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Ghosh A, Mistri B. Socio-demographic and infrastructural variables influencing maternal risk concentration among ever-married women of reproductive age in rural West Bengal, India. Int J Health Plann Manage 2024; 39:1383-1410. [PMID: 38803039 DOI: 10.1002/hpm.3805] [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: 08/21/2022] [Revised: 04/19/2024] [Accepted: 04/26/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world. OBJECTIVES The present study aims to determine prevalence of maternal risk and the influencing variables among ever-married women belonging to the reproductive age group (15-49) of Birbhum district, West Bengal. METHODS A cohort-based retrospective cross-sectional study was carried out among the sample of 229 respondents through a purposive stratified random sampling method and a pre-designed semi-structured questionnaire. The ordinal logistic regression (OLR) model was taken as a tool of assessment. Before developing the proportional OLR model, we have checked the multicollinearity effect among the predictors and the first-order effect modifier was evaluated as well. We performed data analysis using SPSS version 26. RESULTS The result shows that illiterate women (Odds ratios [OR] = 2.81, 95% CI, 0.277-1.791), from lower standard of living (OR = 1.14, 95% CI, -0.845-1.116), married before the age of 15 years (OR = 21.96, 95% CI, -0.55-6.73) and between the age of 15-18 years (OR = 24.51. 95% CI, -0.45-6.85) are more likely to be affected by the higher concentration of maternal risk. Other important predictor is the time of pregnancy registration. Considering the transport and related en-route causalities, the result portraying a clear picture where the distance and travel time becoming significant factors in determining the concentration of maternal risk. CONCLUSION Incidences of child marriages should be restricted. Eradicating factors influencing an individual's decision to seek care would be an essential contribution in excluding the dominant maternal risk factors.
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Affiliation(s)
- Alokananda Ghosh
- Department of Geography, Tehatta Sadananda Mahavidyalaya, Purba Bardhaman, West Bengal, India
| | - Biswaranjan Mistri
- Department of Geography, The University of Burdwan, Burdwan, West Bengal, India
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Sivalogan K, Banda B, Wagner J, Biemba G, Gagne N, Grogan C, Hamomba F, Herlihy JM, Mabeta C, Shankoti P, Simamvwa G, Sooli B, Yeboah-Antwi K, Hamer DH, Semrau KEA. Impact of beliefs on perception of newborn illness, caregiver behaviors, and care-seeking practices in Zambia's Southern province. PLoS One 2023; 18:e0282881. [PMID: 37228055 DOI: 10.1371/journal.pone.0282881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 02/25/2023] [Indexed: 05/27/2023] Open
Abstract
Despite reductions in the number of under-five deaths since the release of the Sustainable Development Goals, the proportion of neonatal deaths among all under-five deaths has remained high. Neonatal health is linked to newborn care practices which are tied to distinct cultural perceptions of health and illness. We assessed how community beliefs in Zambia's Southern Province influence newborn care behaviors, perception of illness, and care-seeking practices, using qualitative data collected between February and April 2010. A total of 339 women participated in 36 focus group discussions (FGDs), with 9 FGDs conducted in each of the four study districts. In addition, 42 in-depth interviews (IDIs) were conducted with various key informants, with 11 IDIs conducted in Choma, 11 IDIs in Monze, 10 IDIs in Livingstone, and 10 IDIs in Mazabuka. The FGDs and IDIs indicate that beliefs among the Tonga people regarding postnatal illness prevention and management influence perceptions of newborn illness and care-seeking practices. Care seeking behaviors including when, why, and where parents seek newborn care are intimately tied to perception of disease among the Tonga people. These beliefs may stem from both indigenous and Western perspectives in Zambia's Southern Province. Findings are consistent with other analyses from Southern Province that highlighted the benefit of integrating local practices with Western biomedical care. Health systems models, led by policy makers and program designers, could aim to find synergies between community practices and formal health systems to support positive behavior change and satisfy multiple stakeholders.
