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Gebhardt GS, de Waard L. Audit as a tool for improving obstetric care in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102477. [PMID: 38581883 DOI: 10.1016/j.bpobgyn.2024.102477] [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: 10/02/2023] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 04/08/2024]
Abstract
Maternal and/or perinatal death review or audits aim to improve the quality of health services and reduce deaths due to causes identified. A death review audit cycle identifies causes of deaths and possible modifiable factors, these can point to potential breaks in the continuity of health care and other health systems faults and challenges. It is an important function of audit cycles to develop, implement, monitor, and review action plans to improve the service. The WHO has produced two handbooks (Making Every Baby Count and Monitoring Emergency Obstetric Care) to guide maternal and perinatal death reviews. Health worker related factors accounts for two thirds of aspects that, if done differently may have prevented the adverse outcome. This emphasises the need for skilled health care workers at every delivery and for deliveries to take place in health facilities.
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Affiliation(s)
- G S Gebhardt
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, South Africa.
| | - L de Waard
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, South Africa
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Lee A, Wang MYF, Roy D, Wang J, Gokhale A, Miranda-Cacdac L, Kuntz M, Grover B, Gray K, Curley KL. Prophylactic Tranexamic Acid Prevents Postpartum Hemorrhage and Transfusions in Cesarean Deliveries: A Systematic Review and Meta-analysis. Am J Perinatol 2024; 41:e2254-e2268. [PMID: 37311543 DOI: 10.1055/a-2109-3730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and PPH resulting in transfusion is the most common maternal morbidity in the United States. Literature demonstrates that tranexamic acid (TXA) can reduce blood loss in cesarean deliveries; however, there is little consensus on the impact on major morbidities like PPH and transfusions. We conducted a systematic review/meta-analysis of randomized controlled trials (RCTs) to evaluate if administration of prophylactic intravenous (IV) TXA prevents PPH and/or transfusions following low-risk cesarean delivery. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Five databases were searched: Cochrane, EBSCO, Ovid, PubMed, and ClinicalKey. RCTs published in English between January 2000 and December 2021 were included. Studies compared PPH and transfusions in cesarean deliveries between prophylactic IV TXA and control (placebo or no placebo). The primary outcome was PPH, and the secondary outcome was transfusions. Random effects models were used to calculate effect size (ES) of exposure in Mantel-Haenszel risk ratios (RR). All analysis was done at a confidence level (CI) of α = 0.5. Modeling showed that TXA led to significantly less risk of PPH than control (RR: 0.43; 95% CI: 0.28-0.67). The effect on transfusion was comparable (RR: 0.39; 95% CI: 0.21-0.73). Heterogeneity was minimal (I 2 = 0%). Due to the large sample sizes needed, many RCTs are not powered to interpret TXA's effect on PPH and transfusions. Pooling these studies in a meta-analysis allows for more power and analysis but is limited by the heterogeneity of studies. Our results minimize heterogeneity while demonstrating that prophylactic TXA can lower PPH occurrence and reduce the need for blood transfusion. We suggest considering prophylactic IV TXA as the standard of care in low-risk cesarean deliveries. KEY POINTS: · Consider TXA prior to incision for singleton, term pregnancies undergoing elective cesarean.. · Prophylactic TXA is effective in preventing PPH and blood transfusions.. · Routine use of TXA has the potential to decrease transfusion-related complications and costs..
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Affiliation(s)
- Amy Lee
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Mary Ying-Fang Wang
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Debosree Roy
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Jenny Wang
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Abha Gokhale
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | | | - Moriah Kuntz
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Bryan Grover
- Department of Obstetrics and Gynecology, Banner University Medical Center Phoenix, Phoenix, Arizona
| | - Kendra Gray
- Department of Obstetrics and Gynecology, Banner University Medical Center Phoenix, Phoenix, Arizona
| | - Kathleen L Curley
- Department of Obstetrics and Gynecology, Banner University Medical Center Phoenix, Phoenix, Arizona
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3
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Ekwuazi EK, Chigbu CO, Ngene NC. Reducing maternal mortality in low- and middle-income countries. Case Rep Womens Health 2023; 39:e00542. [PMID: 37954228 PMCID: PMC10636262 DOI: 10.1016/j.crwh.2023.e00542] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 11/14/2023] Open
Affiliation(s)
- Emeka Kingsley Ekwuazi
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria Nsukka, Nigeria
| | - Chibuike O. Chigbu
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria Nsukka, Nigeria
| | - Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynecology, Leratong Hospital, Krugersdorp, South Africa
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Ikeda S, Shibanuma A, Pokharel A, Silwal RC, Jimba M. Improving the quality of maternal and newborn healthcare at the district level: Addressing newborn deaths in Nepal. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002101. [PMID: 37531345 PMCID: PMC10395984 DOI: 10.1371/journal.pgph.0002101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Abstract
Maternal and newborn care quality can be measured in three dimensions (Dimensions 1: care provision, 2: care experience, and 3: human and physical resources); however, little is known about which dimensions are associated with newborn and perinatal deaths. We examined the association between care quality and newborn and perinatal deaths in Nepal. This study incorporated secondary data from Nepal Service Provision Assessments (NSPA) 2015 (623 delivery facilities, facility inventory survey; 1,509 women, ANC clients interviews; 1,544 women, ANC observation) and Nepal Demographic and Health Surveys (NDHS) 2016 (5,038 women who reported having given birth in the five years preceding data collection). The outcome variables were newborn and perinatal deaths derived from the NDHS. The exposure variables were district-level maternal and newborn care quality scores calculated from the NSPA data. Covariates were women's sociodemographic, health, and obstetric characteristics. We applied the administrative boundary method to link these two surveys. We conducted binary logistic regression analyses to examine the association between care quality and newborn/perinatal deaths. In Dimension 1, higher mean and maximum quality scores at the district level were associated with a lower number of newborn deaths (mean: odds ratio [OR] = 0.04, 95% confidence interval [CI]: 0.00-0.76; max: OR = 0.09, 95% CI: 0.01-0.58), but not with perinatal deaths. In Dimensions 2 and 3, the quality score was not significantly associated with newborn deaths and perinatal. Enhancing the quality of care provision at its average and highest levels in each district may contribute to the reduction of newborn deaths, but not perinatal death. Health administrators should assess the quality of care at the administrative division level and focus on enhancing both average and maximum care quality of health facilities in each region in the care provision dimension.
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Affiliation(s)
- Subaru Ikeda
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Akira Shibanuma
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Alpha Pokharel
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Ram Chandra Silwal
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Masamine Jimba
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
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Wuni FK, Kukeba MW, Zakariah Y, Nyaabila EA, Saanwie AS. Contributory factors to early neonatal deaths in the Upper East Regional Hospital in Ghana. Ghana Med J 2023; 57:128-133. [PMID: 38504758 PMCID: PMC10846648 DOI: 10.4314/gmj.v57i2.7] [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] [Indexed: 03/21/2024] Open
Abstract
Objective This study examined factors identified during early neonatal death audits contributing to preventable newborn deaths at the Upper East Regional Hospital. Method Data for this study was collected retrospectively from perinatal death audit forms using three data collectors. Data collection lasted two weeks, from 18th June to 2nd July 2021. The data collectors submitted 113 filled hard copy data collection forms. This was then entered into a designed Excel sheet and exported to STATA software version 15.0 for analysis. The analysis was descriptive statistics with cross-tabulation. The results were presented in charts and tables focusing on percentages. Results Most of the 113 neonatal deaths were from birth asphyxia (63%). Forty-six (40.7%) of the deaths occurred within 24 hrs after birth. There were 38 factors reported 254 times in the audits as contributory to all the newborn deaths; 17 health personnel-related factors stated 141 (55.5%) times, four transportation and communication-related factors stated 43 (16.9%) times, seven health facility factors stated 31 (12.2%) times. Inappropriate care during transportation to the regional hospital was reported most - 21 times, followed by delay in referral - 18 times. Conclusion The study identified many factors, such as medical personnel-related factors, transportation and communication factors, family-related factors, and health facility administration factors, contributing to early neonatal deaths. Effective implementation of neonatal death audit-based recommendations arising from these contributory factors is critical to preventing avoidable newborn deaths. Funding This project was funded by Upper East Regional Hospital.
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Affiliation(s)
| | - Margaret W. Kukeba
- CK Tedam University for Technology and Applied Sciences, Navrongo, Upper East Region, Ghana
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Clarke-Deelder E, Opondo K, Oguttu M, Burke T, Cohen JL, McConnell M. Immediate postpartum care in low- and middle-income countries: A gap in healthcare quality research and practice. Am J Obstet Gynecol MFM 2023; 5:100764. [PMID: 36216312 DOI: 10.1016/j.ajogmf.2022.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/16/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
The immediate postpartum period carries significant risks for complications such as postpartum hemorrhage and sepsis. Postpartum monitoring, including taking vital signs and monitoring blood loss, is important for the early identification and management of complications, but many women in low- and middle-income countries receive minimal attention in the period following childbirth to facility discharge. The World Health Organization recently released new guidelines on postnatal care, which include recommendations for immediate postpartum monitoring. In light of the new guidelines, this presented an opportune moment to address the gaps in postpartum monitoring in low- and middle-income countries. In this commentary, we bring attention to the importance of immediate postpartum monitoring. We identified opportunities for strengthening this often overlooked aspect of maternity care through improvements in quality measurement and data availability, research into barriers against high-quality care, and innovations in service delivery design.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland (Dr Clarke-Deelder).
| | - Kennedy Opondo
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke)
| | - Monica Oguttu
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu)
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke); Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (Dr Burke); Harvard Medical School, Boston, MA (Dr Burke)
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
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Dynes MM, Daniel GA, Mac V, Picho B, Asiimwe A, Nalutaaya A, Opio G, Kamara V, Kaharuza F, Serbanescu F. A qualitative evaluation and conceptual framework on the use of the Birth weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) matrix for perinatal health in Uganda. BMC Pregnancy Childbirth 2023; 23:86. [PMID: 36726073 PMCID: PMC9890791 DOI: 10.1186/s12884-023-05402-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Perinatal mortality (newborn deaths in the first week of life and stillbirths) continues to be a significant global health threat, particularly in resource-constrained settings. Low-tech, innovative solutions that close the quality-of-care gap may contribute to progress toward the Sustainable Development Goals for health by 2030. From 2012 to 2018, the Saving Mothers, Giving Life Initiative (SMGL) implemented the Birth weight and Age-at-Death Boxes for Intervention and Evaluation System (BABIES) matrix in Western Uganda. The BABIES matrix provides a simple, standardized way to track perinatal health outcomes to inform evidence-based quality improvement strategies. METHODS In November 2017, a facility-based qualitative evaluation was conducted using in-depth interviews with 29 health workers in 16 health facilities implementing BABIES in Uganda. Data were analyzed using directed content analysis across five domains: 1) perceived ease of use, 2) how the matrix was used, 3) changes in behavior or standard operating procedures after introduction, 4) perceived value of the matrix, and 5) program sustainability. RESULTS Values in the matrix were easy to calculate, but training was required to ensure correct data placement and interpretation. Displaying the matrix on a highly visible board in the maternity ward fostered a sense of accountability for health outcomes. BABIES matrix reports were compiled, reviewed, and responded to monthly by interprofessional teams, prompting collaboration across units to fill data gaps and support perinatal death reviews. Respondents reported improved staff communication and performance appraisal, community engagement, and ability to track and link clinical outcomes with actions. Midwives felt empowered to participate in the problem-solving process. Respondents were motivated to continue using BABIES, although sustainability concerns were raised due to funding and staff shortages. CONCLUSIONS District-level health systems can use data compiled from the BABIES matrix to inform policy and guide implementation of community-centered health practices to improve perinatal heath. Future work may consider using the Conceptual Framework on Use of the BABIES Matrix for Perinatal Health as a model to operationalize concepts and test the impact of the tool over time.
