Challenges in implementing emergency obstetric care (EmOC) policies: perspectives and behaviours of frontline health workers in Uganda

Global, regional, and national causes of under-5 mortality in 2000-19: an updated systematic analysis with implications for the Sustainable Development Goals

BACKGROUND

Causes of mortality are a crucial input for health systems for identifying appropriate interventions for child survival. We present an updated series of cause-specific mortality for neonates and children younger than 5 years from 2000 to 2019.

METHODS

We updated cause-specific mortality estimates for neonates and children aged 1-59 months, stratified by level (low, moderate, or high) of mortality. We made a substantial change in the statistical methods used for previous estimates, transitioning to a Bayesian framework that includes a structure to account for unreported causes in verbal autopsy studies. We also used systematic covariate selection in the multinomial framework, gave more weight to nationally representative verbal autopsy studies using a random effects model, and included mortality due to tuberculosis.

FINDINGS

In 2019, there were 5·30 million deaths (95% uncertainty range 4·92-5·68) among children younger than 5 years, primarily due to preterm birth complications (17·7%, 16·1-19·5), lower respiratory infections (13·9%, 12·0-15·1), intrapartum-related events (11·6%, 10·6-12·5), and diarrhoea (9·1%, 7·9-9·9), with 49·2% (47·3-51·9) due to infectious causes. Vaccine-preventable deaths, such as for lower respiratory infections, meningitis, and measles, constituted 21·7% (20·4-25·6) of under-5 deaths, and many other causes, such as diarrhoea, were preventable with low-cost interventions. Under-5 mortality has declined substantially since 2000, primarily because of a decrease in mortality due to lower respiratory infections, diarrhoea, preterm birth complications, intrapartum-related events, malaria, and measles. There is considerable variation in the extent and trends in cause-specific mortality across regions and for different strata of all-cause under-5 mortality.

INTERPRETATION

Progress is needed to improve child health and end preventable deaths among children younger than 5 years. Countries should strategize how to reduce mortality among this age group using interventions that are relevant to their specific causes of death.

FUNDING

Bill & Melinda Gates Foundation; WHO.

Health workers' social networks and their influence in the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda

Health workers' peer networks are known to influence members' behaviours and practices while translating policies into service delivery. However, little remains known about the extent to which this remains true within interventions aimed at addressing the stillbirth burden in low-resource settings like Uganda. The objective of this study was to examine the health workers' social networks and their influence on the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda. A qualitative exploratory design was adopted on a purposively selected sample of 16 key informants. The study was conducted in Mukono district among sub-national health systems, managers, health facility in-charges, and frontline health workers. Data was collected using semi-structured interview guides in a face-to-face interview with respondents. The analysis adopted a thematic approach utilising Atlas. ti software for data management. Participants acknowledged that workplace social networks were influential during the implementation of policies to address stillbirth. The influence exerted was in form of linkage with other services, caution, and advice regarding strict adherence to policy recommendations perhaps reflective of the level of trust in providers' ability to adhere to policy provisions. At the district health management level and among non-state actors, support in perceived areas of weak performance in policy implementation was observed. In addition, timely initiation of contact and subsequent referral was another aspect where health workers exerted influence while translating policies to address the stillbirth burden. While the level of support from among network peers was observed to influence health workers' adoption and implementation of strategies to address the stillbirth burden, different mechanisms triggered subsequent response and level of adherence to recommended policy aspects. Drawing from the elicited responses, we infer that health workers' social networks influence the direction and extent of success in policy implementation to address the stillbirth burden at the subnational level.