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Affiliation(s)
- Kasthuri Sivalogan
- Emory Global Health Institute at Emory University, Atlanta, Georgia, United States of America
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Bowen Banda
- Zambian Center for Applied Health Research and Development, Limited, Lusaka, Zambia
| | - John Wagner
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Godfrey Biemba
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Zambian Center for Applied Health Research and Development, Limited, Lusaka, Zambia
- National Health Research Authority, University Teaching Hospital Paediatric Centre of Excellence, Lusaka, Zambia
| | - Natalie Gagne
- Canadian Federal Department of Indigenous Services Canada, Gatineau, Canada
| | - Caroline Grogan
- Ariadne Labs, Harvard T.H Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Fern Hamomba
- Zambian Center for Applied Health Research and Development, Limited, Lusaka, Zambia
| | - Julie M Herlihy
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Catherine Mabeta
- Zambian Center for Applied Health Research and Development, Limited, Lusaka, Zambia
| | - Peggy Shankoti
- Zambian Center for Applied Health Research and Development, Limited, Lusaka, Zambia
| | - Grace Simamvwa
- Zambian Center for Applied Health Research and Development, Limited, Lusaka, Zambia
| | - Bernadine Sooli
- Zambian Center for Applied Health Research and Development, Limited, Lusaka, Zambia
| | - Kojo Yeboah-Antwi
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Zambian Center for Applied Health Research and Development, Limited, Lusaka, Zambia
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Katherine E A Semrau
- Ariadne Labs, Harvard T.H Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
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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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Gardezi NUZ. Public health insurance and birth outcomes: evidence from Punjab, Pakistan. Health Policy Plan 2021; 36:1-13. [PMID: 33263765 DOI: 10.1093/heapol/czaa115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2020] [Indexed: 11/12/2022] Open
Abstract
Public health insurance targeted towards low-income households has gained traction in many developing countries. However, there is limited evidence as to the effectiveness of these programs in countries where institutional constraints may limit participation by the eligible population. This paper evaluates a recent health insurance initiative introduced in Pakistan and discusses whether eligibility for the programme improves maternal health seeking behaviour. The Prime Minister National Health Program provides free insurance coverage to low-income families. The programme is in the early phases of implementation and has, since 2016, only been rolled out in a few eligible districts within the country. This allows for a comparison of eligible households in districts where the programme has been introduced to those that are eligible to receive insurance at a future date. Using repeated cross-sectional data from multiple rounds of representative household survey, a difference-in-difference model has been estimated. Results show that at least for a specific beneficiary group (i.e. pregnant women), there has been a positive increase in utilization of hospital services. Furthermore, we provide evidence using mother fixed effects that the programme increased the likelihood of a child's birth being documented. Since possession of a birth certificate can secure civic rights for a child, this is an unintended but positive outcome of the programme.
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Zuñiga JA, García A, Kyololo OM, Hamilton-Solum P, Kabimba A, Milimo B, Abbyad CW, Reid DD, Chelagat D. Increasing utilisation of skilled attendants at birth in sub-Saharan Africa: A systematic review of interventions. Int J Nurs Stud 2021; 120:103977. [PMID: 34144356 DOI: 10.1016/j.ijnurstu.2021.103977] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 04/21/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Maternal mortality is a critical global public health concern, especially in low- and middle-income countries in sub-Saharan Africa. Although maternal mortality rates have declined by approximately 39% in sub-Saharan Africa over the last decade, maternal deaths during pregnancy and in childbirth remain high. Interventions to improve mothers' use of skilled birth attendants may decrease maternal mortality in sub-Saharan African countries. OBJECTIVES This systematic literature review examines components of and evaluates the effectiveness of interventions to increase use of skilled birth attendants in sub-Saharan Africa. METHODS Guided by the PRISMA model for systematic reviews, the PubMed, Web of Science, and CIHNAL databases were searched for studies from years 2003 through June 2020. RESULTS The 28 articles included in this review reported on interventions incorporating community health workers, phone or text messages, implementation of community-level initiatives, free health care, cash incentives, an international multi-disciplinary volunteer team, and a group home for pregnant women, which improved use of skilled birth attendants to varying degrees. Only one study reported improved outcomes with the use of community health workers. All of the interventions using text messages increased hospital utilization for births. CONCLUSIONS Interventions implemented in sub-Saharan Africa hold promise for improving maternal health. Multi-level interventions that involve community members and local leaders can help address the multi-faceted issue of poor maternal health outcomes and mortality. Interventions should focus on capacity building and on training and mentoring of formally-trained health care providers and community health workers in order to expand access.