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Affiliation(s)
- Michelle M. Dynes
- grid.416738.f0000 0001 2163 0069Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Gaea A. Daniel
- grid.189967.80000 0001 0941 6502Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA USA
| | - Valerie Mac
- grid.189967.80000 0001 0941 6502Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA USA
| | - Brenda Picho
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Alice Asiimwe
- grid.423308.e0000 0004 0397 2008Baylor College of Medicine Children’s Foundation, Kampala, Uganda
| | - Agnes Nalutaaya
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gregory Opio
- grid.423308.e0000 0004 0397 2008Baylor College of Medicine Children’s Foundation, Kampala, Uganda
| | | | - Frank Kaharuza
- grid.440478.b0000 0004 0648 1247Kampala International University, Western Campus, Ishaka Bushenyi, Uganda
| | - Florina Serbanescu
- grid.416738.f0000 0001 2163 0069Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA USA
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Quality Improvement Models and Methods for Maternal Health in Lower-Resource Settings. Obstet Gynecol Clin North Am 2022; 49:823-839. [DOI: 10.1016/j.ogc.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Banke-Thomas A. The potential utility of an augmented data collection approach in understanding the journey to care of pregnant women for maternal and perinatal death surveillance and response. F1000Res 2022; 11:739. [PMID: 36128551 PMCID: PMC9475203 DOI: 10.12688/f1000research.123210.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 01/13/2023] Open
Abstract
Background: The Maternal and Perinatal Death Surveillance and Response (MPDSR) proposed by the World Health Organization recognises the importance for health systems to understand the reasons underpinning the death of a pregnant woman or her newborn as an essential first step in preventing future similar deaths. Data for the surveillance component of the MPDSR process are typically collected from health facility sources and post-mortem interviews with affected families, though it may be traumatising to them. This brief report aimed to assess the potential utility of an augmented data collection method for mapping journeys of maternal and perinatal deaths, which does not require sourcing additional information from grieving family members. Methods: A descriptive analysis of maternal and perinatal deaths that occurred across 24 public hospitals in Lagos State, Nigeria, between 1 st November 2018 and 30 th October 2019 was conducted. Data on their demographic, obstetric history and complication at presentation, travel to the hospital, and mode of birth were extracted from their hospital records. The extracted travel data was exported to Google Maps, where driving distance and travel time to the hospital for the period of the day of travel were also extracted. Results: Of the 182 maternal deaths, most presented during the week (80.8%), travelled 5-10 km (30.6%) and 10-29 minutes (46.9%), and travelled to the nearest hospital to their places of residence (70.9%). Of the 442 pregnant women who had perinatal deaths, most presented during the week (78.5%), travelled <5 km (26.9%) and 10-29 minutes (38.0%). For both, the least reported travel data was the mode of travel used to care (>90.0%) and the period of the day they travelled (approximately 30.0%). Conclusion: An augmented data collection approach that includes accurate and complete travel data and closer-to-reality estimates of travel time and distance can be beneficial for MPDSR purposes.
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Affiliation(s)
- Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, London, SE10 9LS, UK,Maternal and Reproductive Health Research Collective, Lagos, Nigeria,
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Prasad N, Mwakatundu N, Dominico S, Masako P, Mongo W, Mwanshemele Y, Maro G, Subi L, Chaote P, Rusibamayila N, Ruiz A, Schmidt K, Kasanga MG, Lobis S, Serbanescu F. Improving Maternal and Reproductive Health in Kigoma, Tanzania: A 13-Year Initiative. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00484. [PMID: 35487559 PMCID: PMC9053157 DOI: 10.9745/ghsp-d-21-00484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/02/2022] [Indexed: 11/15/2022]
Abstract
The 13-year Program to Reduce Maternal Deaths in Tanzania employed multifaceted maternal, newborn, and reproductive health interventions that contributed to increasing the availability and utilization of high-quality obstetric and family planning services and reducing maternal and perinatal mortality in Kigoma. The Program to Reduce Maternal Deaths in Tanzania was a 13-year (2006–2019) effort in the Kigoma region that evolved over 3 phases to improve and sustain the availability of, access to, and demand for high-quality maternal and reproductive health care services. The Program intended to bring high-quality care closer to more communities. Cutting across the Program was the routine collection of monitoring and evaluation data. The Program achieved significant reductions in maternal and perinatal mortality, a significant increase in the modern contraceptive prevalence rate, and a significant decline in the unmet need for contraception. By 2017, it was apparent that the Program was on track to meet or surpass many of the targets established by the Government of Tanzania. Over the following 2-plus years, efforts to sustain Program interventions intensified. In April 2019, the Program fully transitioned to Government of Tanzania oversight. Four key lessons were learned during implementation that are relevant to governments, donors, and implementing organizations working to reduce maternal mortality: (1) multistakeholder partnerships are critical; (2) demand creation for services, while critical, must rest on a foundation of well-functioning and high-quality clinical services; (3) it is imperative to not only collect robust monitoring and evaluation data, but to be responsive in real time to what the data reveal; and, (4) it is necessary to develop a deliberate sustainability strategy from the start. The Program in Kigoma demonstrates that decentralizing high-quality maternal and reproductive health services in remote, low-resource settings is both feasible and effective and should be considered in places with similar contexts. By embedding the Program in the existing health system, and through efforts to build local capacity, the improvements seen in Kigoma are likely to be sustained. Follow-up evaluations are planned, providing an opportunity to more directly assess sustainability.
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Affiliation(s)
| | | | | | | | | | | | | | - Leonard Subi
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Paul Chaote
- President's Office Regional Administration and Local Government, Health Social Welfare and Nutrition Division, Dodoma, Tanzania
| | - Neema Rusibamayila
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Alicia Ruiz
- U.S. Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, USA
| | | | | | | | - Florina Serbanescu
- U.S. Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, USA.
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Ogola M, Njuguna EM, Aluvaala J, English M, Irimu G. Audit identified modifiable factors in Hospital Care of Newborns in low-middle income countries: a scoping review. BMC Pediatr 2022; 22:99. [PMID: 35180843 PMCID: PMC8855576 DOI: 10.1186/s12887-021-02965-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/19/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Audit of facility-based care provided to small and sick newborns is a quality improvement initiative that helps to identify the modifiable gaps in newborn care (BMC Pregnancy Childbirth 14: 280, 2014). The aim of this work was to identify literature on modifiable factors in the care of newborns in the newborn units in health facilities in low-middle-income countries (LMICs). We also set out to design a measure of the quality of the perinatal and newborn audit process. METHODS The scoping review was conducted using the methodology outlined by Arksey and O'Malley and refined by Levac et al, (Implement Sci 5:1-9, 2010). We reported our results using the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. We identified seven factors to ensure a successful audit process based on World Health Organisation (WHO) recommendations which we subsequently used to develop a quality of audit process score. DATA SOURCES We conducted a structured search using PubMed, CINAHL, EMBASE, LILACS, POPLINE and African Index Medicus. STUDY SELECTION Studies published in English between 1965 and December 2019 focusing on the identification of modifiable factors through clinical or mortality audits in newborn care in health facilities from LMICs. DATA EXTRACTION We extracted data on the study characteristics, modifiable factors and quality of audit process indicators. RESULTS A total of six articles met the inclusion criteria. Of these, four were mortality audit studies and two were clinical audit studies that we used to assess the quality of the audit process. None of the studies were well conducted, two were moderately well conducted, and four were poorly conducted. The modifiable factors were divided into three time periods along the continuum of newborn care. The period of newborn unit care had the highest number of modifiable factors, and in each period, the health worker related modifiable factors were the most dominant. CONCLUSION Based on the significant number of modifiable factors in the newborn unit, a neonatal audit tool is essential to act as a structured guide for auditing newborn unit care in LMICs. The quality of audit process guide is a useful method of ensuring high quality audits in health facilities.
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Affiliation(s)
- Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya.
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya.
- Pumwani Maternity Hospital, Nairobi, Kenya.
| | | | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Bezerra IMP, Ramos JLS, Pianissola MC, Adami F, da Rocha JBF, Ribeiro MAL, de Castro MR, Bezerra JDF, Smiderle FRN, Sousa LVDA, Siqueira CE, de Abreu LC. Perinatal Mortality Analysis in Espírito Santo, Brazil, 2008 to 2017. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11671. [PMID: 34770185 PMCID: PMC8583128 DOI: 10.3390/ijerph182111671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 12/17/2022]
Abstract
This is an ecological and time-series study using secondary data on perinatal mortality and its components from 2008 to 2017 in Espírito Santo, Brazil. The data were collected from the Mortality Information System (SIM) and Live Births Information System (SINASC) of the Unified Health System Informatics Department (DATASUS) in June 2019. The perinatal mortality rate (×1000 total births) was calculated. Time series were constructed from the perinatal mortality rate for the regions and Espírito Santo. To analyze the trend, the Prais-Winsten model was used. From 2008 to 2017 there were 8132 perinatal deaths (4939 fetal and 3193 early neonatal) out of a total of 542,802 births, a perinatal mortality rate of 15.0/1000 total births. The fetal/early neonatal ratio was 1.5:1, with a strong positive correlation early neonatal mortality rate, perinatal mortality rate, r (9) = 0.8893, with a significance level of p = 0.000574. The presence of differences in trends by health region was observed. Risk factors that stood out were as follows: mother's age ranging between 10 and 19 or 40 and 49 years old, with no education, a gestational age between 22 and 36 weeks, triple and double pregnancy, and a birth weight below 2499 g. Among the causes of death, 49.70% of deaths were concentrated in category of the tenth edition of the International Classification of Diseases, fetuses and newborns affected by maternal factors and complications of pregnancy, labor, and delivery (P00-P04), and 11.03% were in the category of intrauterine hypoxia and birth asphyxia (P20-P21), both related to proper care during pregnancy and childbirth. We observed a slow reduction in the perinatal mortality rate in the state of Espírito Santo from 2008 to 2017.
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Affiliation(s)
- Italla Maria Pinheiro Bezerra
- Departamento de Pós-Graduação em Políticas Públicas e Desenvolvimento Local, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), Vitória 29027502, Brazil
- Departamento de Enfermagem, Laboratório de Escrita Científica, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), Vitória 29027502, Brazil; (J.L.S.R.); (M.C.P.); (F.R.N.S.)
| | - José Lucas Souza Ramos
- Departamento de Enfermagem, Laboratório de Escrita Científica, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), Vitória 29027502, Brazil; (J.L.S.R.); (M.C.P.); (F.R.N.S.)
| | - Micael Colodetti Pianissola
- Departamento de Enfermagem, Laboratório de Escrita Científica, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), Vitória 29027502, Brazil; (J.L.S.R.); (M.C.P.); (F.R.N.S.)
| | - Fernando Adami
- Laboratório de Epidemiologia do Centro Universitário ABC (FMABC), Santo André 09060590, Brazil;
| | - João Batista Francalino da Rocha
- Ciências da Saúde no Centro Universitário ABC (FMABC), Santo André 09060870, Brazil; (J.B.F.d.R.); (M.A.L.R.)
- Centro de Ciências da Saúde e do Desporto (CCSD), Universidade Federal do Acre (UFAC), Rio Branco 69920900, Brazil
| | - Mariane Albuquerque Lima Ribeiro
- Ciências da Saúde no Centro Universitário ABC (FMABC), Santo André 09060870, Brazil; (J.B.F.d.R.); (M.A.L.R.)
- Centro de Ciências da Saúde e do Desporto (CCSD), Universidade Federal do Acre (UFAC), Rio Branco 69920900, Brazil
| | - Magda Ribeiro de Castro
- Departamento de Enfermagem da Universidade Federal do Espírito Santo (UFES), Vitória 29075910, Brazil;
| | - Juliana da Fonsêca Bezerra
- Departamento de Enfermagem Materno Infantil (DEMI) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro 21941901, Brazil;
| | - Fabiana Rosa Neves Smiderle
- Departamento de Enfermagem, Laboratório de Escrita Científica, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), Vitória 29027502, Brazil; (J.L.S.R.); (M.C.P.); (F.R.N.S.)
| | | | - Carlos Eduardo Siqueira
- Environment and Public Health, School for the Environment, Transnational Brazilian Project, The Mauricio Gastón Institute for Latino Community Development and Public Policy, UMass Boston, Boston, MA 02125, USA;
| | - Luiz Carlos de Abreu
- Departamento de Educação Integrada em Saúde na Universidade Federal do Espírito Santo (UFES), Vitória 29027502, Brazil;
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13
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Qiao J, Wang Y, Li X, Jiang F, Zhang Y, Ma J, Song Y, Ma J, Fu W, Pang R, Zhu Z, Zhang J, Qian X, Wang L, Wu J, Chang HM, Leung PCK, Mao M, Ma D, Guo Y, Qiu J, Liu L, Wang H, Norman RJ, Lawn J, Black RE, Ronsmans C, Patton G, Zhu J, Song L, Hesketh T. A Lancet Commission on 70 years of women's reproductive, maternal, newborn, child, and adolescent health in China. Lancet 2021; 397:2497-2536. [PMID: 34043953 DOI: 10.1016/s0140-6736(20)32708-2] [Citation(s) in RCA: 176] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Jie Qiao
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Ministry of Education Key Laboratory of Assisted Reproduction, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.
| | - Yuanyuan Wang
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Ministry of Education Key Laboratory of Assisted Reproduction, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xiaohong Li
- National Office for Maternal and Child Health Surveillance of China, National Center for Birth Defect Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Fan Jiang
- Child Health Advocacy Institute, National Children's Medical Center, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yunting Zhang
- Child Health Advocacy Institute, National Children's Medical Center, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Ma
- Institute of Child and Adolescent Health, Key Laboratory of Reproductive Health, School of Public Health, Peking University, Beijing, China
| | - Yi Song
- Institute of Child and Adolescent Health, Key Laboratory of Reproductive Health, School of Public Health, Peking University, Beijing, China
| | - Jing Ma
- China Program for Health Innovation & Transformation, Department of Population Medicine, Harvard University, Boston, MA, USA
| | - Wei Fu
- China National Health and Development Research Centre, Beijing, China
| | - Ruyan Pang
- China Maternal and Child Health Association, Beijing, China
| | - Zhaofang Zhu
- China National Health and Development Research Centre, Beijing, China
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xu Qian
- School of Public Health & Global Health Institute, Fudan University, Shanghai, China
| | - Linhong Wang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jiuling Wu
- National Center for Women and Children's Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hsun-Ming Chang
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Ministry of Education Key Laboratory of Assisted Reproduction, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Peter C K Leung
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Ministry of Education Key Laboratory of Assisted Reproduction, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Meng Mao
- National Office for Maternal and Child Health Surveillance of China, National Center for Birth Defect Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Duan Ma
- Key Laboratory of Metabolism and Molecular Medicine, Ministry of Education, Department of Biochemistry and Molecular Biology, Fudan University, Shanghai, China
| | - Yan Guo
- Department of Global Health, School of Public Health, Peking University, Beijing, China
| | - Jie Qiu
- Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China
| | - Li Liu
- Department of Population Family and Reproductive Health, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Haidong Wang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Robert J Norman
- Robinson Research Institute, Fertility SA, University of Adelaide, Adelaide, SA, Australia
| | - Joy Lawn
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Robert E Black
- Department of Population Family and Reproductive Health, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - George Patton
- Centre for Adolescent Health, Murdoch Children's Research Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Jun Zhu
- National Office for Maternal and Child Health Surveillance of China, National Center for Birth Defect Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.
