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Inam M, Sheikh S, Khoja A, Abubakar A, Shah R, Samad Z, Ngugi A, Alarakhiya F, Waljee A, Virani SS. Health Data Sciences and Cardiovascular Disease in Africa: Needs and the Way Forward. Curr Atheroscler Rep 2024:10.1007/s11883-024-01235-1. [PMID: 39240493 DOI: 10.1007/s11883-024-01235-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2024] [Indexed: 09/07/2024]
Abstract
PURPOSE OF REVIEW The rising burden of cardiovascular disease (CVD) in Africa is of great concern. Health data sciences is a rapidly developing field which has the potential to improve health outcomes, especially in low-middle income countries with burdened healthcare systems. We aim to explore the current CVD landscape in Africa, highlighting the importance of health data sciences in the region and identifying potential opportunities for application and growth by leveraging health data sciences to improve CVD outcomes. RECENT FINDINGS While there have been a number of initiatives aimed at developing health data sciences in Africa over the recent decades, the progress and growth are still in their early stages. Its maximum potential can be leveraged through adequate funding, advanced training programs, focused resource allocation, encouraging bidirectional international partnerships, instituting best ethical practices, and prioritizing data science health research in the region. The findings of this review explore the current landscape of CVD and highlight the potential benefits and utility of health data sciences to address CVD challenges in Africa. By understanding and overcoming the barriers associated with health data sciences training, research, and application in the region, focused initiatives can be developed to promote research and development. These efforts will allow policymakers to form informed, evidence-based frameworks for the prevention and management of CVDs, and ultimately result in improved CVD outcomes in the region.
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Affiliation(s)
- Maha Inam
- Office of the Vice Provost, Research, Aga Khan University, Karachi, Pakistan
- Department of Medicine, Temple University Hospital, Philadelphia, PA, 19140, USA
| | - Sana Sheikh
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Adeel Khoja
- Department of Medicine, Aga Khan University, Karachi, Pakistan
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, 5000, Australia
| | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Reena Shah
- Department of Medicine, Aga Khan University, Nairobi, Kenya
| | - Zainab Samad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
- Section of Cardiology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Anthony Ngugi
- Department of Population Health, Aga Khan University, Nairobi, Kenya
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | | | - Akbar Waljee
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, USA
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
- Center for Global Health and Equity, University of Michigan, Ann Arbor, USA
| | - Salim S Virani
- Office of the Vice Provost, Research, Aga Khan University, Karachi, Pakistan.
- Department of Medicine, Aga Khan University, Karachi, Pakistan.
- Section of Cardiology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
- The Texas Heart Institute, Houston, TX, USA.
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Silver RM, Reddy U. Stillbirth: we can do better. Am J Obstet Gynecol 2024; 231:152-165. [PMID: 38789073 DOI: 10.1016/j.ajog.2024.05.042] [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: 12/27/2023] [Revised: 04/23/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024]
Abstract
Stillbirth is far too common, occurring in millions of pregnancies per year globally. The rate of stillbirth (defined as death of a fetus prior to birth at 20 weeks' gestation or more) in the United States is 5.73 per 1000. This is approximately 1 in 175 pregnancies accounting for about 21,000 stillbirths per year. Although rates are much higher in low-income countries, the stillbirth rate in the United States is much higher than most high resource countries. Moreover, there are substantial disparities in stillbirth, with rates twice as high for non-Hispanic Black and Native Hawaiian or Other Pacific Islanders compared to non-Hispanic Whites. There is considerable opportunity for reduction in stillbirths, even in high resource countries such as the United States. In this article, we review the epidemiology, risk factors, causes, evaluation, medical and emotional management, and prevention of stillbirth. We focus on novel data regarding genetic etiologies, placental assessment, risk stratification, and prevention.
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Affiliation(s)
- Robert M Silver
- Departments of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, University of Utah, Salt Lake City, UT.
| | - Uma Reddy
- Departments of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, Columbia University, New York, NY
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Mary M, Tappis H, Scudder E, Creanga AA. Complexities of implementing Maternal and Perinatal Death Surveillance and Response in crisis-affected contexts: a comparative case study. Confl Health 2024; 18:45. [PMID: 39010136 PMCID: PMC11251288 DOI: 10.1186/s13031-024-00607-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Maternal and Perinatal Death Surveillance and Response (MPDSR) systems provide an opportunity for health systems to understand the determinants of maternal and perinatal deaths in order to improve quality of care and prevent future deaths from occurring. While there has been broad uptake and learning from low- and middle-income countries, little is known on how to effectively implement MPDSR within humanitarian contexts - where disruptions in health service delivery are common, infrastructural damage and insecurity impact the accessibility of care, and severe financial and human resource shortages limit the quality and capacity to provide services to the most vulnerable. This study aimed to understand how contextual factors influence facility-based MPDSR interventions within five humanitarian contexts. METHODS Descriptive case studies were conducted on the implementation of MPDSR in Cox's Bazar refugee camps in Bangladesh, refugee settlements in Uganda, South Sudan, Palestine, and Yemen. Desk reviews of case-specific MPDSR documentation and in-depth key informant interviews with 76 stakeholders supporting or directly implementing mortality surveillance interventions were conducted between December 2021 and July 2022. Interviews were recorded, transcribed, and analyzed using Dedoose software. Thematic content analysis was employed to understand the adoption, penetration, sustainability, and fidelity of MPDSR interventions and to facilitate cross-case synthesis of implementation complexities. RESULTS Implementation of MPDSR interventions in the five humanitarian settings varied in scope, scale, and approach. Adoption of the interventions and fidelity to established protocols were influenced by availability of financial and human resources, the implementation climate (leadership engagement, health administration and provider buy-in, and community involvement), and complex humanitarian-health system dynamics. Blame culture was pervasive in all contexts, with health providers often facing punishment or criminalization for negligence, threats, and violence. Across contexts, successful implementation was driven by integrating MPDSR within quality improvement efforts, improving community involvement, and adapting programming fit-for-context. CONCLUSIONS The unique contextual considerations of humanitarian settings call for a customized approach to implementing MPDSR that best serves the immediate needs of the crisis, aligns with stakeholder priorities, and supports health workers and humanitarian responders in providing care to the most vulnerable populations.