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Affiliation(s)
- Julie A Zuñiga
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States.
| | - Alexandra García
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States
| | | | - Patricia Hamilton-Solum
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States
| | - Anne Kabimba
- School of Nursing, Moi University, Eldoret Kenya, Kenya
| | - Benson Milimo
- School of Nursing, Moi University, Eldoret Kenya, Kenya
| | - Christine W Abbyad
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States
| | - Davika D Reid
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States
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6
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Ramavhoya IT, Maputle MS, Ramathuba DU, Lebese RT, Netshikweta LM. Managers' support on implementation of maternal guidelines, Limpopo province, South Africa. Curationis 2020; 43:e1-e9. [PMID: 33179945 PMCID: PMC7669946 DOI: 10.4102/curationis.v43i1.1949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 12/13/2019] [Accepted: 01/25/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The report of Saving Mothers indicated a decline of maternal mortality from 12.8% to 12.5% last triennium of 2017. This shows that regardless of availability of national maternal health guidelines, midwives and managers, 25% of maternal deaths were caused by preventable and avoidable factors. As such, support provided by managers is vital in promoting the utilisation of maternal guidelines. OBJECTIVES The objective was to determine the support offered by managers to midwives during the implementation of maternal health guidelines. METHOD The study design was cross-sectional descriptive in a quantitative domain. Simple random sampling was used to select 58 operational managers and two maternal managers. Data were collected using self-administered questionnaires and analysed using Statistical Package for Social Sciences version 23. Descriptive statistics provided by Microsoft Excel in the form of charts was used to describe data. Pearson's correlation test was used to describe relationships amongst variables. RESULTS The results revealed that 83.3% respondents indicated a shortage of staff to attend pregnant women. Fifty-six per cent of managers indicated that shortage of material resources contributed to substandard implementation of maternal guidelines. Supervision and monitoring of implementation of maternal guidelines was difficult as indicated by 53.3%, and 63.3% indicated lack of supervision. CONCLUSION Limited support in terms of monitoring and supervision by managers was strongly indicated as having a negative effect on implementation of maternal guidelines. Capacity building was offered; however, shortage of resources led to poor implementation of maternal guidelines by midwives.
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Affiliation(s)
- Ireen T Ramavhoya
- Department of Biological Natural Science, Limpopo Nursing College, Thohoyandou.
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Gage AD, Carnes F, Blossom J, Aluvaala J, Amatya A, Mahat K, Malata A, Roder-DeWan S, Twum-Danso N, Yahya T, Kruk ME. In Low- And Middle-Income Countries, Is Delivery In High-Quality Obstetric Facilities Geographically Feasible? Health Aff (Millwood) 2020; 38:1576-1584. [PMID: 31479351 DOI: 10.1377/hlthaff.2018.05397] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Delivery in a health facility is a key strategy for reducing maternal and neonatal mortality, yet increasing use of facilities has not consistently translated into reduced mortality in low- and middle-income countries. In such countries, many deliveries occur at primary care facilities, where the quality of care is poor. We modeled the geographic feasibility of service delivery redesign that shifted deliveries from primary care clinics to hospitals in six countries: Haiti, Kenya, Malawi, Namibia, Nepal, and Tanzania. We estimated the proportion of women within two hours of the nearest delivery facility, both currently and under redesign. Today, 83-100 percent of pregnant women in the study countries have two-hour access to a delivery facility. A policy of redesign would reduce two-hour access by at most 10 percent, ranging from 0.6 percent in Malawi to 9.9 percent in Tanzania. Relocating delivery services to hospitals would not unduly impede geographic access to care in the study countries. This policy should be considered in low- and middle-income countries, as it may be an effective approach to reducing maternal and newborn deaths.