| | - Li Song
- Department of Women and Children Health, National Health Commission of the People's Republic of China, Bejing, China.
| | - Therese Hesketh
- Center for Global Health, School of Medicine, Zhejiang University, Hangzhou, China; and Institute for Global Health, University College London, London, UK
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Helfinstein S, Jain M, Ramesh BM, Blanchard J, Kemp H, Gothalwal V, Namasivayam V, Kumar P, Sgaier SK. Facilities are substantially more influential than care providers in the quality of delivery care received: a variance decomposition and clustering analysis in Kenya, Malawi and India. BMJ Glob Health 2021; 5:bmjgh-2020-002437. [PMID: 32816803 PMCID: PMC7440830 DOI: 10.1136/bmjgh-2020-002437] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/02/2020] [Accepted: 07/08/2020] [Indexed: 01/13/2023] Open
Abstract
Introduction Improving the quality of care during childbirth is essential for reducing neonatal and maternal mortality. One barrier to improving quality of care is understanding the appropriate level to target interventions. We examine quality of care data during labour and delivery from multiple countries to assess whether quality varies primarily from nurse to nurse within the same facility, or primarily between facilities. Methods To assess the relative contributions of nurses and facilities to variance in quality of care, we performed a variance decomposition analysis using a linear mixed effect model on two data sources: (1) the number of vital signs assessed for women in labour from a study of nurse practices in Uttar Pradesh, India; 2) broad-scale indices of respectful and competent care generated from Service Provision Assessments in Kenya and Malawi. We used unsupervised clustering, a data mining technique that groups objects together based on similar characteristics, to identify groups of facilities that displayed distinct patterns of vital signs assessment behaviour. Results We found 3–10 times more variance in quality of care was explained by the facility where a patient received care than by the nurse who provided it. The unsupervised clustering analysis revealed groups of facilities with highly distinct patterns of vital signs assessment, even when overall rates of vital signs assessments were similar (eg, some facilities consistently test fetal heart rate, but not other vitals, others only blood pressure). Conclusion Facilities within a region can vary substantially in the quality of care they provide to women in labour, but within a facility, nurses tend to provide similar care. This holds true both for care that can be influenced by equipment availability and technical training (eg, vital signs assessment), as well as cultural aspects (eg, respectful care).
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Affiliation(s)
| | | | - Banadakoppa Manjappa Ramesh
- India Health Action Trust, Lucknow, Uttar Pradesh, India.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James Blanchard
- Centre for Global Public Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Vikas Gothalwal
- India Health Action Trust, Lucknow, Uttar Pradesh, India.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vasanthakumar Namasivayam
- India Health Action Trust, Lucknow, Uttar Pradesh, India.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Pankaj Kumar
- National Health Mission, Government of Uttar Pradesh, Lucknow, Uttar Pradesh, India
| | - Sema K Sgaier
- Surgo Foundation, Washington, DC, USA .,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
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15
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Cahyanti RD, Widyawati W, Hakimi M. The reliability of maternal audit instruments to assign cause of death in maternal deaths review process: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2021; 21:380. [PMID: 34001025 PMCID: PMC8127245 DOI: 10.1186/s12884-021-03840-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 04/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal Death Reviews (MDR) can assist in formulating prevention strategies to reduce maternal mortality. To support MDR, an adequate MDR instrument is required to accurately identify the underlying causes of maternal deaths. We conducted a systematic review and meta-analysis to determine the reliability of maternal death instruments for conducting the MDR process. METHOD Three databases: PubMed, ProQuest and EBSCO were systematically searched to identify related research articles published between January 2004 and July 2019. The review and meta-analysis involved identification of measurement tools to conduct MDR in all or part of maternal audit. Eligibiliy and quality of studies were evaluated using the Modified Quality Appraisal of Diagnostic Reliability (QAREL) Checklist: Reliability Studies. RESULTS Overall, 242 articles were identified. Six articles examining the instrument used for MDR in 4 countries (4 articles on verbal autopsy (VA) and 2 articles on facility-based MDR) were included. None of studies identified reliability in evaluation instruments assessing maternal audit cycle as a comprehensive approach. The pooled kappa for the MDR instruments was 0.72 (95%CI:0.43-0.99; p < 0.001) with considerable heterogeneity (I2 = 96.19%; p < 0.001). Subgroup analysis of MDR instruments showed pooled kappa in VA of 0.89 (95%CI:0.52-1.25) and facility-based MDR of 0.48 (95%CI:0.15-0.82). Meta-regression analysis tended to show the high heterogeneity was likely associated with sample sizes, regions, and year of publications. CONCLUSIONS The MDR instruments appear feasible. Variation of the instruments suggest the need for judicious selection of MDR instruments by considering the study population and assessment during the target periods.
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Affiliation(s)
- Ratnasari D Cahyanti
- Doctoral Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.,Obstetrics and Gynecology Department, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Widyawati Widyawati
- Pediatric and Maternity Nursing Department, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Mohammad Hakimi
- Obstetrics and Gynecology Department, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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16
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Nkhwalume L, Mashalla Y. Health care workers experiences in emergency obstetric care following implementation of an in-service training program: case of 2 Referral Hospitals in Botswana. Afr Health Sci 2021; 21:51-58. [PMID: 34447424 PMCID: PMC8367308 DOI: 10.4314/ahs.v21i1.9s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Maternal mortality rate remains a challenge in many developing countries. Objectives This study explored experiences of Health Care Workers on Emergency Obstetrics Care (EMOC) in-service training and its effect on maternal mortality. Methods Descriptive qualitative study design was conducted using in-depth interviews and focus group discussions. Participants were EMOC trained midwives and doctors purposively selected from the 2 referral hospitals in the country. Data were transcribed verbatim, coded, and analysed using Grounded Theory approach. Results Four themes emerged including training, EMOC implementation, maternal death factors and EMOC prioritisation. The duration of training was viewed inadequate but responsiveness to and confidence in managing obstetric emergencies improved post EMOC training. Staff shortage, HCWs non-adherence and negative attitude to EMOC guidelines; delays in instituting interventions, inadequate community involvement, minimal or no health talk to women and their partners and communities on sexual reproductive matters and non-prioritisation of EMOC by authorities were concerns raised. Conclusion Strengthening health education at health facility levels, stakeholders' involvement; and prioritising EMOC in-service training are necessary in reducing the national maternal mortality.
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Affiliation(s)
| | - Yohana Mashalla
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
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17
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Lapidot R, Larson Williams A, MacLeod WB, Mwale M, Olowojesiku R, Enslen A, Mwananyanda L, Munanjala G, Chimoga C, Ngoma B, Thea DL, Gill CJ. Verbal Autopsies for Out-of-Hospital Infant Deaths in Zambia. Pediatrics 2021; 147:peds.2020-1767. [PMID: 33664096 DOI: 10.1542/peds.2020-1767] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In Zambia, a significant number of infants die in the community. It is hypothesized that delays in care contribute to many of these so-called "brought in dead" infants. METHODS We analyzed free-text narratives from verbal autopsies, in which families narrate the final series of events leading to each infant's death. Using the 3-delays model framework and working iteratively to achieve consensus, we coded each narrative using NVivo software to identify, characterize, and quantify the contribution of delays and other factors to the fatal outcome. RESULTS Verbal autopsies were collected from 230 families of brought in dead infants younger than 6 months of age. As many as 82.8% of infants had 1 or more delays in care. The most-common delay was in the family's decision to seek care (54.8%), even as severe symptoms were frequently described. Similarly, 27.8% of infants died en route to a health care facility. Delays in receiving adequate care, including infants dying while waiting in line at a clinic or during referral from a clinic to a hospital, occurred in 24.7% of infants. A third of infants had been previously evaluated by a clinician in the days before their death. CONCLUSIONS Delays in care were the rule rather than the exception in this population of Zambian infants. Accessing care requires families to navigate significant logistic barriers, and balance complex forces in deciding to seek care. Strategies to avoid such delays could save many infants lives.
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Affiliation(s)
- Rotem Lapidot
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts; .,Department of Pediatrics, School of Medicine and
| | - Anna Larson Williams
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - William B MacLeod
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | | | | | - Andrew Enslen
- School of Medicine, University of California, San Diego, San Diego, California
| | - Lawrence Mwananyanda
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts.,Right to Care, Equip, Lusaka, Zambia
| | | | | | | | - Donald L Thea
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - Christopher John Gill
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
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18
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Gopal DP, Chetty U, O'Donnell P, Gajria C, Blackadder-Weinstein J. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthc J 2021; 8:40-48. [PMID: 33791459 DOI: 10.7861/fhj.2020-0233] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bias is the evaluation of something or someone that can be positive or negative, and implicit or unconscious bias is when the person is unaware of their evaluation. This is particularly relevant to policymaking during the coronavirus pandemic and racial inequality highlighted during the support for the Black Lives Matter movement. A literature review was performed to define bias, identify the impact of bias on clinical practice and research as well as clinical decision making (cognitive bias). Bias training could bridge the gap from the lack of awareness of bias to the ability to recognise bias in others and within ourselves. However, there are no effective debiasing strategies. Awareness of implicit bias must not deflect from wider socio-economic, political and structural barriers as well ignore explicit bias such as prejudice.
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Affiliation(s)
- Dipesh P Gopal
- Barts and The London School of Medicine and Dentistry, London, UK
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19
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Ximba SW, Baloyi OB, Ann Jarvis M. Midwives' perceived role in up referral of high-risk pregnancies in primary healthcare settings, eThekwini district, South Africa. Health SA 2021; 26:1546. [PMID: 33824728 PMCID: PMC8008006 DOI: 10.4102/hsag.v26i0.1546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2022] Open
Abstract
Background South African maternal and neonatal mortality rates remain unnecessarily high, which are considered avoidable through timeous identification, treatment and referral. An efficient referral process of high-risk pregnant women is dependent on the midwives’ ability to respond with relevance to the maternal and neonatal healthcare needs. The attainment of improved maternal and neonatal outcomes commences at the primary healthcare level, with the midwife, recognised as the first person responsible and accountable for pregnant women’s healthcare. Aim To explore midwives’ perceptions of their role in the referral of high-risk pregnant women from primary health care clinics to expert-centred sites. Methods A qualitative, exploratory, descriptive in nature approach, underpinned by a social constructivism paradigm, guided the methodology. Purposive sampling was used to select both the primary health care clinics in the feeder zone and the registered midwives working in these clinics. Data were collected through four focus group discussions and analysed using content analysis. The principles of trustworthiness were observed. Setting Department of Health primary health care clinics in the eThekwini district, South Africa. Results The midwives understood their role in the up referral of high-risk pregnant women but experienced many interruptions in its execution. Four categories emerged from the data, namely, enhanced by team support in the clinics, restrictions in transfer to expert-centred sites, impeding social determinants and midwifery competence facilitates referral process. Conclusion Global initiatives cannot guarantee maternal and neonatal health because of the challenges experienced by the midwives in the execution of their roles as they interface with the healthcare team.
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Affiliation(s)
- Siyabonga W Ximba
- Department of Nursing, College of Health Sciences, University of Kwazulu-Natal, Durban, South Africa
| | - Olivia B Baloyi
- Department of Nursing, College of Health Sciences, University of Kwazulu-Natal, Durban, South Africa
| | - Mary Ann Jarvis
- Department of Nursing, College of Health Sciences, University of Kwazulu-Natal, Durban, South Africa
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20
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Maternal death surveillance and response in Tanzania: comprehensiveness of narrative summaries and action points from maternal death reviews. BMC Health Serv Res 2021; 21:52. [PMID: 33430848 PMCID: PMC7802180 DOI: 10.1186/s12913-020-06036-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/21/2020] [Indexed: 11/24/2022] Open
Abstract
Background Maternal deaths reviews are proposed as one strategy to address high maternal mortality in low and middle-income countries, including Tanzania. Review of maternal deaths relies on comprehensive documentation of medical records that can reveal the sequence of events leading to death. The World Health Organization’s and the Tanzanian Maternal Death and Surveillance (MDSR) system propose the use of narrative summaries during maternal death reviews for discussing the case to categorize causes of death, identify gaps in care and recommend action plans to prevent deaths. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). To identify gaps in documenting information and developing recommendations, comprehensiveness of written narrative summaries and action plans were assessed. Methods A total of 76 facility maternal deaths that occurred in two regions in Southern Tanzania in 2018 were included for analysis. Using a prepared checklist from Tanzania 2015 MDSR guideline, we assessed comprehensiveness by presence or absence of items in four domains, each with several attributes. These were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. Less than 75% completeness of attributes in all domains was considered poor while 95% and above were good/comprehensive. Action plans were assessed by application of SMART criteria and according to the place of planned implementation (community, facility or higher level of health system). Results Almost half of narrative summaries (49%) scored poor, and only1% scored good/comprehensive. Summaries missed key information such as demographic characteristics, time between diagnosis of complication and commencing treatment (65%), investigation results (47%), summary of case evolution (51%) and referral information (47%). A total of 285 action points were analysed. Most action points, 242(85%), recommended strategies to be implemented at health facilities and were mostly about service delivery, 120(42%). Only 42% (32/76) of the action points were deemed to be SMART. Conclusions Abstraction of information to prepare narrative summaries used in the MDSR system is inadequately done. Most recommendations were unspecific with a focus on improving quality of care in health facilities.