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Affiliation(s)
- Meighan Mary
- International Health Department, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD, 21205, USA.
- Center for Humanitarian Health, Johns Hopkins University, Baltimore, MD, USA.
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Hannah Tappis
- International Health Department, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Center for Humanitarian Health, Johns Hopkins University, Baltimore, MD, USA
- Jhpiego, Baltimore, MD, USA
| | | | - Andreea A Creanga
- International Health Department, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD, 21205, USA
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Mary M, Tappis H, Scudder E, Creanga AA. Implementation of maternal and perinatal death surveillance and response and related death review interventions in humanitarian settings: A scoping review. J Glob Health 2024; 14:04133. [PMID: 38991208 PMCID: PMC11239189 DOI: 10.7189/jogh.14.04133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
Background The global population impacted by humanitarian crises continues to break records each year, leaving strained and fractured health systems reliant upon humanitarian assistance in more than 60 countries. Yet little is known about implementation of maternal and perinatal death surveillance and response (MPDSR) within crisis-affected contexts. This scoping review aimed to synthesise evidence on the implementation of MPDSR and related death review interventions in humanitarian settings. Methods We searched for peer-reviewed and grey literature in English and French published in 2016-22 that reported on MPDSR and related death review interventions within humanitarian settings. We screened and reviewed 1405 records, among which we identified 25 peer-reviewed articles and 11 reports. We then used content and thematic analysis to understand the adoption, appropriateness, fidelity, penetration, and sustainability of these interventions. Results Across the 36 records, 33 unique programmes reported on 37 interventions within humanitarian contexts in 27 countries, representing 69% of the countries with a 2023 United Nations humanitarian appeal. Most identified programmes focussed on maternal death interventions; were in the pilot or early-mid implementation phases (1-5 years); and had limited integration within health systems. While we identified substantive documentation of MPDSR and related death review interventions, extensive gaps in evidence remain pertaining to the adoption, fidelity, penetration, and sustainability of these interventions. Across humanitarian contexts, implementation was influenced by severe resource limitations, variable leadership, pervasive blame culture, and mistrust within communities. Conclusions Emergent MPDSR implementation dynamics show a complex interplay between humanitarian actors, communities, and health systems, worthy of in-depth investigation. Future mixed methods research evaluating the gamut of identified MPDSR programmes in humanitarian contexts will greatly bolster the evidence base. Investment in comparative health systems research to understand how best to adapt MPDSR and related death review interventions to humanitarian contexts is a crucial next step.
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Affiliation(s)
- Meighan Mary
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Humanitarian Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hannah Tappis
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Humanitarian Health, Johns Hopkins University, Baltimore, Maryland, USA
- Jhpiego, Baltimore Maryland, USA
| | | | - Andreea A Creanga
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Ssegujja E, Andipatin M. Translating lessons to reinforce national stillbirth response; multi-stakeholder perspectives regarding priorities and opportunities to deliver quality evidence-based interventions within a limited-resource context in Uganda. BMC Health Serv Res 2024; 24:715. [PMID: 38858756 PMCID: PMC11165756 DOI: 10.1186/s12913-024-11180-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 06/05/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND There is noted increase in attention towards implementation of evidence-based interventions in response to the stillbirth burden in low- and middle-income countries including Uganda. Recent results reporting some of the strategies adopted have tended to focus much attention towards their overall effect on the stillbirth burden. More is needed regarding stakeholder reflections on priorities and opportunities for delivering quality services within a limited resource setting like Uganda. This paper bridges this knowledge gap. METHODS Data collection occurred between March and June 2019 at the national level. Qualitative interviews were analysed using a thematic analysis technique. RESULTS Identified priorities included; a focus on supportive functions such as the referral system, attention to the demand side component of maternal health services, and improvements in the support supervision particularly focusing on empowering subnational level actors. The need to strengthen the learning for better implementation of strategies which are compatible with context was also reported. A comprehensive and favourable policy environment with the potential to direct implementation of strategies, harnessing the private sector contribution as well as the role of national level champions and patient advocates to amplify national stillbirth reduction efforts for continued visibility and impact were recommended. CONCLUSION Great potential exists within the current strategies to address the national stillbirth burden. However, priorities such as improving the supportive functions of MCH service delivery and attention to the demand side need to be pursued more for better service delivery with opportunities including a favourable policy environment primed to better serve the current strategies. This calls for dedicated efforts targeted at addressing gaps within the existing priorities and opportunities for better delivery of national strategies to address the stillbirth burden in Uganda.