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Affiliation(s)
- Anna D Gage
- Anna D. Gage ( ) is a student in the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Fei Carnes
- Fei Carnes is a geographic information systems (GIS) specialist in the Center for Geographic Analyses, Harvard University, in Cambridge, Massachusetts
| | - Jeff Blossom
- Jeff Blossom is the GIS service manager in the Center for Geographic Analyses, Harvard University
| | - Jalemba Aluvaala
- Jalemba Aluvaala is a research fellow in the Department of Paediatrics and Child Health, University of Nairobi School of Medicine, in Kenya
| | - Archana Amatya
- Archana Amatya is an assistant professor of community medicine and public health at the Tribhuvan University Teaching Hospital, in Kathmandu, Nepal
| | - Kishori Mahat
- Kishori Mahat is an advisor in Quality Assurance and Regulation, Nepal Health Sector Support Programme, Department for International Development, in Kathmandu
| | - Address Malata
- Address Malata is principal of the College of Nursing, Malawi University of Science and Technology, in Limbe
| | - Sanam Roder-DeWan
- Sanam Roder-DeWan is a researcher in the Ifakara Health Institute, in Dar es Salaam, Tanzania
| | | | - Talhiya Yahya
- Talhiya Yahya is head of the Quality Management Unit, Ministry of Health, Community Development, Gender, Elderly, and Children, in Dar es Salaam
| | - Margaret E Kruk
- Margaret E. Kruk is an associate professor in the Department of Global Health and Population, Harvard T. H. Chan School of Public Health
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8
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Kaiser JL, Fong RM, Ngoma T, McGlasson KL, Biemba G, Hamer DH, Bwalya M, Chasaya M, Scott NA. The effects of maternity waiting homes on the health workforce and maternal health service delivery in rural Zambia: a qualitative analysis. HUMAN RESOURCES FOR HEALTH 2019; 17:93. [PMID: 31801578 PMCID: PMC6894259 DOI: 10.1186/s12960-019-0436-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/04/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Maternity waiting homes (MWHs) are a potential strategy to address low facility delivery rates resulting from access-associated barriers in resource-limited settings. Within a cluster-randomized controlled trial testing a community-generated MWH model in rural Zambia, we qualitatively assessed how MWHs affect the health workforce and maternal health service delivery at their associated rural health centers. METHODS Four rounds of in-depth interviews with district health staff (n = 21) and health center staff (n = 73) were conducted at intervention and control sites over 24 months. We conducted a content analysis using a mixed inductive-deductive approach. Data were interpreted through the lens of the World Health Organzation Health Systems Framework. RESULTS Nearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman's final stage of pregnancy and labor onset, detect complications earlier, and either more confidently manage those complications at the health center or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. When understaffing and overwork were frequently discussed, this satisfaction in providing better care was a meaningful departure. CONCLUSIONS MWHs may benefit staff at rural health centers and the health system more broadly, allowing for the provision of more timely and comprehensive obstetric care. We recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities. Considering the limited numbers of skilled birth attendants available in rural Zambia, it is important to strategically select locations for new MWHs. TRIAL REGISTRATION Clinicaltrials.gov, NCT02620436. Registered December 3, 2015, https://clinicaltrials.gov/ct2/show/NCT02620436.
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Affiliation(s)
- Jeanette L. Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - Rachel M. Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | | | - Godfrey Biemba
- National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA USA
| | - Misheck Bwalya
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | | | - Nancy A. Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
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Iverson KR, Svensson E, Sonderman K, Barthélemy EJ, Citron I, Vaughan KA, Powell BL, Meara JG, Shrime MG. Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries. Int J Health Policy Manag 2019; 8:521-537. [PMID: 31657175 PMCID: PMC6815989 DOI: 10.15171/ijhpm.2019.43] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services. Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates. Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study. Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.