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21
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/24/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 01/25/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Chai P, Zhang Y, Zhou M, Liu S, Kinfu Y. Health system productivity in China: a comparison of pre- and post-2009 healthcare reform. Health Policy Plan 2020; 35:257-266. [PMID: 31828335 DOI: 10.1093/heapol/czz157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2019] [Indexed: 11/13/2022] Open
Abstract
In 2009, China launched an ambitious health system reform that combined extending social health insurance scheme with improving efficiency, access and quality of care in the country. To assess the impact of the policy on efficiency and productivity change, we investigated the country's health system performance at provincial levels during pre- and post-reform period. Outputs were measured using multiple health outcomes (namely, non-communicable diseases free healthy life years and infant and maternal survival rates), while health expenditure, number of medical personnel and hospital beds per 1000 residents were used as proxy measures for health inputs. Changes in productivity were quantified using a bootstrap Malmquist productivity index (MPI). The analysis focused on the period between 2004 and 2015. This was to capture pre- and post-policy implementation experience and to ensure that enough time was allowed for the policy to work through. Finally, a bootstrap Tobit regression model for panel data was applied to examine the potential effects of contextual factors on productivity change. The result showed that the reform has had negative effects on productivity. Only scale efficiency had improved steadily, but the decline in the scale of technological change observed during the same period meant that the progress in scale efficiency had been masked. Better economic performance (as measured by per capita Gross Domestic Product (GDP)) and higher human resource to capital investment ratio (as measured by density of medical staff per hospital beds) tended to boost productivity growth, while population aging, low educational attainment and higher percentage of out-of-pocket (OOP) payments had adverse effects. Improving health system productivity in China requires improving financial risk protection and maintaining proper balance between human and capital investment in the country.
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Affiliation(s)
- Peipei Chai
- Faculty of Health, University of Canberra, Building 22, 11 Kirinari Street, Bruce, ACT 2617, Australia.,Department of Health Economics and National Health Accounts Research, China National Health Development Research Center, B3 Wudong Building, 9 Chegongzhuang Street, Xicheng District, Beijing 100044, China
| | - Yuhui Zhang
- Department of Health Economics and National Health Accounts Research, China National Health Development Research Center, B3 Wudong Building, 9 Chegongzhuang Street, Xicheng District, Beijing 100044, China
| | - Maigeng Zhou
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China
| | - Shiwei Liu
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China
| | - Yohannes Kinfu
- Faculty of Health, University of Canberra, Building 22, 11 Kirinari Street, Bruce, ACT 2617, Australia
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Exley J, Hanson C, Umar N, Willey B, Shuaibu A, Marchant T. Provision of essential evidence-based interventions during facility-based childbirth: cross-sectional observations of births in northeast Nigeria. BMJ Open 2020; 10:e037625. [PMID: 33099494 PMCID: PMC7590366 DOI: 10.1136/bmjopen-2020-037625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 09/12/2020] [Accepted: 09/22/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To measure the provision of evidence-based preventive and promotive interventions to women, and subsequently their newborns, during childbirth in a high-mortality setting. DESIGN AND PARTICIPANTS Cross-sectional observations of care provided to women, and their newborns during the intrapartum and immediate postpartum period using a standardised checklist capturing healthcare worker behaviours regarding lifesaving and respectful care. SETTING Ten primary healthcare facilities in Gombe state, northeast Nigeria. The northeast region of Nigeria has some of the highest maternal and newborn death rates globally. MAIN OUTCOME MEASURES Data on 50 measures of internationally recommended evidence-based interventions and good practice. RESULTS 1875 women were admitted to a health facility during the observation period; of these, 1804 gave birth in the facility and did not experience an adverse event or death. Many clinical interventions around the time of birth were routinely implemented, including provision of uterotonic (96% (95% CI 93% to 98%)), whereas risk-assessment measures, such as history-taking or checking vital signs were rarely completed: just 2% (95% CI 2% to 7%) of women had their temperature taken and 12% (95% CI 9% to 16%) were asked about complications during the pregnancy. CONCLUSIONS The majority of women did not receive the recommended routine processes of childbirth care they and their newborns needed to benefit from their choice to deliver in a health facility. In particular, few benefited from even basic risk assessments, leading to missed opportunities to identify risks. To continue with the recommendation of childbirth care in primary healthcare facilities in high mortality settings like Gombe, it is crucial that birth attendant capacity, capability and prioritisation processes are addressed.
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Affiliation(s)
- Josephine Exley
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
- Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Nasir Umar
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Barbara Willey
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Abdulrahman Shuaibu
- The Executive Secretary, Gombe State Primary Health Care Development Agency, Gombe, Nigeria
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Masereka EM, Naturinda A, Tumusiime A, Munguiko C. Implementation of the Perinatal Death Surveillance and Response guidelines: Lessons from annual health system strengthening interventions in the Rwenzori Sub-Region, Western Uganda. Nurs Open 2020; 7:1497-1505. [PMID: 32802370 PMCID: PMC7424478 DOI: 10.1002/nop2.524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/01/2020] [Indexed: 11/21/2022] Open
Abstract
Aim To determine the health facility-based perinatal mortality rate, its causes and avoidable factors using the perinatal mortality surveillance and response guidelines. Design This was an action study conducted in one of the districts in Western Uganda from 1 January-31 December 2019. Methods A total of 20 perinatal death cases were recruited consecutively. Data were collected using a Ministry of Health Perinatal Death Surveillance and Response (PDSR) questionnaire containing questions on pregnancy, delivery and immediate postnatal care. We used descriptive statistics to describe key data elements. Results We found a health facility-based perinatal mortality rate of 17.3 deaths per 1,000 live births. Birth asphyxia was the most common cause of perinatal deaths. Seven, three and ten mothers delayed seeking, reaching and receiving appropriate health care, respectively.
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Affiliation(s)
- Enos Mirembe Masereka
- Department of Nursing and MidwiferySchool of MedicineKabale UniversityKabaleUganda
- Department of Nursing and MidwiferySchool of Health SciencesMountains of the Moon UniversityFort PortalUganda
| | - Amelia Naturinda
- Infectious Diseases InstituteSchool of MedicineCollege of Health SciencesMakerere UniversityKampalaUganda
| | - Alex Tumusiime
- Department of Nursing and MidwiferySchool of MedicineKabale UniversityKabaleUganda
| | - Clement Munguiko
- Department of Nursing and MidwiferySchool of Health SciencesMountains of the Moon UniversityFort PortalUganda
- Department of NursingSchool of Health SciencesSoroti UniversitySorotiUganda
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Said A, Malqvist M, Pembe AB, Massawe S, Hanson C. Causes of maternal deaths and delays in care: comparison between routine maternal death surveillance and response system and an obstetrician expert panel in Tanzania. BMC Health Serv Res 2020; 20:614. [PMID: 32623999 PMCID: PMC7336440 DOI: 10.1186/s12913-020-05460-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background To reduce maternal mortality Tanzania introduced Maternal Death Surveillance and Response (MDSR) system in 2015 as recommended by World Health Organization (WHO). All health facilities are to notify and review all maternal deaths inorder to recommend quality improvement actions to reduce deaths in future. The system relies on consistent and correct categorization of causes of maternal deaths and three phases of delays. To assess its adequacy we compared the routine MDSR categorization of causes of death and three phases of delays to those assigned by an independent expert panel with additional information from Verbal Autopsy (VA). Methods Our cross-sectional study included 109 reviewed maternal deaths from two regions in Tanzania for the year 2018. We abstracted the underlying medical causes of death and the three phases of delays from MDSR system records. We interviewed bereaved families using the standard WHO VA questionnaire. The obstetrician expert panel assigned underlying causes of death based on information from medical files and VA according to International Classification of Disease to Death in Pregnancy Childbirth and Puerperium (ICD-MM). They assigned causes to nine ICD-MM groups and identified the three phases of delays. We used Cohen’s K statistic to compare causes of deaths and delays categorization. Results Comparison of underlying causes was done for 99 deaths. While 109 and 84 deaths for expert panel and MDSR respectively were analyzed for delays because of missing data in MDSR system. Expert panel and MDSR system assigned the same underlying causes in 64(64.6%) deaths (K statistic 0.60). Agreement increased in 80 (80.8%) when causes were assigned by ICD-MM groups (K statistic 0.76). The obstetrician expert panel identified phase one delays in 74 (67.9%), phase two in 24 (22.0%) and phase three delays in all 101 (100%) deaths that were assessed for this delay while MDSR system identified delays in 42 (50.0%), 10 (11.9%) and 78 (92.9%).The expert panel found human errors in management in 94 (93.1%) while MDSR system reported in 53 (67.9%) deaths. Conclusions MDSR committees performed reasonably well in assigning underlying causes of death. The obstetrician expert panel found more delays than reported in MDSR system indicating difficulties within MDSR teams to critically review deaths.
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Affiliation(s)
- Ali Said
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. .,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Mats Malqvist
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Siriel Massawe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach. Glob Health Action 2020; 12:1672314. [PMID: 31599213 PMCID: PMC6792038 DOI: 10.1080/16549716.2019.1672314] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Somali women suffer from one of the highest maternal mortality rates in the world. Somalia characterises a specific low-income country situation with a mix of newly urbanized and nomadic culture combined with a frail health care infrastructure set in a post-conflict era. Very little is known about the effects that these contextual factors can have on maternal mortality. Objectives: To explore and describe causes and contributing factors concerning maternal deaths in the Bosaso District, Puntland State of Somalia. Methods: Data was collected using an adapted Verbal Autopsy tool. In 2017 30 cases of maternal deaths occurring in 2016 in the Bosaso District were reviewed. Information was assessed by three independent reviewers who classified the cause of death and the contributing factors. The Three Delay Model was employed to identify socio-cultural and economic and health system factors that may have contributed to these maternal deaths. Results: Direct obstetric deaths accounted for 28 cases. Among these, haemorrhage was the leading cause, followed by eclampsia, sepsis and obstructed labour. Two cases were indirect obstetric deaths, caused by anaemia. All three types of delay were frequent among the studied cases. Delay in deciding to seek care was found in 25 cases, delay in reaching care in 22 cases and delay in receiving health care in 24 cases. Lack of knowledge, money, transportation, poor access and availability of adequate services, as well as substandard management by health care providers, were all underlying the delays. Conclusion: A comprehensive intervention programme is needed in order to decrease maternal mortality among Somali women. Such a programme must include health education, improved referral systems and strategic upgrading of care services.
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Affiliation(s)
- Jamila Ahmed Aden
- Faculty of Medicine and Health Sciences, East Africa University , Bosaso , Puntland State of Somalia, Somalia.,Social Medicine and Global Health, Department of Clinical Sciences Malmö, Lund University , Lund , Sweden.,Department of Epidemiology and Global Health, Umeå University , Umeå , Sweden
| | - Hinda Jama Ahmed
- Faculty of Medicine and Health Sciences, East Africa University , Bosaso , Puntland State of Somalia, Somalia
| | - Per-Olof Östergren
- Social Medicine and Global Health, Department of Clinical Sciences Malmö, Lund University , Lund , Sweden
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Gebretsadik A, Tarekegne Z, Teshome M. Retrospective review of maternal deaths in Hawassa Comprehensive Specialised Hospital, in Southern Ethiopia. J OBSTET GYNAECOL 2019; 40:659-665. [PMID: 31512545 DOI: 10.1080/01443615.2019.1648398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to evaluate the causes of and contributors to maternal death at Hawassa Referral Comprehensive Specialised Hospital (HRCSH). A health facility-based, maternal death review was used. All maternal deaths that occurred between January 2016 and August 2017 in HRCSH were included. Data were collected using a structured data collection sheet and analysed. Eighty-two maternal deaths that occurred over a 20-month period were reviewed, of which 77 met the inclusion criteria. A total of 8466 births occurred in HRCSH during the study period. The overall facility-based maternal mortality rate (MMR) was 910 deaths per 100,000 live births. The majority of maternal deaths (69 deaths; 89.6%) were due to direct causes, with pregnancy-induced hypertension as the leading direct cause of 33 deaths (42.8%). Eight avoidable factors were identified in this review. Twenty-six patients (33.9%) died as a result of a combination of three or more factors. Patient-oriented and transport/referral factors were the most common avoidable factors, with each contributing to 62 deaths (80.5%). Prenatal patients would benefit from receiving information regarding danger signs that could assist in the early detection of health problems and increase the likelihood that they seek health care.Impact StatementWhat is already known on this subject? Most maternal deaths are preventable. However, maternal mortality rates remain high despite the presence of multiple measures in the southern part of Ethiopia. There is no adequate information about the maternal death rate in the study setting.What do the results of this study add? Hawassa Referral Comprehensive Specialised Hospital is a regional health centre. This study found that combinations of several factors may be contributing to a high maternal death rate. Most notably, transport, delay management initiation after admission and referral factors account for the majority of maternal deaths.What is the implication of these findings for clinical practice/or further research? Identification of potential problems could assist context-based management of problems. It helps in improving the level of practical skills for the management of pregnancy-related complications like hypertension. It also solves problems in the health services system like access to interventions. It insists on intersectoral collaboration to solve the transportation problems.