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Affiliation(s)
- Eric Ssegujja
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, P.O. Box 7076, Kampala, Uganda.
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, Republic of South Africa.
| | - Michelle Andipatin
- Department of Psychology, University of the Western Cape, Cape Town, South Africa
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Harsha Kumar HN, Baliga SB, Kushtagi P, Kamath N, Rao SS. A study on awareness and perception about perinatal death auditing among health care workers in two districts of Karnataka State, India. J Family Med Prim Care 2024; 13:2336-2340. [PMID: 39027855 PMCID: PMC11254086 DOI: 10.4103/jfmpc.jfmpc_1225_23] [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: 07/27/2023] [Revised: 12/04/2023] [Accepted: 12/13/2023] [Indexed: 07/20/2024] Open
Abstract
Background To start perinatal death auditing, doctors should have good knowledge about it. Objectives To know the awareness and perceptions of doctors about different aspects of perinatal death auditing like 1) different types of contributors; 2) high-risk approach; 3) consequences; 4) documentary requirements; and 5) existing system of mortality meeting/child death reviews. Methodology The perinatal death auditing project was implemented in two districts of Karnataka state. As a part of the pre-intervention survey, awareness and perceptions of doctors and a few health care administrators were explored. They were requested to participate in the study. Those who consented were approached in their hospitals and interviewed. Trained medical social workers conducted the interviews. Awareness was scored from 0 to 3 with 0 being no knowledge and 3 being good knowledge. Perceptions were scored from 0 to 3 with 0 being no negative perceptions and 3 being fear of legal consequences. The responses were documented, scored, and described. Results Though 22 doctors were eligible, only 16 consented to participate in the study. Knowledge of doctors about different contributors was inadequate. They were apprehensive about legal consequences. They knew that documentation could protect them and be useful in a court of law. They were not clear about the conduct of mortality meeting/existing system of child death reviews. Conclusion Knowledge was inadequate. They were apprehensive about legal consequences. Training of doctors and allaying apprehensions are required for starting perinatal death auditing.
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Affiliation(s)
- HN Harsha Kumar
- Department of Community Medicine, Subbaiah Institute of Medical Sciences, Shimoga, Karnataka, India
| | - Shantaram B. Baliga
- Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
| | - Pralhad Kushtagi
- Department of Obstetrics and Gyneacology, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
| | - Nutan Kamath
- Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
| | - Suchetha S. Rao
- Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
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Domingues RMSM, Dias MAB, Nakamura-Pereira M, Pacagnella RDC, Lansky S, Gama SGND, Esteves-Pereira AP, Bittencourt SA, Miranda Theme Filha M, Ayres BVDS, Baldisserotto ML, Leite TH, Leal MDC. Perinatal mortality, severe maternal morbidity and maternal near miss: protocol of a study integrated with the Birth in Brazil II survey. CAD SAUDE PUBLICA 2024; 40:e00248222. [PMID: 38695462 PMCID: PMC11057478 DOI: 10.1590/0102-311xpt248222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 05/06/2024] Open
Abstract
Brazil presents high maternal and perinatal morbidity and mortality. Cases of severe maternal morbidity, maternal near miss, and perinatal deaths are important health indicators and share the same determinants, being closely related to living conditions and quality of perinatal care. This article aims to present the study protocol to estimate the perinatal mortality rate and the incidence of severe maternal morbidity and maternal near miss in the country, identifying its determinants. Cross-sectional study integrated into the research Birth in Brazil II, conducted from 2021 to 2023. This study will include 155 public, mixed and private maternities, accounting for more than 2,750 births per year, participating in the Birth in Brazil II survey. We will collect retrospective data from maternal and neonatal records of all hospitalizations within a 30-day period in these maternities, applying a screening form to identify cases of maternal morbidity and perinatal deaths. Medical record data of all identified cases will be collected after hospital discharge, using a standardized instrument. Cases of severe maternal morbidity and maternal near miss will be classified based on the definition adopted by the World Health Organization. The perinatal deaths rate and the incidence of severe maternal morbidity and maternal near miss will be estimated. Cases will be compared to controls obtained in the Birth in Brazil II survey, matched by hospital and duration of pregnancy, in order to identify factors associated with negative outcomes. Results are expected to contribute to the knowledge on maternal morbidity and perinatal deaths in Brazil, as well as the development of strategies to improve care.