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Affiliation(s)
- Katherine R Iverson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,General Surgery Department, University of California Davis Medical Center, Sacramento, CA, USA
| | - Emma Svensson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Lund University, Lund, Sweden
| | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Kerry A Vaughan
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany L Powell
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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Mallick L, Dontamsetti T, Pullum T, Fleuret J. Using the Uganda Demographic and Health Surveys from 2011 and 2016 to assess changes in Saving Mothers, Giving Life intervention districts. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Ngoma T, Asiimwe AR, Mukasa J, Binzen S, Serbanescu F, Henry EG, Hamer DH, Lori JR, Schmitz MM, Marum L, Picho B, Naggayi A, Musonda G, Conlon CM, Komakech P, Kamara V, Scott NA. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S68-S84. [PMID: 30867210 PMCID: PMC6519669 DOI: 10.9745/ghsp-d-18-00367] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/13/2018] [Indexed: 12/22/2022]
Abstract
The Saving Mothers, Giving Life initiative employed 2 key strategies to improve the ability of pregnant women to reach maternal care: (1) increase the number of emergency obstetric and newborn care facilities, including upgrading existing health facilities, and (2) improve accessibility to such facilities by renovating and constructing maternity waiting homes, improving communication and transportation systems, and supporting community-based savings groups. These interventions can be adapted in low-resource settings to improve access to maternity care services. Background: Between June 2011 and December 2016, the Saving Mothers, Giving Life (SMGL) initiative in Uganda and Zambia implemented a comprehensive approach targeting the persistent barriers that impact a woman's decision to seek care (first delay), ability to reach care (second delay), and ability to receive adequate care (third delay). This article addresses how SMGL partners implemented strategies specifically targeting the second delay, including decreasing the distance to facilities capable of managing emergency obstetric and newborn complications, ensuring sufficient numbers of skilled birth attendants, and addressing transportation challenges. Methods: Both quantitative and qualitative data collected by SMGL implementing partners for the purpose of monitoring and evaluation were used to document the intervention strategies and to describe the change in outputs and outcomes related to the second delay. Quantitative data sources included pregnancy outcome monitoring data in facilities, health facility assessments, and population-based surveys. Qualitative data were derived from population-level verbal autopsy narratives, programmatic reports and SMGL-related publications, and partner-specific evaluations that include focus group discussions and in-depth interviews. Results: The proportion of deliveries in any health facility or hospital increased from 46% to 67% in Uganda and from 63% to 90% in Zambia between baseline and endline. Distance to health facilities was reduced by increasing the number of health facilities capable of providing basic emergency obstetric and newborn care services in both Uganda and Zambia—a 200% and 167% increase, respectively. Access to facilities improved through integrated transportation and communication services efforts. In Uganda there was a 6% increase in the number of health facilities with communication equipment and a 258% increase in facility deliveries supported by transportation vouchers. In Zambia, there was a 31% increase in health facilities with available transportation, and the renovation and construction of maternity waiting homes resulted in a 69% increase in the number of health facilities with associated maternity waiting homes. Conclusion: The collective SMGL strategies addressing the second delay resulted in increased access to delivery services as seen by the increase in the proportion of facility deliveries in SMGL districts, improved communication and transportation services, and an increase in the number of facilities with associated maternity waiting homes. Sustaining and improving on these efforts will need to be ongoing to continue to address the second delay in Uganda and Zambia.
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Affiliation(s)
| | - Alice R Asiimwe
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Joseph Mukasa
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Susanna Binzen
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jody R Lori
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Michelle M Schmitz
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence Marum
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired
| | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | | | - Patrick Komakech
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Vincent Kamara
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
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12
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Morof D, Serbanescu F, Goodwin MM, Hamer DH, Asiimwe AR, Hamomba L, Musumali M, Binzen S, Kekitiinwa A, Picho B, Kaharuza F, Namukanja PM, Murokora D, Kamara V, Dynes M, Blanton C, Nalutaaya A, Luwaga F, Schmitz MM, LaBrecque J, Conlon CM, McCarthy B, Kroelinger C, Clark T. Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care. GLOBAL HEALTH, SCIENCE AND PRACTICE 2019; 7:S85-S103. [PMID: 30867211 PMCID: PMC6519670 DOI: 10.9745/ghsp-d-18-00272] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/21/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Saving Mothers, Giving Life (SMGL) is a 5-year initiative implemented in participating districts in Uganda and Zambia that aimed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care: seeking, reaching, and receiving. Approaches to addressing the third delay included adequate health facility infrastructure, specifically sufficient equipment and medications; trained providers to provide quality evidence-based care; support for referrals to higher-level care; and effective maternal and perinatal death surveillance and response. METHODS SMGL used a mixed-methods approach to describe intervention strategies, outcomes, and health impacts. Programmatic and monitoring and evaluation data-health facility assessments, facility and community surveillance, and population-based mortality studies-were used to document the effectiveness of intervention components. RESULTS During the SMGL initiative, the proportion of facilities providing emergency obstetric and newborn care (EmONC) increased from 10% to 25% in Uganda and from 6% to 12% in Zambia. Correspondingly, the delivery rate occurring in EmONC facilities increased from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia. Nearly all facilities had at least one trained provider on staff by the endline evaluation. Staffing increases allowed a higher proportion of health centers to provide care 24 hours a day/7 days a week by endline-from 74.6% to 82.9% in Uganda and from 64.8% to 95.5% in Zambia. During this period, referral communication improved from 93.3% to 99.0% in Uganda and from 44.6% to 100% in Zambia, and data systems to identify and analyze causes of maternal and perinatal deaths were established and strengthened. CONCLUSION SMGL's approach was associated with improvements in facility infrastructure, equipment, medication, access to skilled staff, and referral mechanisms and led to declines in facility maternal and perinatal mortality rates. Further work is needed to sustain these gains and to eliminate preventable maternal and perinatal deaths.