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Affiliation(s)
| | - Zerai Tarekegne
- School of Medicine, Department of Obstetrics and Gynecology, Hawassa University, Hawassa, Ethiopia
| | - Million Teshome
- School of Medicine, Department of Obstetrics and Gynecology, Hawassa University, Hawassa, Ethiopia
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Chai P, Zhang Y, Zhou M, Liu S, Kinfu Y. Technical and scale efficiency of provincial health systems in China: a bootstrapping data envelopment analysis. BMJ Open 2019; 9:e027539. [PMID: 31383699 PMCID: PMC6686990 DOI: 10.1136/bmjopen-2018-027539] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 06/12/2019] [Accepted: 07/05/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE With escalating health expenditures and increasing health needs, improving health system performance has become imperative in China and internationally. The objective of this study is to examine the efficiency of China's health system and to understand the underlying causes of the variation in efficiency across provinces. SETTING A system-wide perspective is adopted, focusing on performance in maternal health, child health and non-communicable diseases (NCDs) in the 31 provinces of mainland China during 2015. METHODS Analyses were performed using bootstrapping data envelopment technique. Health outcomes were measured by infant survival rates, maternal survival rates and healthy life years calculated only considering NCDs. Health inputs were measured using health expenditure, and density of medical personnel and hospital beds. The model also examined the impact of environmental factors on health system efficiency. RESULTS Due to wide-spread scale inefficiency in the country, the average bias-corrected overall technical efficiency (OTE) was 0.8022 (95% CI values ranging from 0.7251 to 0.8492). Socioeconomic status, hospitalisation rate and share of out-of-pocket expenditures were significant determinants of OTE. Nearly 60% of the provinces operated at a decreasing return to scale, meaning that a gain in efficiency could be achieved only through downsizing the scale of operation. CONCLUSIONS Given the pervasive nature of diminishing returns across provinces, health policy makers must explore the optimum operational scale which is people-centred and focused on prevention, rather than on treatment, of diseases. Moreover, due consideration should be afforded to social determinants of health and health financing arrangements to complement health-sector based reforms and meet the ambitious goals of the Healthy China 2030 Plan.
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Affiliation(s)
- Peipei Chai
- Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
- National Health Accounts and Policy Studies, China National Health Development Research Center, Beijing, China
| | - Yuhui Zhang
- National Health Accounts and Policy Studies, China National Health Development Research Center, Beijing, China
| | - Maigeng Zhou
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Shiwei Liu
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yohannes Kinfu
- Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
- Department of Health Metrics Sciences, University of Washington, Seattle, Washington, USA
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Saltarelli RMF, Prado RRD, Monteiro RA, Machado ÍE, Teixeira BDSM, Malta DC. Deaths preventable by actions of the Unified Health System in the population of the Brazilian Southeast Region. CIENCIA & SAUDE COLETIVA 2019; 24:887-898. [PMID: 30892510 DOI: 10.1590/1413-81232018243.01282017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 03/22/2017] [Indexed: 11/22/2022] Open
Abstract
This paper aims to analyze the mortality trend in the population aged 5-69 years residing in the Southeast and Federal Units (UF), using the "Brazilian List of Preventable Deaths Causes". An ecological study on time series of the standardized mortality rate from preventable and non-preventable causes, with adjustments for ill-defined causes and underreporting of notified deaths, from 2000 to 2013. A declining mortality rate from preventable (2.4% per year) and non-preventable causes (1.5% per year) was found in the population aged 5-69 years living in the Southeast in the period 2000-2013. A drop in all groups of preventable deaths causes and stability in the maternal death causes was observed. Deaths from noncommunicable diseases fell 2.7% annually and were higher in the age group of 60-69 years in 2013 (211.8/100,000 inhabitants for deaths from ischemic heart disease, 146.3/100,000 inhabitants for cerebrovascular diseases and 96.5/100,000 inhabitants for diabetes). The highest preventable death rates are from chronic noncommunicable diseases and external causes, both of which are sensitive to health promotion and intersectoral interventions, which reinforces the need for integrated health policies.
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Affiliation(s)
| | | | | | - Ísis Eloah Machado
- Escola de Enfermagem, Universidade Federal de Minas Gerais. Belo Horizonte MG Brasil
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Nkwanyana NM, Voce AS, Mnqayi SO, Sartorius B, Schneider H. A health system framework for perinatal care in South African district hospitals: a Delphi technique. BMC Health Serv Res 2019; 19:402. [PMID: 31221153 PMCID: PMC6585044 DOI: 10.1186/s12913-019-4200-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/30/2019] [Indexed: 11/12/2022] Open
Abstract
Background The majority of perinatal deaths occurring in low- and middle- income countries are preventable. South Africa is a middle-income country with consistently high perinatal mortality rates and most factors contributing to preventable deaths are linked to the functioning of the health system. Particularly of concern in South Africa is the high perinatal mortality in district hospitals, where most births occur and where intrapartum care is provided to women of low and intermediate risk. Therefore, it is crucial to strengthen the health system for perinatal care in district hospitals. There is currently no consolidated documented framework outlining contextual health system domains and indicators that are key to providing effective perinatal care in district hospitals. The purpose of this study was to derive key health system domains and indicators necessary to measure the performance of the health system for perinatal care in South African district hospitals. Methods The Delphi technique was used in collecting data from a panel with experts drawn from disciplines connected with the functioning of the health system for perinatal care in South Africa. The study enrolled thirteen experts from whom data on key health system domains and indicators for perinatal care were derived. The project reference group gave guidance to the development of the framework and ascertained its relevance to the South African setting. Results The Facility Based Health System Framework for Perinatal Care comprising domains and indicators necessary to measure health system performance in South African district hospitals was derived from data. The broad structure of the proposed framework aligns with the WHO Health Systems Framework. Each critical building block has detailed domains and indicators that illuminate essential facility-level and programme-specific elements that require attention for strengthening the health system for perinatal care. Conclusion The proposed framework can enable district hospital management teams to identify gaps in the health system for perinatal care, which need to be strengthened in order to alleviate the burden of perinatal deaths in district hospitals.
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Affiliation(s)
| | - Anna Silvia Voce
- Discipline of Public Health Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sthandwa Octavia Mnqayi
- King Cetshwayo Health District Office, KwaZulu-Natal Department of Health, Empangeni, South Africa
| | - Benn Sartorius
- Discipline of Public Health Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Schneider
- School of Public Health and SAMRC Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa
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A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results. PLoS One 2019; 14:e0217617. [PMID: 31150458 PMCID: PMC6544255 DOI: 10.1371/journal.pone.0217617] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 05/15/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Health care provider (HCP) performance in low- and middle-income countries (LMICs) is often inadequate. The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of the effectiveness and cost of strategies to improve HCP performance in LMICs. We present the HCPPR's methods, describe methodological and contextual attributes of included studies, and examine time trends of study attributes. METHODS The HCPPR includes studies from LMICs that quantitatively evaluated any strategy to improve HCP performance for any health condition, with no language restrictions. Eligible study designs were controlled trials and interrupted time series. In 2006, we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies. Data from eligible reports were double-abstracted and entered into a database, which is publicly available. The primary outcome measure was the strategy's effect size. We assessed time trends with logistic, Poisson, and negative binomial regression modeling. We were unable to register with PROSPERO (International Prospective Register of Systematic Reviews) because the protocol was developed prior to the PROSPERO launch. RESULTS We screened 105,299 citations and included 824 reports from 499 studies of 161 intervention strategies. Most strategies had multiple components and were tested by only one study each. Studies were from 79 countries and had diverse methodologies, geographic settings, HCP types, work environments, and health conditions. Training, supervision, and patient and community supports were the most commonly evaluated strategy components. Only 33.6% of studies had a low or moderate risk of bias. From 1958-2003, the number of studies per year and study quality increased significantly over time, as did the proportion of studies from low-income countries. Only 36.3% of studies reported information on strategy cost or cost-effectiveness. CONCLUSIONS Studies have reported on the efficacy of many strategies to improve HCP performance in LMICs. However, most studies have important methodological limitations. The HCPPR is a publicly accessible resource for decision-makers, researchers, and others interested in improving HCP performance.
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Sway A, Nthumba P, Solomkin J, Tarchini G, Gibbs R, Ren Y, Wanyoro A. Burden of surgical site infection following cesarean section in sub-Saharan Africa: a narrative review. Int J Womens Health 2019; 11:309-318. [PMID: 31191039 PMCID: PMC6512794 DOI: 10.2147/ijwh.s182362] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cesarean section (CS) is the most common operative procedure performed in sub-Saharan Africa (SSA), accounting for as much as 80% of the surgical workload. In contrast to CSs performed in high-income countries, CSs performed in SSA are accompanied by high morbidity and mortality rates. This operation is the most important known variable associated with an increased probability of postpartum bacterial infection. The objective of this review was to assess surgical outcomes related to CS in SSA. PubMed (including Medline), CINAHL, Embase, and the World Health Organization’s Global Health Library were searched without date or language restrictions. A total of 26 studies reporting surgical site–infection rates after CS were identified, representing 14,063 women from 14 countries. The vast majority (76.7%) of CSs performed were emergency operations. The overall CS rate for women included in this review was 12.4% (range: 1.0%–41.9%). Only 17 of 26 total studies reported a significant proportion of women receiving antimicrobials of any kind. The surgical site–infection rate was 15.6% and the wound-infection rate 10.3%.
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Affiliation(s)
- Angie Sway
- Medical Writing, World Surgical Infection Society, Cincinnati, OH, USA,
| | - Peter Nthumba
- Plastic, Reconstructive and Hand Surgery, AIC Kijabe Hospital, Kijabe, Kenya
| | - Joseph Solomkin
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Giorgio Tarchini
- Department of Infectious Disease, Cleveland Clinic Florida, Weston, FL, USA
| | - Ronald Gibbs
- Department of Obstetrics and Gynecology, University of Colorado Hospital, Denver, CO, USA
| | - Yanhan Ren
- Research and Implementation, World Surgical Infection Society, Cincinnati, OH, USA
| | - Anthony Wanyoro
- Department of Obstetrics and Gynecology, School of Medicine, Kenyatta University, Nairobi, Kenya
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Baharuddin M, Amelia D, Suhowatsky S, Kusuma A, Suhargono MH, Eng B. Maternal death reviews: A retrospective case series of 90 hospital-based maternal deaths in 11 hospitals in Indonesia. Int J Gynaecol Obstet 2019; 144 Suppl 1:59-64. [PMID: 30815870 DOI: 10.1002/ijgo.12736] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the factors contributing to hospital-based maternal deaths in Indonesia, given most women deliver with skilled birth attendants and in health facilities. METHODS A retrospective review of case records examined quality of care issues related to maternal mortality in hospital settings. The review abstracted information from blinded medical records of 90 women who died in 11 hospitals from January to June 2014. Specialists from the Indonesian Society of Obstetrics and Gynecology reviewed abstracted records to determine causes of death and identify contextual factors for these deaths. RESULTS Seventy-five of the 90 maternal deaths (83%) reviewed were due to direct obstetric causes. Severe pre-eclampsia and eclampsia combined were the leading direct cause of death (42%). Human resource/health worker factors were more frequently identified than supply, facility, or infrastructure factors. Ninety percent of maternal deaths were classified as preventable. CONCLUSION The review exercise yielded useful information on factors contributing to preventable maternal mortality in hospitals in Indonesia. Results helped focus quality improvement efforts and increased awareness of the value of routine, in-depth facility-based maternal death reviews.
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Affiliation(s)
| | | | | | - Ary Kusuma
- Indonesian Society of Obstetrics and Gynecology, Jakarta, Indonesia
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Munabi-Babigumira S, Glenton C, Willcox M, Nabudere H. Ugandan health workers' and mothers' views and experiences of the quality of maternity care and the use of informal solutions: A qualitative study. PLoS One 2019; 14:e0213511. [PMID: 30856217 PMCID: PMC6411106 DOI: 10.1371/journal.pone.0213511] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 02/22/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Although the coverage of maternity services in some low and middle-income countries (LMIC) has greatly improved, the quality of maternity care remains poor, and maternal mortality rates are high. In this study, we describe the meaning and determinants of maternity care quality from the perspective of health workers and mothers in Uganda, the informal solutions used by health workers to manage their daily challenges, and we suggest ways in which maternal care quality can be improved. METHODS We conducted a qualitative study in the Mpigi and Rukungiri districts of Uganda. Twenty-eight health workers based at selected health centres participated in structured interviews. Thirty-six mothers, half of whom had delivered at health facilities, participated in focus group discussions. Data were analysed thematically, and informed by the WHO framework on quality of care for maternal and newborn health and by Lipsky's street level bureaucracy concept. RESULTS According to health workers, knowledge of clinical standards and processes, timeliness, and women's choice during labour, as well as resources, physical infrastructure; collaboration with mothers, professionals and community health workers; were important aspects of good quality care. Mothers' perceptions of good quality care were largely similar to health workers' views, though mothers were more concerned about health workers' interaction skills. Structural challenges sometimes led health workers to develop informal solutions such as asking mothers to purchase their own supplies with variable implications on the quality of care. While several of these informal solutions were useful in addressing bottlenecks in the health system, they sometimes placed additional burdens and personal costs on health workers, created mistrust, inequity in care and negative experiences among mothers who could not afford the extra costs. CONCLUSIONS Health system structural factors; including technical, interpersonal, resource and infrastructural factors; impede the provision and experience of good quality maternity care at health centres in Uganda. Improving the quality of care will require strategies that address these core problems in the health system structure. Such structural reforms will require political support to commit resources, skilful management and leadership that seek to change organisational behaviour and build trust through good quality, woman-centred maternity care.