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Affiliation(s)
| | - Marcos Augusto Bastos Dias
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Sônia Lansky
- Secretaria Municipal de Saúde de Belo Horizonte, Belo Horizonte, Brasil
| | | | | | | | | | | | | | | | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Bhutani VK, Vidavalur R, Wong RJ. Advances to diminish global newborn kernicterus mortality. J Perinatol 2024; 44:493-500. [PMID: 38151598 DOI: 10.1038/s41372-023-01862-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE Initiatives, "Every Newborn Action Plans" and "Sustainable Developmental Goals," are profoundly shaping global infant mortality trends. Concurrently, professional organizations recommended curricula to prevent extreme hyperbilirubinemia (EHB) sequelae. Therefore we assessed if these efforts have successfully decreased EHB-related mortality over time. STUDY DESIGN We used the Global Burden of Diseases 2019 database to determine neonatal and infant mortality and the burden of kernicterus from 1990-2019. RESULTS Globally, kernicterus accounted for 2.8 million infant deaths and trended downwards significantly from 1990 to 2019. By 2019, kernicterus-related mortality was 4 and 293 per million livebirths in high (HICs) and low income countries (LICs), respectively. 82% of deaths occurred in LICs and lower-middle income-countries. Average declines of mortality rates were 6.2% and 3.0% for HICs and LICs, respectively. CONCLUSIONS Kernicterus-related mortality has been effectively reduced to <5 per million in HICs. Skills and knowledge transfer can potentially transform frontline services to bridge discordant kernicteric outcomes worldwide.
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Affiliation(s)
- Vinod K Bhutani
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Ramesh Vidavalur
- Department of Neonatology, Cayuga Medical Center of Ithaca, Ithaca, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Ronald J Wong
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
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O'Connor E, Leitao S, Fogarty AP, Greene R, O'Donoghue K. A systematic review of standardised tools used in perinatal death review programmes. Women Birth 2024; 37:88-97. [PMID: 37793961 DOI: 10.1016/j.wombi.2023.09.006] [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: 06/06/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Reducing preventable perinatal deaths is the focus of perinatal death surveillance and response programmes. Standardised review tools can help identify modifiable factors in perinatal deaths. AIM This systematic review aimed to identify, compare, and appraise perinatal mortality review tools (PMRTs) in upper-middle to high-income countries. METHODS Four major scientific databases were searched for publications relating to perinatal death reviews. There were no restrictions on date, study, or publication type. Professional websites for each country were searched for relevant material. The Appraisal of Guidelines Research and Evaluation Health Systems (AGREE-HS) checklist was used for quality appraisal of each tool. A narrative synthesis was used to describe and compare tools. FINDINGS Ten PMRTs were included. Five PMRTs were from high-income countries, four from upper-middle income countries and one was designed for use in a global context. The structure, content, and quality of each PMRT varied. Each tool collected information about the antepartum, intrapartum, and neonatal periods and a section to classify perinatal deaths using a standardised classification system. All tools reviewed the care provided. Five tools included recommendation development for changes to clinical care. Four tools mentioned parent involvement in the review process. For quality appraisal, one review tool scored "high quality", six scored "moderate quality" and two scored "poor quality". CONCLUSION There is little standardisation when it comes to PMRTs. Guidance on structuring PMRTs in a standardised way is needed. Recommendation development from a review is important to highlight changes to care required to reduce preventable perinatal deaths.
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Affiliation(s)
- Emily O'Connor
- INFANT Research Centre, University College Cork, Cork, Ireland; Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland; National Perinatal Epidemiology Centre, Dept. of Obstetrics and Gynaecology, 5th Floor, Cork University Maternity Hospital, Ireland.
| | - Sara Leitao
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland; National Perinatal Epidemiology Centre, Dept. of Obstetrics and Gynaecology, 5th Floor, Cork University Maternity Hospital, Ireland
| | - Amy P Fogarty
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Richard Greene
- National Perinatal Epidemiology Centre, Dept. of Obstetrics and Gynaecology, 5th Floor, Cork University Maternity Hospital, Ireland
| | - Keelin O'Donoghue
- INFANT Research Centre, University College Cork, Cork, Ireland; Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
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Mensah Abrampah NA, Okwaraji YB, Oteng KF, Asiedu EK, Larsen-Reindorf R, Blencowe H, Jackson D. District health management and stillbirth recording and reporting: a qualitative study in the Ashanti Region of Ghana. BMC Pregnancy Childbirth 2024; 24:91. [PMID: 38287283 PMCID: PMC10826143 DOI: 10.1186/s12884-024-06272-x] [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: 09/29/2023] [Accepted: 01/13/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Despite global efforts to reduce maternal and neonatal mortality, stillbirths remain a significant public health challenge in many low- and middle-income countries. District health systems, largely seen as the backbone of health systems, are pivotal in addressing the data gaps reported for stillbirths. Available, accurate and complete data is essential for District Health Management Teams (DHMTs) to understand the burden of stillbirths, evaluate interventions and tailor health facility support to address the complex challenges that contribute to stillbirths. This study aims to understand stillbirth recording and reporting in the Ashanti Region of Ghana from the perspective of DHMTs. METHODS The study was conducted in the Ashanti Region of Ghana. 15 members of the regional and district health directorates (RHD/DHD) participated in semi-structured interviews. Sampling was purposive, focusing on RHD/DHD members who interact with maternity services or stillbirth data. Thematic analyses were informed by an a priori framework, including theme 1) experiences, perceptions and attitudes; theme 2) stillbirth data use; and theme 3) leadership and support mechanisms, for stillbirth recording and reporting. RESULTS Under theme 1, stillbirth definitions varied among respondents, with 20 and 28 weeks commonly used. Fresh and macerated skin appearance was used to classify timing with limited knowledge of antepartum and intrapartum stillbirths. For theme 2, data quality checks, audits, and the district health information management system (DHIMS-2) data entry and review are functions played by the DHD. Midwives were blamed for data quality issues on omissions and misclassifications. Manual entry of data, data transfer from the facility to the DHD, limited knowledge of stillbirth terminology and periodic closure of the DHIMS-2 were seen to proliferate gaps in stillbirth recording and reporting. Under theme 3, perinatal audits were acknowledged as an enabler for stillbirth recording and reporting by the DHD, though audits are mandated for only late-gestational stillbirths (> 28 weeks). Engagement of other sectors, e.g., civil/vital registration and private health facilities, was seen as key in understanding the true population-level burden of stillbirths. CONCLUSION Effective district health management ensures that every stillbirth is accurately recorded, reported, and acted upon to drive improvements. A large need exists for capacity building on stillbirth definitions and data use. Recommendations are made, for example, terminology standardization and private sector engagement, aimed at reducing stillbirth rates in high-mortality settings such as Ghana.
