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Lazzerini M, Ciuch M, Rusconi S, Covi B. Facilitators and barriers to the effective implementation of the individual maternal near-miss case reviews in low/middle-income countries: a systematic review of qualitative studies. BMJ Open 2018; 8:e021281. [PMID: 29961025 PMCID: PMC6042547 DOI: 10.1136/bmjopen-2017-021281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The maternal near-miss cases review (NMCR), a type of clinical audit, proved to be effective in improving quality of care and decreasing maternal mortality in low/middle-income countries (LMICs). However, challenges in its implementation have been described. OBJECTIVES Synthesising the evidence on facilitators and barriers to the effective implementation of NMCR in LMICs. DESIGN Systematic review of qualitative studies. DATA SOURCES MEDLINE, LILACS, Global Health Library, SCI-EXPANDED, SSCI, Cochrane library and Embase were searched in December 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Qualitative studies exploring facilitators and/or barriers of implementing NMCR in LMIC were included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data, performed thematic analysis and assessed risk of bias. RESULTS Out of 25 361 papers retrieved, 9 studies from Benin, Brazil, Burkina Faso, Cote D'Ivoire, Ghana, Malawi, Morocco, Tanzania, Uganda could be included in the review. The most frequently reported barriers to NMCR implementation were the following: absence of national guidelines and local protocols; insufficient training on how to perform the audit; lack of leadership, coordination, monitoring and supervision; lack of resources and work overload; fear of blame and punishment; poor knowledge of evidenced-based medicine; hierarchical differences among staff and poor understating of the benefits of the NMCR. Major facilitators to NMCR implementation included: good leadership and coordination; training of all key staff; a good cultural environment; clear staff's perception on the benefits of conducting audit; patient empowerment and the availability of external support. CONCLUSIONS In planning the NMCR implementation in LMICs, policy-makers should consider actions to prevent and mitigate common challenges to successful NMCR implementation. Future studies should aim at documenting facilitators and barriers to NMCR outside the African Region.
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Affiliation(s)
- Marzia Lazzerini
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Margherita Ciuch
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Silvia Rusconi
- Department of Obstetrics and Gynecology, Hospital of Padova, Padova, Italy
| | - Benedetta Covi
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
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Bacci A, Hodorogea S, Khachatryan H, Babojonova S, Irsa S, Jansone M, Dondiuc I, Matarazde G, Lazdane G, Lazzerini M. What is the quality of the maternal near-miss case reviews in WHO European Region? Cross-sectional study in Armenia, Georgia, Latvia, Republic of Moldova and Uzbekistan. BMJ Open 2018; 8:e017696. [PMID: 29654004 PMCID: PMC5898291 DOI: 10.1136/bmjopen-2017-017696] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 12/12/2017] [Accepted: 12/14/2017] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES The maternal near-miss case review (NMCR) cycle is a type of clinical audit aiming at improving quality of maternal healthcare by discussing near-miss cases. In several countries this approach has been introduced and supported by WHO and partners since 2004, but information on the quality of its implementation is missing. This study aimed at evaluating the quality of the NMCR implementation in selected countries within WHO European Region. DESIGN Cross-sectional study. SETTINGS Twenty-three maternity units in Armenia, Georgia, Latvia, Moldova and Uzbekistan. ASSESSMENT TOOLS A predefined checklist including 50 items, according to WHO methodology. Quality in the NMCR implementation was defined by summary scores ranging from 0 (totally inappropriate) to 3 (appropriate). RESULTS Quality of the NMCR implementation was heterogeneous among different countries, and within the same country. Overall, the first part of the audit cycle (from case identification to case analysis) was fairly well performed (mean score 2.00, 95% CI 1.94 to 2.06), with the exception of the 'inclusion of users' views' (mean score 0.66, 95% CI 0.11 to 1.22), while the second part (developing recommendations, implementing them and ensuring quality) was poorly performed (mean score 0.66, 95% CI 0.11 to 1.22). Each country had at least one champion facility, where quality of the NMCR cycle was acceptable. Quality of the implementation was not associated with its duration. Gaps in implementation were of technical, organisational and attitudinal nature. CONCLUSIONS Ensuring quality in the NMCR may be difficult but achievable. The high heterogeneity in results within the same country suggests that quality of the NMCR implementation depends, to a large extent, from hospital factors, including staff's commitment, managerial support and local coordination. Efforts should be put in preventing and mitigating common barriers that hamper successful NMCR implementation.