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Affiliation(s)
- Susan Munabi-Babigumira
- Global Health Unit, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Claire Glenton
- Global Health Unit, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
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Sander A, Wauer R. From single-case analysis of neonatal deaths toward a further reduction of the neonatal mortality rate. J Perinat Med 2018; 47:125-133. [PMID: 30067511 DOI: 10.1515/jpm-2018-0003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 06/25/2018] [Indexed: 11/15/2022]
Abstract
Background The infant mortality rate (IMR), a key indicator of the quality of a healthcare system, has remained at approximately 3.5‰ for the past 10 years in Germany. Generic quality indicators (QIs), as used in Germany since 2010, greatly help in ensuring such a good value but do not seem to be able to further reduce the IMR. The neonatal mortality rate (NMR) contributes to 65-70% of the IMR. We therefore propose single-case analysis of neonatal deaths as an additional method and show an efficient way to implement this approach. Methods We used the Nordic-Baltic classification (NBC) to detect avoidable neonatal deaths. We applied this classification to a sample of 1968 neonatal death records, which represent over 90% of all neonatal deaths in East Berlin from 1973 to 1989. All cases were analyzed as to their preventability based on the complete perinatal and clinical data by a special commission of different experts. The NBC was automatically applied through natural language processing and an ontology-based terminology server. Results The NBC was used to select the group of cases that had a high potential of avoidance. The selected group represented 6.0% of all cases, and 60.4% of the cases within that group were judged avoidable or conditionally avoidable. The automatic detection of malformations showed an F1 score of 0.94. Conclusion The results show that our method can be applied automatically and is a powerful and highly specific tool for selecting potentially avoidable neonatal deaths and thus for supporting efficient single-case analysis.
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Affiliation(s)
- André Sander
- ID GmbH & Co. KGaA, Platz vor dem Neuen Tor 2, 10115 Berlin, Germany, Phone: +49 30 266260, Fax: +49 30 26626111
| | - Roland Wauer
- Klinik für Neonatologie, Charité-Universitätsmedizin Berlin, 10098 Berlin, Germany
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Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. LANCET GLOBAL HEALTH 2018; 6:e1163-e1175. [PMID: 30309799 PMCID: PMC6185992 DOI: 10.1016/s2214-109x(18)30398-x] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 11/09/2022]
Abstract
Background Inadequate health-care provider performance is a major challenge to the delivery of high-quality health care in low-income and middle-income countries (LMICs). The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of strategies to improve health-care provider performance in LMICs. Methods For this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 1960s to 2016. Eligible study designs were controlled trials and interrupted time series. We only included strategy-versus-control group comparisons. We present results of improving health-care provider practice outcomes expressed as percentages (eg, percentage of patients treated correctly) or as continuous measures (eg, number of medicines prescribed per patient). Effect sizes were calculated as absolute percentage-point changes. The summary measure for each comparison was the median effect size (MES) for all primary outcomes. Strategy effectiveness was described with weighted medians of MES. This study is registered with PROSPERO, number CRD42016046154. Findings We screened 216 477 citations and selected 670 reports from 337 studies of 118 strategies. Most strategies had multiple intervention components. For professional health-care providers (generally, facility-based health workers), the effects were near zero for only implementing a technology-based strategy (median MES 1·0 percentage points, IQR −2·8 to 9·9) or only providing printed information for health-care providers (1·4 percentage points, −4·8 to 6·2). For percentage outcomes, training or supervision alone typically had moderate effects (10·3–15·9 percentage points), whereas combining training and supervision had somewhat larger effects than use of either strategy alone (18·0–18·8 percentage points). Group problem solving alone showed large improvements in percentage outcomes (28·0–37·5 percentage points), but, when the strategy definition was broadened to include group problem solving alone or other strategy components, moderate effects were more typical (12·1 percentage points). Several multifaceted strategies had large effects, but multifaceted strategies were not always more effective than simpler ones. For lay health-care providers (generally, community health workers), the effect of training alone was small (2·4 percentage points). Strategies with larger effect sizes included community support plus health-care provider training (8·2–125·0 percentage points). Contextual and methodological heterogeneity made comparisons difficult, and most strategies had low quality evidence. Interpretation The impact of strategies to improve health-care provider practices varied substantially, although some approaches were more consistently effective than others. The breadth of the HCPPR makes its results valuable to decision makers for informing the selection of strategies to improve health-care provider practices in LMICs. These results also emphasise the need for researchers to use better methods to study the effectiveness of interventions. Funding Bill & Melinda Gates Foundation, CDC Foundation.
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Affiliation(s)
- Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Samantha Y Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA; CDC Foundation, Atlanta, GA, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathleen A Holloway
- World Health Organization, Southeast Asia Regional Office, New Delhi, India; International Institute of Health Management Research, Jaipur, India; Institute of Development Studies, University of Sussex, Brighton, UK
| | - John Chalker
- Pharmaceuticals & Health Technologies Group, Management Sciences for Health, Arlington, VA, USA
| | - Dennis Ross-Degnan
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Ngwenya S. Stillbirth rate and causes in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe. Trop Doct 2018; 48:310-313. [PMID: 30089419 DOI: 10.1177/0049475518789030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A global concern is to end preventable stillbirths by the year 2030. The objective of this study was to document the stillbirth rate and causes of stillbirths in a low-resource setting. This was a retrospective descriptive study carried out at Mpilo Central Hospital, a tertiary teaching referral government hospital in Bulawayo, Zimbabwe during the period January to December 2016. There were 8801 live births and 268 stillbirths (rate: 30.5/1000). The majority(81.3%) were macerated. Pre-term labour, pre-eclampsia, eclampsia and abruptio placenta accounted for 51.1%. In 29.9%, the cause could not be identified. A high proportion of macerated stillbirths were unexplained; hence this calls for a renewed focus on community-based approaches to reduce delays in seeking care. Investment in robust diagnostic means and further training of healthcare workers to improve case definition are both urgently required.
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Affiliation(s)
- Solwayo Ngwenya
- 1 Consultant Obstetrician and Gynaecologist, Head of Department of Obstetrics & Gynaecology, Clinical Director, Mpilo Central Hospital, Mzilikazi, Zimbabwe.,2 Founder and Chief Executive Officer, Royal Women's Clinic, Hillside, Zimbabwe.,3 Part-Lecturer, National University of Science and Technology, Medical School, Bulawayo, Matabeleland, Zimbabwe
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Ghimire PR, Agho KE, Akombi BJ, Wali N, Dibley M, Raynes-Greenow C, Renzaho AMN. Perinatal Mortality in South Asia: Systematic Review of Observational Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1428. [PMID: 29986453 PMCID: PMC6069066 DOI: 10.3390/ijerph15071428] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study aimed to systematically review observational studies on perinatal mortality in South Asia. METHODS This review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Five computerized bibliographic databases: MEDLINE, CINAHL, Embase, PsycINFO, and Scopus were searched for published studies which reported factors associated with perinatal mortality in South Asia from 1 January 2000 to 20 March 2018. All relevant observational studies (cohort, cross-sectional and case-control) were reviewed. RESULTS Fourteen studies met the selection criteria. The most common factors associated with perinatal mortality were: low socioeconomic status, lack of quality health-care services, pregnancy/obstetric complications and lack of antenatal care. CONCLUSIONS Interventions to reduce perinatal mortality in the South Asia should focus on the provision of adequate antenatal care and quality healthcare services which are accessible to women of low socioeconomic status.
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Affiliation(s)
- Pramesh Raj Ghimire
- School of Science and Health, Western Sydney University, Locked Bag1797, Penrith, NSW 2571, Australia.
| | - Kingsley E Agho
- School of Science and Health, Western Sydney University, Locked Bag1797, Penrith, NSW 2571, Australia.
| | - Blessing J Akombi
- School of Science and Health, Western Sydney University, Locked Bag1797, Penrith, NSW 2571, Australia.
| | - Nidhi Wali
- School of Social Sciences and Psychology, Western Sydney University, Locked Bag1797, Penrith, NSW 2751, Australia.
| | - Michael Dibley
- Sydney School of Public Health, The University of Sydney, Edward Ford Building (A27), Sydney, NSW 2006, Australia.
| | - Camille Raynes-Greenow
- Sydney School of Public Health, The University of Sydney, Edward Ford Building (A27), Sydney, NSW 2006, Australia.
| | - Andre M N Renzaho
- School of Social Sciences and Psychology, Western Sydney University, Locked Bag1797, Penrith, NSW 2751, Australia.
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Sandakabatu M, Nasi T, Titiulu C, Duke T. Evaluating the process and outcomes of child death review in the Solomon Islands. Arch Dis Child 2018; 103:685-690. [PMID: 29618484 PMCID: PMC6047158 DOI: 10.1136/archdischild-2017-314662] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/08/2018] [Accepted: 03/10/2018] [Indexed: 11/14/2022]
Abstract
While maternal and perinatal mortality auditing has been strongly promoted by the World Health Organization (WHO), there has been very limited promotion or evaluation of child death auditing in low/middle-income settings. In 2017, a standardised child death review process was introduced in the paediatric department of the National Hospital in Honiara, Solomon Islands. We evaluated the process and outcomes of child death reviews. The child death auditing process was assessed through systematic observations made at each of the weekly meetings using the following standards for evaluation: (1) adapted WHO tools for paediatric auditing; (2) the five stages of the audit cycle; (3) published principles of paediatric audit; and (4) WHO and Solomon Islands national clinical standards of Hospital Care for Children. Thirty-three child death review meetings were conducted over 6 months, reviewing 66 neonatal and child deaths. Some areas of the process were satisfactory and other areas were identified for improvement. The latter included use of a more systematic classification of causes of death, inclusion of social risk factors and community problems in the modifiable factors and more follow-up with implementation of action plans. Areas for improvement were in communication, clinical assessment and treatment, availability of laboratory tests, antenatal clinic attendance and equipment for high dependency neonatal and paediatric care. Many of the changes recommended by audit require a quality improvement team to implement. Child death auditing can be done in resource-limited settings and yield useful information of gaps which are linked to preventable deaths; however, using the data to produce meaningful changes in practice is the greatest challenge. Audit is an iterative and evolving process that needs a structure, tools, evaluation, and needs to be embedded in the culture of a hospital as part of overall quality improvement, and requires a quality improvement team to follow-up and implement action plans.
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Affiliation(s)
- Mathew Sandakabatu
- Department of Paediatrics, Honiara National Referral Hospital, Honiara, Solomon Islands
| | - Titus Nasi
- Department of Paediatrics, Honiara National Referral Hospital, Honiara, Solomon Islands
| | - Carol Titiulu
- Department of Paediatrics, Honiara National Referral Hospital, Honiara, Solomon Islands
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, Parkville, Victoria, Australia
- Child health, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
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Scott RH, Filippi V, Moore AM, Acharya R, Bankole A, Calvert C, Church K, Cresswell JA, Footman K, Gleason J, Machiyama K, Marston C, Mbizvo M, Musheke M, Owolabi O, Palmer J, Smith C, Storeng K, Yeung F. Setting the research agenda for induced abortion in Africa and Asia. Int J Gynaecol Obstet 2018; 142:241-247. [PMID: 29745418 DOI: 10.1002/ijgo.12525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/05/2018] [Accepted: 05/04/2018] [Indexed: 11/07/2022]
Abstract
Provision of safe abortion is widely recognized as vital to addressing the health and wellbeing of populations. Research on abortion is essential to meet the UN Sustainable Development Goals. Researchers in population health from university, policy, and practitioner contexts working on two multidisciplinary projects on family planning and safe abortion in Africa and Asia were brought together for a workshop to discuss the future research agenda on induced abortion. Research on care-seeking behavior, supply of abortion care services, and the global and national policy context will help improve access to and experiences of safe abortion services. A number of areas have potential in designing intervention strategies, including clinical innovations, quality improvement mechanisms, community involvement, and task sharing. Research on specific groups, including adolescents and young people, men, populations affected by conflict, marginalized groups, and providers could increase understanding of provision, access to and experiences of induced abortion. Methodological and conceptual advances, for example in the measurement of induced abortion incidence, complications, and client satisfaction, conceptualizations of induced abortion access and care, and methods for follow-up of patients who have induced abortions, will improve the accuracy of measurements of induced abortion, and add to understanding of women's experiences of induced abortions and abortion care.