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Affiliation(s)
- Nana A Mensah Abrampah
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - Yemisrach B Okwaraji
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Kenneth Fosu Oteng
- Ashanti Regional Health Directorate, Ghana Health Service, Kumasi, Ghana
| | - Ernest Konadu Asiedu
- National Centre for Coordination for Early Warning and Response Mechanisms, Accra, Ghana
| | | | - Hannah Blencowe
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Debra Jackson
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Medeiros PB, Bailey C, Pollock D, Liley H, Gordon A, Andrews C, Flenady V. Neonatal near-miss audits: a systematic review and a call to action. BMC Pediatr 2023; 23:573. [PMID: 37978460 PMCID: PMC10655277 DOI: 10.1186/s12887-023-04383-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Neonatal near-miss (NNM) can be considered as an end of a spectrum that includes stillbirths and neonatal deaths. Clinical audits of NNM might reduce perinatal adverse outcomes. The aim of this review is to evaluate the effectiveness of NNM audits for reducing perinatal mortality and morbidity and explore related contextual factors. METHODS PubMed, Embase, Scopus, CINAHL, LILACS and SciELO were searched in February/2023. Randomized and observational studies of NNM clinical audits were included without restrictions on setting, publication date or language. PRIMARY OUTCOMES perinatal mortality, morbidity and NNM. SECONDARY OUTCOMES factors contributing to NNM and measures of quality of care. Study characteristics, methodological quality and outcome were extracted and assessed by two independent reviewers. Narrative synthesis was performed. RESULTS Of 3081 titles and abstracts screened, 36 articles had full-text review. Two studies identified, rated, and classified contributing care factors and generated recommendations to improve the quality of care. No study reported the primary outcomes for the review (change in perinatal mortality, morbidity and NNM rates resulting from an audit process), thus precluding meta-analysis. Three studies were multidisciplinary NNM audits and were assessed for additional contextual factors. CONCLUSION There was little data available to determine the effectiveness of clinical audits of NNM. While trials randomised at patient level to test our research question would be difficult or unethical for both NNM and perinatal death audits, other strategies such as large, well-designed before-and-after studies within services or comparisons between services could contribute evidence. This review supports a Call to Action for NNM audits. Adoption of formal audit methodology, standardised NNM definitions, evaluation of parent's engagement and measurement of the effectiveness of quality improvement cycles for improving outcomes are needed.
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Affiliation(s)
- P B Medeiros
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia.
- Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia.
| | - C Bailey
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - D Pollock
- JBI, School of Public Health, University of Adelaide, Adelaide, SA, Australia
| | - H Liley
- Mater Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - A Gordon
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
- University of Sydney, Sydney, NSW, Australia
| | - C Andrews
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - V Flenady
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
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August F, Nyamhanga TM, Kakoko DCV, Sirili NS, Frumence GM. Facilitators for and Barriers to the Implementation of Performance Accountability Mechanisms for Quality Improvement in the Delivery of Maternal Health Services in a District Hospital in Pwani Region, Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6366. [PMID: 37510598 PMCID: PMC10379119 DOI: 10.3390/ijerph20146366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 07/30/2023]
Abstract
Tanzania experiences a burden of maternal mortality and morbidity. Despite the efforts to institute accountability mechanisms, little is known about quality improvement in the delivery of maternal health services. This study aimed at exploring barriers and facilitators to enforcing performance accountability mechanisms for quality improvement in maternal health services. A case study design was used to conduct semi-structured interviews with thirteen key informants. Data were analyzed using thematic analyses. The findings were linked to two main performance accountability mechanisms: maternal and perinatal death reviews (MPDRs) and monitoring and evaluation (M&E). Prioritization of the maternal health agenda by the government and the presence of maternal death review committees were the main facilitators for MPDRs, while negligence, inadequate follow-up, poor record-keeping, and delays were the main barriers facing MPDRs. M&E was facilitated by the availability of health management information systems, day-to-day ward rounds, online ordering of medicines, and the use of biometrics. Non-use of data for decision-making, supervision being performed on an ad hoc basis, and inadequate health workforce were the main barriers to M&E. The findings underscore that barriers to the performance accountability mechanisms are systemic and account for limited effectiveness in the improvement of quality of care.