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Affiliation(s)
- Alberta Bacci
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Stelian Hodorogea
- State Medical and Pharmaceutical University "N. Testemitanu", Chisinau, Moldova
| | | | | | - Signe Irsa
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | | | | | - Gunta Lazdane
- Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Marzia Lazzerini
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
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Varela PLR, Oliveira RRD, Melo EC, Mathias TADF. Pregnancy complications in Brazilian puerperal women treated in the public and private health systems. Rev Lat Am Enfermagem 2018; 25:e2949. [PMID: 29319740 PMCID: PMC5768206 DOI: 10.1590/1518-8345.2156.2949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 06/07/2017] [Indexed: 11/22/2022] Open
Abstract
Objective: to analyze the prevalence of pregnancy complications and sociodemographic profile
of puerperal patients with complications, according to the form of financing of
the childbirth service. Method: cross-sectional study with interview of 928 puerperal women whose childbirth was
financed by the Unified Health System, health plans and private sources (other
sources than the Unified Health System). The sample was calculated based on the
births registered in the Information System on Live Births, stratified by hospital
and form of financing of the childbirth service. Data were analyzed using the
chi-square and Fisher’s exact tests. Results: the prevalence was 87.8% for all puerperal women, with an average of 2.4
complications per woman. In the case of deliveries covered by the Unified Health
System, urinary tract infection (38.2%), anemia (26.0%) and leucorrhea (23.5%)
were more frequent. In turn, vaginal bleeding (26.4%), urinary tract infection
(23.9%) and leucorrhoea (23.7%) were prevalent in deliveries that were not covered
by the Unified Health System. Puerperal women that had their delivery covered by
the Unified Health System reported a greater number of intercurrences related to
infectious diseases, while women who used health plans and private sources
reported intercurrences related to chronic diseases. A higher frequency of
puerperal adolescents, non-white women, and women without partner among those
assisted in the Unified Health System (p < 0.001). Conclusion: the high prevalence of complications indicates the need for monitoring and
preventing diseases during pregnancy, especially in the case of pregnant women
with unfavorable sociodemographic characteristics.
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Affiliation(s)
| | - Rosana Rosseto de Oliveira
- Post-doctoral fellow, Departamento de Enfermagem, Universidade Estadual de Maringá, Maringá, PR, Brazil. Scholarship holder at Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil
| | - Emiliana Cristina Melo
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Estadual do Norte do Paraná, Bandeirantes, PR, Brazil
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Cecatti JG, Silveira C, Souza RT, Fernandes KG, Surita FG. EXPERIENCE WITH THE BRAZILIAN NETWORK FOR STUDIES IN REPRODUCTIVE AND PERINATAL HEALTH: THE POWER OF COLLABORATION IN POSTGRADUATE PROGRAMS. Rev Col Bras Cir 2017; 42 Suppl 1:89-93. [PMID: 27437983 DOI: 10.1590/0100-69912015s01027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 09/12/2015] [Indexed: 12/11/2022] Open
Abstract
The scientific collaboration in networks may be developed among countries, academic institutions and among peer researchers. Once established, they contribute for knowledge dissemination and a strong structure for research in health. Several advantages are attributed to working in networks: the inclusion of a higher number of subjects in the studies; generation of stronger evidence with a higher representativeness of the population (secondary generalization and external validity); higher likelihood of articles derived from these studies to be accepted in high impact journals with a wide coverage; a higher likelihood of obtaining budgets for sponsorship; easier data collection on rare conditions; inclusions of subjects from different ethnic groups and cultures, among others. In Brazil, the Brazilian Network for Studies on Reproductive and Perinatal Health was created in 2008 with the initial purpose of developing a national network of scientific cooperation for the surveillance of severe maternal morbidity. Since the establishment of this Network, five studies were developed, some of them already finished and others almost being completed, and two new ones being implemented. Results of the activities in this Network have been very productive and with a positive impact on not only the Postgraduate Program of Obstetrics and Gynecology from the University of Campinas, its coordinating center, but also on other participating centers. A considerable number of scientific articles was published, master´s dissertations and PhD theses were presented, and post-doctorate programs were performed, including students from several areas of health, from distinct regions and from several institutions of the whole country. This represents a high social impact taking into account the relevance of the studied topics for the country. As colaborações científicas em rede podem ocorrer entre países, instituições acadêmicas e entre pares de pesquisadores e, uma vez estabelecidas, contribuem para a disseminação do