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Affiliation(s)
- Rachel H Scott
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | - Clara Calvert
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | | | - Cicely Marston
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | | | - Katerini Storeng
- London School of Hygiene & Tropical Medicine, London, UK.,University of Oslo, Oslo, Norway
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Wright J, Eichler R. A Review of Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services in Low- and Middle-Income Countries. Health Syst Reform 2018. [DOI: 10.1080/23288604.2018.1440344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Bayo P, Itua I, Francis SP, Boateng K, Tahir EO, Usman A. Estimating the met need for emergency obstetric care (EmOC) services in three payams of Torit County, South Sudan: a facility-based, retrospective cross-sectional study. BMJ Open 2018; 8:e018739. [PMID: 29444779 PMCID: PMC5829877 DOI: 10.1136/bmjopen-2017-018739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine the met need for emergency obstetric care (EmOC) services in three Payams of Torit County, South Sudan in 2015 and to determine the frequency of each major obstetric complication. DESIGN This was a retrospective cross-sectional study. SETTING Four primary healthcare centres (PHCCs) and one state hospital in three payams (administrative areas that form a county) in Torit County, South Sudan. PARTICIPANTS All admissions in the obstetrics and gynaecology wards (a total of 2466 patient admission files) in 2015 in all the facilities designated to conduct deliveries in the study area were reviewed to identify obstetric complications. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was met need for EmOC, which was defined as the proportion of all women with direct major obstetric complications in 2015 treated in health facilities providing EmOC services. The frequency of each complication and the interventions for treatment were the secondary outcomes. RESULTS Two hundred and fifty four major obstetric complications were admitted in 2015 out of 390 expected from 2602 pregnancies, representing 65.13% met need. The met need was highest (88%) for Nyong Payam, an urban area, compared with the other two rural payams, and 98.8% of the complications were treated from the hospital, while no complications were treated from three PHCCs. The most common obstetric complications were abortions (45.7%), prolonged obstructed labour (23.2%) and haemorrhage (16.5%). Evacuation of the uterus for retained products (42.5%), caesarean sections (32.7%) and administration of oxytocin for treatment of postpartum haemorrhage (13.3%) were the most common interventions. CONCLUSION The met need for EmOC in Torit County is low, with 35% of women with major obstetric complications not accessing care, and there is disparity with Nyong Payam having a higher met need. We suggest more support supervision to the PHCCs to increase access for the rural population.
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Affiliation(s)
- Pontius Bayo
- Department of Obstetrics and Gynecology, St Mary’s Hospital Lacor, Gulu, Uganda
- Department of Maternal and Child Health, WHO, Juba, South Sudan
| | - Imose Itua
- School of Public Health, University of Liverpool, Liverpool, UK
| | | | | | - Elijo Omoro Tahir
- Department of Pharmaceuticals, Torit State Hospital, Torit, South Sudan
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Yigzaw T, Abebe F, Belay L, Assaye Y, Misganaw E, Kidane A, Ademie D, van Roosmalen J, Stekelenburg J, Kim YM. Quality of Midwife-provided Intrapartum Care in Amhara Regional State, Ethiopia. BMC Pregnancy Childbirth 2017; 17:261. [PMID: 28814285 PMCID: PMC5558781 DOI: 10.1186/s12884-017-1441-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 08/02/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite much progress recently, Ethiopia remains one of the largest contributors to the global burden of maternal and newborn deaths and stillbirths. Ethiopia's plan to meet the sustainable development goals for maternal and child health includes unprecedented emphasis on improving quality of care. The purpose of this study was to assess the quality of midwifery care during labor, delivery and immediate postpartum period. METHODS A cross-sectional study using multiple data collection methods and a 2-stage cluster sampling technique was conducted from January 25 to February 14, 2015 in government health facilities of the Amhara National Regional State of Ethiopia. Direct observation of performance was used to determine competence of midwives in providing care during labor, delivery, and the first 6 h after childbirth. Inventory of drugs, medical equipment, supplies, and infrastructure was conducted to identify availability of resources in health facilities. Structured interview was done to assess availability of resources and performance improvement opportunities. Data analysis involved calculating percentages, means and chi-square tests. RESULTS A total of 150 midwives and 56 health facilities were included in the study. The performance assessment showed 16.5% of midwives were incompetent, 72.4% were competent, and 11.1% were outstanding in providing routine intrapartum care. Forty five midwives were observed while managing 54 obstetric and newborn complications and 41 (91%) of them were rated competent. Inventory of resources found that the proportion of facilities with more than 75% of the items in each category was 32.6% for drugs, 73.1% for equipment, 65.4% for supplies, 47.9% for infection prevention materials, and 43.6% for records and forms. Opportunities for performance improvement were inadequate, with 31.3% reporting emergency obstetric and newborn care training, and 44.7% quarterly or more frequent supportive supervision. Health centers fared worse in provider competence, physical resources, and quality improvement practices except for supportive supervision visits and in-service training. CONCLUSIONS Although our findings indicate most midwives are competent in giving routine and emergency intrapartum care, the major gaps in the enabling environment and the significant proportion of midwives with unsatisfactory performance suggest that the conditions for providing quality intrapartum care are not optimal.
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Affiliation(s)
| | | | | | | | | | | | | | - Jos van Roosmalen
- Faculty of Earth and Life Sciences, Vrije Universiteit, Amsterdam, Netherlands
| | - Jelle Stekelenburg
- Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, Leeuwarden, Netherlands
- Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
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Barber RM, Fullman N, Sorensen RJD, Bollyky T, McKee M, Nolte E, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, Abdulle AM, Abdurahman AA, Abera SF, Abraham B, Abreha GF, Adane K, Adelekan AL, Adetifa IMO, Afshin A, Agarwal A, Agarwal SK, Agarwal S, Agrawal A, Kiadaliri AA, Ahmadi A, Ahmed KY, Ahmed MB, Akinyemi RO, Akinyemiju TF, Akseer N, Al-Aly Z, Alam K, Alam N, Alam SS, Alemu ZA, Alene KA, Alexander L, Ali R, Ali SD, Alizadeh-Navaei R, Alkerwi A, Alla F, Allebeck P, Allen C, Al-Raddadi R, Alsharif U, Altirkawi KA, Martin EA, Alvis-Guzman N, Amare AT, Amini E, Ammar W, Amo-Adjei J, Amoako YA, Anderson BO, Androudi S, Ansari H, Ansha MG, Antonio CAT, Ärnlöv J, Artaman A, Asayesh H, Assadi R, Astatkie A, Atey TM, Atique S, Atnafu NT, Atre SR, Avila-Burgos L, Avokpaho EFGA, Quintanilla BPA, Awasthi A, Ayele NN, Azzopardi P, Saleem HOB, Bärnighausen T, Bacha U, Badawi A, Banerjee A, Barac A, Barboza MA, Barker-Collo SL, Barrero LH, Basu S, Baune BT, Baye K, Bayou YT, Bazargan-Hejazi S, Bedi N, Beghi E, Béjot Y, Bello AK, Bennett DA, Bensenor IM, Berhane A, Bernabé E, Bernal OA, Beyene AS, Beyene TJ, Bhutta ZA, Biadgilign S, Bikbov B, Birlik SM, Birungi C, Biryukov S, Bisanzio D, Bizuayehu HM, Bose D, Brainin M, Brauer M, Brazinova A, Breitborde NJK, Brenner H, Butt ZA, Cárdenas R, Cahuana-Hurtado L, Campos-Nonato IR, Car J, Carrero JJ, Casey D, Caso V, Castañeda-Orjuela CA, Rivas JC, Catalá-López F, Cecilio P, Cercy K, Charlson FJ, Chen AZ, Chew A, Chibalabala M, Chibueze CE, Chisumpa VH, Chitheer AA, Chowdhury R, Christensen H, Christopher DJ, Ciobanu LG, Cirillo M, Coggeshall MS, Cooper LT, Cortinovis M, Crump JA, Dalal K, Danawi H, Dandona L, Dandona R, Dargan PI, das Neves J, Davey G, Davitoiu DV, Davletov K, De Leo D, Del Gobbo LC, del Pozo-Cruz B, Dellavalle RP, Deribe K, Deribew A, Des Jarlais DC, Dey S, Dharmaratne SD, Dicker D, Ding EL, Dokova K, Dorsey ER, Doyle KE, Dubey M, Ehrenkranz R, Ellingsen CL, Elyazar I, Enayati A, Ermakov SP, Eshrati B, Esteghamati A, Estep K, Fürst T, Faghmous IDA, Fanuel FBB, Faraon EJA, Farid TA, Farinha CSES, Faro A, Farvid MS, Farzadfar F, Feigin VL, Feigl AB, Fereshtehnejad SM, Fernandes JG, Fernandes JC, Feyissa TR, Fischer F, Fitzmaurice C, Fleming TD, Foigt N, Foreman KJ, Forouzanfar MH, Franklin RC, Frostad J, G/hiwot TT, Gakidou E, Gambashidze K, Gamkrelidze A, Gao W, Garcia-Basteiro AL, Gebre T, Gebremedhin AT, Gebremichael MW, Gebru AA, Gelaye AA, Geleijnse JM, Genova-Maleras R, Gibney KB, Giref AZ, Gishu MD, Giussani G, Godwin WW, Gold A, Goldberg EM, Gona PN, Goodridge A, Gopalani SV, Goto A, Graetz N, Greaves F, Griswold M, Guban PI, Gugnani HC, Gupta PC, Gupta R, Gupta R, Gupta T, Gupta V, Habtewold TD, Hafezi-Nejad N, Haile D, Hailu AD, Hailu GB, Hakuzimana A, Hamadeh RR, Hambisa MT, Hamidi S, Hammami M, Hankey GJ, Hao Y, Harb HL, Hareri HA, Haro JM, Hassanvand MS, Havmoeller R, Hay RJ, Hay SI, Hendrie D, Heredia-Pi IB, Hoek HW, Horino M, Horita N, Hosgood HD, Htet AS, Hu G, Huang H, Huang JJ, Huntley BM, Huynh C, Iburg KM, Ileanu BV, Innos K, Irenso AA, Jahanmehr N, Jakovljevic MB, James P, James SL, Javanbakht M, Jayaraman SP, Jayatilleke AU, Jeemon P, Jha V, John D, Johnson C, Johnson SC, Jonas JB, Juel K, Kabir Z, Kalkonde Y, Kamal R, Kan H, Karch A, Karema CK, Karimi SM, Kasaeian A, Kassebaum NJ, Kastor A, Katikireddi SV, Kazanjan K, Keiyoro PN, Kemmer L, Kemp AH, Kengne AP, Kerbo AA, Kereselidze M, Kesavachandran CN, Khader YS, Khalil I, Khan AR, Khan EA, Khan G, Khang YH, Khoja ATA, Khonelidze I, Khubchandani J, Kibret GD, Kim D, Kim P, Kim YJ, Kimokoti RW, Kinfu Y, Kissoon N, Kivipelto M, Kokubo Y, Kolk A, Kolte D, Kopec JA, Kosen S, Koul PA, Koyanagi A, Kravchenko M, Krishnaswami S, Krohn KJ, Defo BK, Bicer BK, Kuipers EJ, Kulkarni VS, Kumar GA, Kumsa FA, Kutz M, Kyu HH, Lager ACJ, Lal A, Lal DK, Lalloo R, Lallukka T, Lan Q, Langan SM, Lansingh VC, Larson HJ, Larsson A, Laryea DO, Latif AA, Lawrynowicz AEB, Leasher JL, Leigh J, Leinsalu M, Leshargie CT, Leung J, Leung R, Levi M, Liang X, Lim SS, Lind M, Linn S, Lipshultz SE, Liu P, Liu Y, Lo LT, Logroscino G, Lopez AD, Lorch SA, Lotufo PA, Lozano R, Lunevicius R, Lyons RA, Macarayan ERK, Mackay MT, El Razek HMA, El Razek MMA, Mahdavi M, Majeed A, Malekzadeh R, Malta DC, Mantovani LG, Manyazewal T, Mapoma CC, Marcenes W, Marks GB, Marquez N, Martinez-Raga J, Marzan MB, Massano J, Mathur MR, Maulik PK, Mazidi M, McAlinden C, McGrath JJ, McNellan C, Meaney PA, Mehari A, Mehndiratta MM, Meier T, Mekonnen AB, Meles KG, Memish ZA, Mengesha MM, Mengiste DT, Mengistie MA, Menota BG, Mensah GA, Mereta ST, Meretoja A, Meretoja TJ, Mezgebe HB, Micha R, Millear A, Mills EJ, Minnig S, Mirarefin M, Mirrakhimov EM, Mock CN, Mohammad KA, Mohammed S, Mohanty SK, Mokdad AH, Mola GLD, Molokhia M, Monasta L, Montico M, Moradi-Lakeh M, Moraga P, Morawska L, Mori R, Moses M, Mueller UO, Murthy S, Musa KI, Nachega JB, Nagata C, Nagel G, Naghavi M, Naheed A, Naldi L, Nangia V, Nascimento BR, Negoi I, Neupane SP, Newton CR, Ng M, Ngalesoni FN, Ngunjiri JW, Nguyen G, Ningrum DNA, Nolte S, Nomura M, Norheim OF, Norrving B, Noubiap JJN, Obermeyer CM, Ogbo FA, Oh IH, Okoro A, Oladimeji O, Olagunju AT, Olivares PR, Olsen HE, Olusanya BO, Olusanya JO, Opio JN, Oren E, Ortiz A, Osborne RH, Osman M, Owolabi MO, PA M, Pain AW, Pakhale S, Castillo EP, Pana A, Papachristou C, Parsaeian M, Patel T, Patton GC, Paudel D, Paul VK, Pearce N, Pereira DM, Perez-Padilla R, Perez-Ruiz F, Perico N, Pesudovs K, Petzold M, Phillips MR, Pigott DM, Pillay JD, Pinho C, Polinder S, Pond CD, Prakash V, Purwar M, Qorbani M, Quistberg DA, Radfar A, Rafay A, Rahimi K, Rahimi-Movaghar V, Rahman M, Rahman MHU, Rai RK, Ram U, Rana SM, Rankin Z, Rao PV, Rao PC, Rawaf S, Rego MAS, Reitsma M, Remuzzi G, Renzaho AMNN, Resnikoff S, Rezaei S, Rezai MS, Ribeiro AL, Roba HS, Rokni MB, Ronfani L, Roshandel G, Roth GA, Rothenbacher D, Roy NK, Sachdev PS, Sackey BB, Saeedi MY, Safiri S, Sagar R, Sahraian MA, Saleh MM, Salomon JA, Samy AM, Sanabria JR, Sanchez-Niño MD, Sandar L, Santos IS, Santos JV, Milicevic MMS, Sarmiento-Suarez R, Sartorius B, Satpathy M, Savic M, Sawhney M, Saylan MI, Schöttker B, Schutte AE, Schwebel DC, Seedat S, Seid AM, Seifu CN, Sepanlou SG, Serdar B, Servan-Mori EE, Setegn T, Shackelford KA, Shaheen A, Shahraz S, Shaikh MA, Shakh-Nazarova M, Shamsipour M, Islam SMS, Sharma J, Sharma R, She J, Sheikhbahaei S, Shen J, Shi P, Shigematsu M, Shin MJ, Shiri R, Shoman H, Shrime MG, Sibamo ELS, Sigfusdottir ID, Silva DAS, Silveira DGA, Sindi S, Singh A, Singh JA, Singh OP, Singh PK, Singh V, Sinke AH, Sinshaw AE, Skirbekk V, Sliwa K, Smith A, Sobngwi E, Soneji S, Soriano JB, Sousa TCM, Sposato LA, Sreeramareddy CT, Stathopoulou V, Steel N, Steiner C, Steinke S, Stokes MA, Stranges S, Strong M, Stroumpoulis K, Sturua L, Sufiyan MB, Suliankatchi RA, Sun J, Sur P, Swaminathan S, Sykes BL, Tabarés-Seisdedos R, Tabb KM, Taffere GR, Talongwa RT, Tarajia M, Tavakkoli M, Taveira N, Teeple S, Tegegne TK, Tehrani-Banihashemi A, Tekelab T, Tekle DY, Shifa GT, Terkawi AS, Tesema AG, Thakur JS, Thomson AJ, Tillmann T, Tiruye TY, Tobe-Gai R, Tonelli M, Topor-Madry R, Tortajada M, Troeger C, Truelsen T, Tura AK, Uchendu US, Ukwaja KN, Undurraga EA, Uneke CJ, Uthman OA, van Boven JFM, Van Dingenen R, Varughese S, Vasankari T, Venketasubramanian N, Violante FS, Vladimirov SK, Vlassov VV, Vollset SE, Vos T, Wagner JA, Wakayo T, Waller SG, Walson JL, Wang H, Wang YP, Watkins DA, Weiderpass E, Weintraub RG, Wen CP, Werdecker A, Wesana J, Westerman R, Whiteford HA, Wilkinson JD, Wiysonge CS, Woldeyes BG, Wolfe CDA, Won S, Workicho A, Workie SB, Wubshet M, Xavier D, Xu G, Yadav AK, Yaghoubi M, Yakob B, Yan LL, Yano Y, Yaseri M, Yimam HH, Yip P, Yonemoto N, Yoon SJ, Younis MZ, Yu C, Zaidi Z, El Sayed Zaki M, Zambrana-Torrelio C, Zapata T, Zenebe ZM, Zodpey S, Zoeckler L, Zuhlke LJ, Murray CJL. Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet 2017; 390:231-266. [PMID: 28528753 PMCID: PMC5528124 DOI: 10.1016/s0140-6736(17)30818-8] [Citation(s) in RCA: 307] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/26/2017] [Accepted: 02/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. METHODS We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. FINDINGS Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0-42·8) in 1990 to 53·7 (52·2-55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. INTERPRETATION This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. FUNDING Bill & Melinda Gates Foundation.