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Affiliation(s)
- Francis August
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam P.O. Box 65015, Tanzania
| | - Tumaini Mwita Nyamhanga
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam P.O. Box 65015, Tanzania
| | - Deodatus Conatus Vitalis Kakoko
- Department of Behavioral Sciences, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam P.O. Box 65015, Tanzania
| | - Nathanael Shauri Sirili
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam P.O. Box 65015, Tanzania
| | - Gasto Msoffee Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam P.O. Box 65015, Tanzania
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de Barros Medeiros P, Liley H, Andrews C, Gordon A, Heazell AE, Kent AL, Leisher SH, Flenady V. Current approach and attitudes toward neonatal near-miss and perinatal audits: An exploratory international survey. Aust N Z J Obstet Gynaecol 2023; 63:352-359. [PMID: 36447356 PMCID: PMC10952158 DOI: 10.1111/ajo.13634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/06/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Combined with perinatal mortality review, neonatal near-miss (NNM) audit has the potential to inform strategies to better prevent adverse perinatal outcomes. Nonetheless, there is lack of standardised definitions of NNM and limited evidence of implementation of NNM audits. AIM To describe definitions of NNM and assess current approaches and attitudes toward perinatal mortality and morbidity audit. MATERIALS AND METHODS Online survey from December 2021 to February 2022, with a mix of Likert scales, polar, pool, multi-choice, and open-ended questions, disseminated through national and international organisations to perinatal healthcare workers from high-income countries. RESULTS One hundred and twenty participants came from Australia (n = 86), New Zealand (n = 18), Canada (n = 7), USA (n = 4), Netherlands (n = 2), other countries (n = 3). Neonatologists (35%), midwives (21.7%), obstetricians (12.5%), neonatal nurse practitioners (11.7%) and others (23.3%) responded. Most respondents thought the main characteristics to define NNM were birth asphyxia needing therapeutic hypothermia (68.3%), unexpected resuscitation at birth (67.5%), need for intubation/chest compression/adrenaline (65.0%) and metabolic acidosis at birth (60.0%). There were 97.5% of participants who considered NNM important for identifying cases for perinatal morbidity audits. However, only 10.0% of their institutions used a NNM definition. Overall, 98.4% of participants considered perinatal mortality and morbidity audits important to prevent adverse outcomes. CONCLUSION Neonatal near-miss audit is viewed as a valuable tool to reduce adverse neonatal outcomes. There was reasonable consensus that NNM encompassed evidence of birth asphyxia and/or advanced neonatal resuscitation. Data from this international survey identifies a starting point for a consensus definition of NNM, which can be used for perinatal audits to identify opportunities for improvement.
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Affiliation(s)
- Poliana de Barros Medeiros
- Centre of Research Excellence in StillbirthMater Research Institute, The University of QueenslandBrisbaneQueenslandAustralia
- Department of Paediatrics and NeonatologySunshine Coast University HospitalSunshine CoastQueenslandAustralia
| | - Helen Liley
- Mater Research InstituteThe University of QueenslandBrisbaneQueenslandAustralia
- Department of NeonatologyMater Mothers' HospitalBrisbaneQueenslandAustralia
| | - Christine Andrews
- Centre of Research Excellence in StillbirthMater Research Institute, The University of QueenslandBrisbaneQueenslandAustralia
| | - Adrienne Gordon
- Centre of Research Excellence in StillbirthMater Research Institute, The University of QueenslandBrisbaneQueenslandAustralia
- University of SydneySydneyNew South WalesAustralia
| | - Alexander E.P. Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Department of Obstetrics, Saint Mary's HospitalManchester University NHS Foundation TrustManchesterUK
- International Stillbirth AllianceMillburnNew JerseyUSA
| | - Alison L. Kent
- Department of PaediatricsUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
- Australian National University, College of Health and MedicineCanberraAustralian Capital TerritoryAustralia
| | - Susannah H. Leisher
- Centre of Research Excellence in StillbirthMater Research Institute, The University of QueenslandBrisbaneQueenslandAustralia
- International Stillbirth AllianceMillburnNew JerseyUSA
| | - Vicki Flenady
- Centre of Research Excellence in StillbirthMater Research Institute, The University of QueenslandBrisbaneQueenslandAustralia
- International Stillbirth AllianceMillburnNew JerseyUSA
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14
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Kinney MV, George AS, Rhoda NR, Pattinson RC, Bergh AM. From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa. GLOBAL HEALTH: SCIENCE AND PRACTICE 2023; 11:GHSP-D-22-00213. [PMID: 37116922 PMCID: PMC10141437 DOI: 10.9745/ghsp-d-22-00213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/07/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa. METHODS Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation. RESULTS Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice. CONCLUSION This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust.