conhecimento e estruturação da pesquisa em saúde. Diversas vantagens são atribuídas ao trabalho em rede como: a inclusão de maior número de participantes nos estudos; gerar evidências mais fortes e com maior representatividade da população (generalização secundária e validade externa); maior facilidade das publicações oriundas dos estudos serem aceitas em periódicos de impacto e abrangência; maior probabilidade de obtenção de verbas para financiamento; maior facilidade na coleta de dados sobre condições raras; inclusão de participantes de diferentes grupos étnicos e culturas, entre outras. No Brasil a Rede Brasileira de Estudos em Saúde Reprodutiva e Perinatal foi criada em 2008 com o objetivo inicial de desenvolver rede nacional de cooperação científica para vigilância da morbidade materna grave. Desde sua formação, cinco estudos foram desenvolvidos, alguns já encerrados e outros em fase de finalização, com outros dois em fase final de implantação. Os resultados das atividades desta Rede têm sido bastante produtivos e impactaram positivamente não apenas no Programa de Pós-Graduação em Tocoginecologia da Universidade Estadual de Campinas, seu centro coordenador, mas também o de outros centros participantes, uma vez que expressivo número de artigos científicos foi publicado, mestrados e doutorados foram defendidos e pós-doutorados finalizados, de alunos de diversas áreas da saúde, de diferentes regiões e de várias instituições de todo o país, com alto impacto social dada a relevância dos temas estudados para o país.
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Affiliation(s)
- José G Cecatti
- Postgraduate Program in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, School of Medical Sciences, Campinas State University, Campinas, SP, Brazil
| | - Carla Silveira
- Postgraduate Program in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, School of Medical Sciences, Campinas State University, Campinas, SP, Brazil
| | - Renato T Souza
- Postgraduate Program in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, School of Medical Sciences, Campinas State University, Campinas, SP, Brazil
| | - Karayna G Fernandes
- Postgraduate Program in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, School of Medical Sciences, Campinas State University, Campinas, SP, Brazil
| | - Fernanda G Surita
- Postgraduate Program in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, School of Medical Sciences, Campinas State University, Campinas, SP, Brazil
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Cecatti JG, Costa ML, Haddad SM, Parpinelli MA, Souza JP, Sousa MH, Surita FG, Pinto E Silva JL, Pacagnella RC, Passini R. Network for Surveillance of Severe Maternal Morbidity: a powerful national collaboration generating data on maternal health outcomes and care. BJOG 2015; 123:946-53. [PMID: 26412586 DOI: 10.1111/1471-0528.13614] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify cases of severe maternal morbidity (SMM) during pregnancy and childbirth, their characteristics, and to test the feasibility of scaling up World Health Organization criteria for identifying women at risk of a worse outcome. DESIGN Multicentre cross-sectional study. SETTING Twenty-seven referral maternity hospitals from all regions of Brazil. POPULATION Cases of SMM identified among 82 388 delivering women over a 1-year period. METHODS Prospective surveillance using the World Health Organization's criteria for potentially life-threatening conditions (PLTC) and maternal near-miss (MNM) identified and assessed cases with severe morbidity or death. MAIN OUTCOME MEASURES Indicators of maternal morbidity and mortality; sociodemographic, clinical and obstetric characteristics; gestational and perinatal outcomes; main causes of morbidity and delays in care. RESULTS Among 9555 cases of SMM, there were 140 deaths and 770 cases of MNM. The main determining cause of maternal complication was hypertensive disease. Criteria for MNM conditions were more frequent as the severity of the outcome increased, all combined in over 75% of maternal deaths. CONCLUSIONS This study identified around 9.5% of MNM or death among all cases developing any severe maternal complication. Multicentre studies on surveillance of SMM, with organised collaboration and adequate study protocols can be successfully implemented, even in low-income and middle-income settings, generating important information on maternal health and care to be used to implement appropriate health policies and interventions. TWEETABLE ABSTRACT Surveillance of severe maternal morbidity was proved to be possible in a hospital network in Brazil.
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Affiliation(s)
- J G Cecatti
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - M L Costa
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - S M Haddad
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - M A Parpinelli
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - J P Souza
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - M H Sousa
- Centre for Research on Reproductive Health of Campinas (Cemicamp), Campinas, Brazil
| | - F G Surita
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - J L Pinto E Silva
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - R C Pacagnella
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - R Passini
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
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