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Agyepong IA, Kwamie A, Frimpong E, Defor S, Ibrahim A, Aryeetey GC, Lokossou V, Sombie I. Spanning maternal, newborn and child health (MNCH) and health systems research boundaries: conducive and limiting health systems factors to improving MNCH outcomes in West Africa. Health Res Policy Syst 2017; 15:54. [PMID: 28722556 PMCID: PMC5516848 DOI: 10.1186/s12961-017-0212-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite improvements over time, West Africa lags behind global as well as sub-Saharan averages in its maternal, newborn and child health (MNCH) outcomes. This is despite the availability of an increasing body of knowledge on interventions that improve such outcomes. Beyond our knowledge of what interventions work, insights are needed on others factors that facilitate or inhibit MNCH outcome improvement. This study aimed to explore health system factors conducive or limiting to MNCH policy and programme implementation and outcomes in West Africa, and how and why they work in context. METHODS We conducted a mixed methods multi-country case study focusing predominantly, but not exclusively, on the six West African countries (Burkina Faso, Benin, Mali, Senegal, Nigeria and Ghana) of the Innovating for Maternal and Child Health in Africa initiative. Data collection involved non-exhaustive review of grey and published literature, and 48 key informant interviews. We validated our findings and conclusions at two separate multi-stakeholder meetings organised by the West African Health Organization. To guide our data collection and analysis, we developed a unique theoretical framework of the link between health systems and MNCH, in which we conceptualised health systems as the foundations, pillars and roofing of a shelter for MNCH, and context as the ground on which the foundation is laid. RESULTS A multitude of MNCH policies and interventions were being piloted, researched or implemented at scale in the sub-region, most of which faced multiple interacting conducive and limiting health system factors to effective implementation, as well as contextual challenges. Context acted through its effect on health system factors as well as on the social determinants of health. CONCLUSIONS To accelerate and sustain improvements in MNCH outcomes in West Africa, an integrated approach to research and practice of simultaneously addressing health systems and contextual factors alongside MNCH service delivery interventions is needed. This requires multi-level, multi-sectoral and multi-stakeholder engagement approaches that span current geographical, language, research and practice community boundaries in West Africa, and effectively link the efforts of actors interested in health systems strengthening with those of actors interested in MNCH outcome improvement.
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Affiliation(s)
- Irene Akua Agyepong
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Aku Kwamie
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Edith Frimpong
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Selina Defor
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Abdallah Ibrahim
- University of Ghana School of Public Health, P.O. Box LG13, Legon, Accra, Ghana
| | | | - Virgil Lokossou
- West African Health Organization, Bobo-Dioulasso, 01BP 153 Bobo-Dioulasso 01, Burkina Faso
| | - Issiaka Sombie
- West African Health Organization, Bobo-Dioulasso, 01BP 153 Bobo-Dioulasso 01, Burkina Faso
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Mohammadi S, Carlbom A, Taheripanah R, Essén B. Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran: a qualitative interview study. Int J Equity Health 2017; 16:121. [PMID: 28687082 PMCID: PMC5500928 DOI: 10.1186/s12939-017-0617-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 06/28/2017] [Indexed: 11/29/2022] Open
Abstract
Background Providing equitable maternal care to migrants is a seriously challenging task for hosting countries. Iran, the second-most accessed country for refugees from Afghanistan, has achieved maternal health improvement. However, Afghan women with near-miss morbidity faced pre-hospital delays and disparity in maternal care at hospitals. This study explores experiences of maternal care among Afghan women surviving near-miss morbidity to increase insight into healthcare improvements for migrants. Methods A qualitative study was conducted at university hospitals in Tehran, from April 2013 to May 2014. A total of 11 Afghan women and 4 husbands were interviewed when women recovered from near-miss morbidity that occurred around the childbirth period. Mothers were identified prospectively using the WHO maternal near-miss approach. Thematic analysis was used along with a data-driven approach to organize data guided by the ‘three delays model’ theoretical framework. Results Mistreatment in the form of discrimination and insufficient medical attention were key experiences. Participants commonly perceived poor women–professional communication and delays in recognizing obstetric complications despite repeated care-seeking. Financial constraints, costly care, lack of health insurance, and low literacy were experienced barriers to accessing care to a lesser extent. Non-somatic consequences of near-miss morbidity affected mothers and families for extended periods. Conclusions Near-miss survivors’ experiences provided remarkable insights into maternal care of Afghans in Iran. The challenge for the health system and professionals is to provide equitable care with dignity and improve communication skills with caring attitudes toward ethnic minorities. Antenatal visits provide the best and most appropriate opportunities to tackle health illiteracy in Afghan women.
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Affiliation(s)
- Soheila Mohammadi
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, SE-751 85, Uppsala, Sweden. .,Infertility and Reproductive Health Research Center (IRHRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Aje Carlbom
- Faculty of Health and Society, Malmö University, Malmö, Sweden
| | - Robabeh Taheripanah
- Infertility and Reproductive Health Research Center (IRHRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, SE-751 85, Uppsala, Sweden
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Ngwenya S. Reducing fresh full term intrapartum stillbirths through leadership and accountability in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe. BMC Res Notes 2017; 10:246. [PMID: 28683767 PMCID: PMC5501452 DOI: 10.1186/s13104-017-2567-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 06/26/2017] [Indexed: 11/10/2022] Open
Abstract
Background Stillbirths are distressing to the parents and healthcare workers. Globally large numbers of babies are stillborn. A number of strategies have been implemented to try and reduce stillbirths worldwide. The objective of this study was to assess the impact of leadership and accountability changes on reducing full term intrapartum stillbirths. Methods Leadership and accountability changes were implemented in January 2016. This retrospective cohort study was carried out to assess the impact of the changes on fresh full term intrapartum stillbirths covering the period 6 months prior to the implementation date and 12 months after the implementation date. The changes included leadership and accountability. Fresh full term stillbirths (>37 weeks gestation) occurring during the intrapartum stage of labour were analysed to see if there would be any reduction in numbers after the measures were put in place. Results There was a reduction in the number of fresh full term intrapartum stillbirths after the introduction of the measures. There was a statistical difference before and after implementation of the changes, 50% vs 0%, P = 0.025. There was a reduction in the time it took to perform an emergency caesarean section from a mean of 30 to 15 min by the end of the study, a 50% reduction. Conclusions Clear and consistent clinical leadership and accountability can help in the global attempts to reduce stillbirth figures. Simple measures can contribute to improving perinatal outcomes.
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Affiliation(s)
- Solwayo Ngwenya
- Department of Obstetrics & Gynaecology, Mpilo Central Hospital, Vera Road, Mzilikazi, P.O. Box 2096, Bulawayo, Matabeleland, Zimbabwe. .,Department of Obstetrics & Gynaecology, Royal Women's Clinic, 52A Cecil Avenue, Hillside, Bulawayo, Matabeleland, Zimbabwe. .,National University of Science and Technology, Medical School, Bulawayo, Matabeleland, Zimbabwe.
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Musafili A, Persson LÅ, Baribwira C, Påfs J, Mulindwa PA, Essén B. Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis. BMC Pregnancy Childbirth 2017; 17:85. [PMID: 28284197 PMCID: PMC5346214 DOI: 10.1186/s12884-017-1269-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 03/03/2017] [Indexed: 11/13/2022] Open
Abstract
Background Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals. Methods Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model. Results Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths. Conclusions Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1269-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aimable Musafili
- Paediatric and Child Health Department, University of Rwanda, Kigali, Rwanda. .,Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Akademiska Sjukhuset, Uppsala, SE-751 85, Sweden.
| | - Lars-Åke Persson
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Akademiska Sjukhuset, Uppsala, SE-751 85, Sweden
| | - Cyprien Baribwira
- Center for International Health, Education, and Biosecurity (CIHEB), Institute of Human Virology, University of Maryland, School of Medicine MGIC-Rwanda, KG, 6 AV no 22, Kigali, Rwanda
| | - Jessica Påfs
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Akademiska Sjukhuset, Uppsala, SE-751 85, Sweden
| | | | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Akademiska Sjukhuset, Uppsala, SE-751 85, Sweden
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Mohammadi S, Saleh Gargari S, Fallahian M, Källestål C, Ziaei S, Essén B. Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran. BMC Pregnancy Childbirth 2017; 17:64. [PMID: 28193186 PMCID: PMC5307813 DOI: 10.1186/s12884-017-1239-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 01/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. METHODS An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. RESULTS Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient- (31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. CONCLUSIONS Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.
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Affiliation(s)
- Soheila Mohammadi
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden. .,Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Soraya Saleh Gargari
- Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Fallahian
- Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Carina Källestål
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden
| | - Shirin Ziaei
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden
| | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden
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