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Affiliation(s)
- Mary V. Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Asha S. George
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Natasha R. Rhoda
- Mowbray Maternity Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Robert C. Pattinson
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council and Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Anne-Marie Bergh
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council and Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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15
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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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16
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Gondwe MJ, Joshua E, Kaliati H, Aminu M, Allen S, Desmond N. Factors impacting-stillbirth and neonatal death audit in Malawi: a qualitative study. BMC Health Serv Res 2022; 22:1191. [PMID: 36138396 PMCID: PMC9502637 DOI: 10.1186/s12913-022-08578-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background Over one million babies are stillborn or die within the first 28 days of life each year due to preventable causes and poor-quality care in resource-constrained countries. Death audit may be a valuable tool for improving quality of care and decreasing mortality. However, challenges in implementing audit and their subsequent action plans have been reported, with few successfully implemented and sustained. This study aimed to identify factors that affect stillbirth and neonatal death audit at the facility level in the southern region of Malawi. Methods Thirty-eight semi-structured interviews and seven focus group discussions with death audit committee members were conducted. Thematic analysis was guided by a conceptual framework applied deductively, combined with inductive line-by-line coding to identify additional emerging themes. Results The factors that affected audit at individual, facility and national level were related to training, staff motivation, power dynamics and autonomy, audit organisation and data support. We found that factors were linked because they informed each other. Inadequate staff training was caused by a lack of financial allocation at the facility level and donor-driven approaches to training at the national level, with training taking place only with support from funders. Staff motivation was affected by the institutional norms of reliance on monetary incentives during meetings, gazetted at the national level so that audits happened only if such incentives were available. This overshadowed other benefits and non-monetary incentives which were not promoted at the facility level. Inadequate resources to support audit were informed by limited facility-level autonomy and decision-making powers which remained controlled at the national level despite decentralisation. Action plan implementation challenges after audit meetings resulted from inadequate support at the facility level and inadequate audit policy and guidelines at the national level. Poor documentation affected audit processes informed by inadequate supervision and promotion of data usage at both facility and national levels. Conclusions Given that the factors that facilitate or inhibit audits are interconnected, implementers, policymakers and managers need to be aware that addressing barriers is likely to require a whole health systems approach targeting all system levels. This will require behavioural and complex intervention approaches.
Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08578-y.
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Affiliation(s)
- Mtisunge Joshua Gondwe
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. .,Behaviour and Health Group, Malawi Liverpool Wellcome Trust- Clinical Research Programme, PO Box 30096, Chichiri, Blantyre 3, Malawi.
| | - Emily Joshua
- Behaviour and Health Group, Malawi Liverpool Wellcome Trust- Clinical Research Programme, PO Box 30096, Chichiri, Blantyre 3, Malawi
| | - Hendrina Kaliati
- Behaviour and Health Group, Malawi Liverpool Wellcome Trust- Clinical Research Programme, PO Box 30096, Chichiri, Blantyre 3, Malawi
| | - Mamuda Aminu
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Stephen Allen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Nicola Desmond
- Behaviour and Health Group, Malawi Liverpool Wellcome Trust- Clinical Research Programme, PO Box 30096, Chichiri, Blantyre 3, Malawi.,Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Gutman A, Harty T, O'Donoghue K, Greene R, Leitao S. Perinatal mortality audits and reporting of perinatal deaths: systematic review of outcomes and barriers. J Perinat Med 2022; 50:684-712. [PMID: 35086187 DOI: 10.1515/jpm-2021-0363] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/21/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Perinatal deaths are a devastating experience for all families and healthcare professionals involved. Audit of perinatal mortality (PNM) is essential to better understand the factors associated with perinatal death, to identify key deficiencies in healthcare provision and should be utilised to improve the quality of perinatal care. However, barriers exist to successful audit implementation and few countries have implemented national perinatal audit programs. CONTENT We searched the PubMed, EMBASE and EBSCO host, including Medline, Academic Search Complete and CINAHL Plus databases for articles that were published from 1st January 2000. Articles evaluating perinatal mortality audits or audit implementation, identifying risk or care factors of perinatal mortality through audits, in middle and/or high-income countries were considered for inclusion in this review. Twenty articles met inclusion criteria. Incomplete datasets, nonstandard audit methods and classifications, and inadequate staff training were highlighted as barriers to PNM reporting and audit implementation. Failure in timely detection and management of antenatal maternal and fetal conditions and late presentation or failure to escalate care were the most common substandard care factors identified through audit. Overall, recommendations for perinatal audit focused on standardised audit tools and training of staff. Overall, the implementation of audit recommendations remains unclear. SUMMARY This review highlights barriers to audit practices and emphasises the need for adequately trained staff to participate in regular audit that is standardised and thorough. To achieve the goal of reducing PNM, it is crucial that the audit cycle is completed with continuous re-evaluation of recommended changes.
