Wanyonyi
- Department of Obstetrics and Gynecology, Aga Khan University, Nairobi, Kenya
| | - Peter Waiswa
- Department of Public Health Sciences–Global Health, Karolinska Institutet, Stockholm, Sweden
- College of Health Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Muchabayiwa F. Gidiri
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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18
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Uneke CJ, Uro-Chukwu HC. Improving quality of antenatal care through provision of medical supply kits. LANCET GLOBAL HEALTH 2018; 6:e4-e5. [PMID: 29241614 DOI: 10.1016/s2214-109x(17)30471-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 11/27/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Chigozie Jesse Uneke
- African Institute for Health Policy and Health Systems, Ebonyi State University, PMB 053 Abakaliki, Nigeria; Department of Medical Microbiology/Parasitology, Faculty of Clinical Medicine, Ebonyi State University, PMB 053 Abakaliki, Nigeria.
| | - Henry Chukwuemeka Uro-Chukwu
- African Institute for Health Policy and Health Systems, Ebonyi State University, PMB 053 Abakaliki, Nigeria; National Obstetrics Fistula Centre, Abakaliki, Nigeria
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19
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Benova L, Tunçalp Ö, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Glob Health 2018; 3:e000779. [PMID: 29662698 PMCID: PMC5898334 DOI: 10.1136/bmjgh-2018-000779] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Antenatal care (ANC) provides a critical opportunity for women and babies to benefit from good-quality maternal care. Using 10 countries as an illustrative analysis, we described ANC coverage (number of visits and timing of first visit) and operationalised indicators for content of care as available in population surveys, and examined how these two approaches are related. METHODS We used the most recent Demographic and Health Survey to analyse ANC related to women's most recent live birth up to 3 years preceding the survey. Content of care was assessed using six components routinely measured across all countries, and a further one to eight additional country-specific components. We estimated the percentage of women in need of ANC, and using ANC, who received each component, the six routine components and all components. RESULTS In all 10 countries, the majority of women in need of ANC reported 1+ ANC visits and over two-fifths reported 4+ visits. Receipt of the six routine components varied widely; blood pressure measurement was the most commonly reported component, and urine test and information on complications the least. Among the subset of women starting ANC in the first trimester and receiving 4+ visits, the percentage receiving all six routinely measured ANC components was low, ranging from 10% (Jordan) to around 50% in Nigeria, Nepal, Colombia and Haiti. CONCLUSION Our findings suggest that even among women with patterns of care that complied with global recommendations, the content of care was poor. Efficient and effective action to improve care quality relies on development of suitable content of care indicators.
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Affiliation(s)
- Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Özge Tunçalp
- Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child and Adolescent Health, WHO, Geneva, Switzerland
| | - Oona Maeve Renee Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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