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Affiliation(s)
- Diane Morof
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
- U.S. Public Health Service Commissioned Corps, Rockville, MD, USA
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mary M Goodwin
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Alice R Asiimwe
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Leoda Hamomba
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Masuka Musumali
- Family Health Division, U.S. Agency for International Development, Lusaka, Zambia
| | - Susanna Binzen
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Frank Kaharuza
- HIV Health Office, U.S. Agency for International Development, Kampala, Uganda
| | | | - Dan Murokora
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Vincent Kamara
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Michelle Dynes
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- U.S. Public Health Service Commissioned Corps, Rockville, MD, USA
| | - Curtis Blanton
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Agnes Nalutaaya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fredrick Luwaga
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Michelle M Schmitz
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jonathan LaBrecque
- Bureau for Global Health, U.S. Agency for International Development, Washington DC. Now with Boston Children's Hospital, Boston, MA, USA
| | | | - Brian McCarthy
- Eck Institute for Global Health, University of Notre Dame, Notre Dame, IN, USA
| | - Charlan Kroelinger
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Thomas Clark
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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Larson E, Gage AD, Mbaruku GM, Mbatia R, Haneuse S, Kruk ME. Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster-randomised study in rural Tanzania. Trop Med Int Health 2019; 24:636-646. [PMID: 30767422 PMCID: PMC6499631 DOI: 10.1111/tmi.13220] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objectives Reduction in maternal and newborn mortality requires that women deliver in high quality health facilities. However, many facilities provide sub‐optimal quality of care, which may be a reason for less than universal facility utilisation. We assessed the impact of a quality improvement project on facility utilisation for childbirth. Methods In this cluster‐randomised experiment in four rural districts in Tanzania, 12 primary care clinics and their catchment areas received a quality improvement intervention consisting of in‐service training, mentoring and supportive supervision, infrastructure support, and peer outreach, while 12 facilities and their catchment areas functioned as controls. We conducted a census of all deliveries within the catchment area and used difference‐in‐differences analysis to determine the intervention's effect on facility utilisation for childbirth. We conducted a secondary analysis of utilisation among women whose prior delivery was at home. We further investigated mechanisms for increased facility utilisation. Results The intervention led to an increase in facility births of 6.7 percentage points from a baseline of 72% (95% Confidence Interval: 0.6, 12.8). The intervention increased facility delivery among women with past home deliveries by 18.3 percentage points (95% CI: 10.1, 26.6). Antenatal quality increased in intervention facilities with providers performing an additional 0.5 actions across the full population and 0.8 actions for the home delivery subgroup. Conclusions We attribute the increased use of facilities to better antenatal quality. This increased utilisation would lead to lower maternal mortality only in the presence of improvement in care quality.
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Affiliation(s)
- Elysia Larson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anna D Gage
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Margaret E Kruk
- 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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Kaiser JL, Fong RM, Hamer DH, Biemba G, Ngoma T, Tusing B, Scott NA. How a woman's interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc Sci Med 2019; 220:312-321. [PMID: 30500609 PMCID: PMC6323354 DOI: 10.1016/j.socscimed.2018.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/31/2018] [Accepted: 11/06/2018] [Indexed: 11/16/2022]
Abstract
To reduce maternal mortality, countries must continue to seek ways to increase access to skilled care during pregnancy and delivery. In Zambia, while antenatal attendance is high, many barriers exist that prevent women from delivering with a skilled health provider. This study explores how the individuals closest to a pregnant woman in rural Zambia can influence a woman's decision to seek and her ability to access timely maternity care. At four rural health centers, a free listing (n = 167) exercise was conducted with mothers, fathers, and community elders. Focus group discussions (FGD) (n = 135) were conducted with mothers, fathers, mothers-in-law, and community health workers (CHWs) to triangulate findings. We analyzed the FGD data against a framework that overlaid the Three Delays Framework and the Social Ecological Model. Respondents cited husbands, female relatives, and CHWs as the most important influencers during a woman's maternity period. Husbands have responsibilities to procure resources, especially baby clothes, and provide the ultimate permission for a woman to attend ANC or deliver at a facility. Female relatives escort the woman to the facility, assist during her wait, provide emotional support, assist the nurse during delivery, and care for the woman after delivery. CHWs educate the woman during pregnancy about the importance of facility delivery. No specific individual has the role of assisting with the woman's household responsibilities or identifying transport to the health facility. When husbands, female relatives, or CHWs do not fulfill their roles, this presents a barrier to a woman deciding to deliver at the health facility (Delay 1) or reaching a health facility (Delay 2). An intervention to help women better plan for acquiring the needed resources and identifying the individuals to escort her and those to perform her household responsibilities could help to reduce these barriers to accessing timely maternal care.
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Affiliation(s)
- Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA.
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA; Section of Infectious Diseases, Department of Medicine, Boston Medical Center, One Boston Medical Center Pl, Boston, MA, 02118, USA
| | - Godfrey Biemba
- Zambia Center for Applied Health Research and Development, Plot 4186 Addis Ababa Drive, Long Acres, P.O. Box 30910, Lusaka, Zambia
| | - Thandiwe Ngoma
- Zambia Center for Applied Health Research and Development, Plot 4186 Addis Ababa Drive, Long Acres, P.O. Box 30910, Lusaka, Zambia
| | - Brittany Tusing
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA
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15
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Henry EG, Semrau K, Hamer DH, Vian T, Nambao M, Mataka K, Scott NA. The influence of quality maternity waiting homes on utilization of facilities for delivery in rural Zambia. Reprod Health 2017; 14:68. [PMID: 28558800 PMCID: PMC5450262 DOI: 10.1186/s12978-017-0328-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/19/2017] [Indexed: 11/25/2022] Open
Abstract
Background Residential accommodation for expectant mothers adjacent to health facilities, known as maternity waiting homes (MWH), is an intervention designed to improve access to skilled deliveries in low-income countries like Zambia where the maternal mortality ratio is estimated at 398 deaths per 100,000 live births. Our study aimed to assess the relationship between MWH quality and the likelihood of facility delivery in Kalomo and Choma Districts in Southern Province, Zambia. Methods We systematically assessed and inventoried the functional capacity of all existing MWH using a quantitative facility survey and photographs of the structures. We calculated a composite score and used multivariate regression to quantify MWH quality and its association with the likelihood of facility delivery using household survey data collected on delivery location in Kalomo and Choma Districts from 2011–2013. Results MWH were generally in poor condition and composite scores varied widely, with a median score of 28.0 and ranging from 12 to 66 out of a possible 75 points. Of the 17,200 total deliveries captured from 2011–2013 in 40 study catchment area facilities, a higher proportion occurred in facilities where there was either a MWH or the health facility provided space for pregnant waiting mothers compared to those with no accommodations (60.7% versus 55.9%, p <0.001). After controlling for confounders including implementation of Saving Mothers Giving Life, a large-scale maternal health systems strengthening program, among women whose catchment area facilities had an MWH, those women with MWHs in their catchment area that were rated medium or high quality had a 95% increase in the odds of facility delivery than those whose catchment area MWHs were of poor quality (OR: 1.95, 95% CI 1.76, 2.16). Conclusions Improving both the availability and the quality of MWH represents a potentially useful strategy to increasing facility delivery in rural Zambia. Trial registration The Zambia Chlorhexidine Application Trial is registered at Clinical Trials.gov (identifier: NCT01241318)
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Affiliation(s)
- Elizabeth G Henry
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | - Katherine Semrau
- Ariadne Labs, Boston, USA.,Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA.,Department of Medicine, Harvard Medical School, Boston, USA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, USA.,Zambia Center for Applied Health Research and Development (ZCAHRD) Limited, Lusaka, Zambia
| | - Taryn Vian
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | | | - Kaluba Mataka
- Zambia Center for Applied Health Research and Development (ZCAHRD) Limited, Lusaka, Zambia
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, USA.
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