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Affiliation(s)
- Arlene Gutman
- School of Medicine and Health, University College Cork, Cork, Ireland.,Pregnancy Loss Research Group (PLRG), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Tommy Harty
- School of Medicine and Health, University College Cork, Cork, Ireland.,Cork University Hospital, Cork, Ireland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group (PLRG), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland.,Cork University Maternity Hospital, Cork, Ireland.,The Irish Centre for Maternal and Child Health Research (INFANT), University College Cork, Cork, Ireland
| | - Richard Greene
- Department of Obstetrics and Gynaecology, School of Medicine and Health, University College Cork, Cork, Ireland.,Cork University Maternity Hospital, Cork, Ireland.,National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - Sara Leitao
- Department of Obstetrics and Gynaecology, School of Medicine and Health, University College Cork, Cork, Ireland.,Pregnancy Loss Research Group (PLRG), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland.,National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
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18
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Congo B, Yaméogo WME, Millogo T, Compaoré R, Tougri H, Ouédraogo CMR, Kouanda S. Barriers to the implementation of quality maternal death reviews in health districts in Burkina Faso. Int J Gynaecol Obstet 2022; 158 Suppl 2:29-36. [PMID: 35616151 DOI: 10.1002/ijgo.14232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To identify barriers to the implementation of maternal death reviews in health districts in Burkina Faso. METHODS We conducted a multiple case study in seven health facilities chosen by contrasted purposive sampling. Sampling criteria were based on intrahospital maternal mortality rates and the location of the health facility. Data collection was conducted from April 27 to May 30, 2015, using structured and semistructured interviews and data extraction from source documents. Data were analyzed using a thematic approach. RESULTS Barriers to quality maternal death reviews identified were primarily implementation conditions, including poor skills and motivation of healthcare personnel, low interest in quality of care, lack of suitable equipment, insufficient coordination and collaboration between health services, insufficient monitoring, and weakness in programming and conducting the reviews. CONCLUSION Barriers to achieving quality maternal death reviews remain numerous at the operational level of the health system. Taking steps to remove these barriers is key to improving the quality of maternal death reviews and childbirth outcomes in Burkina Faso.
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Affiliation(s)
- Boukaré Congo
- African Institute of Public Health (AIPH), Ouagadougou, Burkina Faso
| | - Wambi M E Yaméogo
- African Institute of Public Health (AIPH), Ouagadougou, Burkina Faso
| | - Tieba Millogo
- African Institute of Public Health (AIPH), Ouagadougou, Burkina Faso
| | | | - Halima Tougri
- Institute for Research and Health Sciences, Ouagadougou, Burkina Faso
| | | | - Seni Kouanda
- African Institute of Public Health (AIPH), Ouagadougou, Burkina Faso
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19
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Zethof S, Christou A, Benova L, van Roosmalen J, van den Akker T. "Too much, too late": data on stillbirths to improve interpretation of caesarean section rates. Bull World Health Organ 2022; 100:289-291. [PMID: 35386563 PMCID: PMC8958836 DOI: 10.2471/blt.21.287539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/31/2022] [Accepted: 02/07/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Siem Zethof
- Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, Netherlands
| | - Aliki Christou
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, Netherlands
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Heen E, Størdal K, Abdi A, Walmann FV, Lundeby KM. Facility-based care of small and sick newborns: experiences with establishing a neonatal special care unit in Somaliland. JOURNAL OF GLOBAL HEALTH REPORTS 2022. [DOI: 10.29392/001c.33619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Ketil Størdal
- Medical Faculty, University of Oslo, Oslo, Norway; Norwegian Institute of Public Health, Oslo, Norway; Ostfold Hospital Trust, Sarpsborg, Norway
| | | | | | - Karen M Lundeby
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Pediatric Department, Hargeisa Group Hospital, Hargeisa, Somaliland
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Subedi N, Kandel D, Ghale T, Gurung B, Shrestha B, Paudel S. Causes of perinatal mortality and associated maternal factors in a tertiary referral hospital of Gandaki province of Nepal: a cross-sectional study from a hospital-based surveillance. BMC Pregnancy Childbirth 2022; 22:245. [PMID: 35331187 PMCID: PMC8952269 DOI: 10.1186/s12884-022-04596-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Perinatal and neonatal death rates have decreased recently but it still poses a major challenge to the health system of Nepal. The study was conducted to explore the pattern and causes of perinatal deaths. METHODS This was a descriptive cross-sectional study conducted from September 2020 to June 2021 using the data of perinatal mortality of three years from June 15, 2017, to June 14, 2020. The demographic parameters of the mother consisted of maternal age, place of residence, ethnicity, antenatal care, the number of antenatal visits, gravida, gestational weeks, and the mode of delivery. The causes of death were categorized into fetal and early neonatal deaths. Fetal deaths were further classified as macerated stillbirth and fresh stillbirth. The attribution of the causes of deaths to fetal/neonatal and maternal conditions was done as per the guidelines of the WHO application of ICD-10 to deaths during the perinatal period. RESULTS There were a total of 145 perinatal deaths from 144 mothers among which 92 (63.5%) were males. Ten mothers (6.9%) had not sought even single antenatal care, whereas 32 (22.9%) had visited for antenatal care one to three times. At least one cause of death was identified in 114 (78.6%) and remained unknown in 31(21.4%) cases. Among the 28 cases of macerated stillbirths, the cause of death was not identified in 14 (50%), whereas preterm labor was attributed to the cause of death in four (14.3%). In 53 of the fresh stillbirths, intrapartum hypoxia was identified as the cause of death in 20 (37.7%) cases, preterm labor in nine (17%), and was left unknown in 15 (28.3%) cases. Among the 64 early neonatal deaths, prematurity was attributed as the cause of death in 32 (50%) cases, birth asphyxia, and infections each in 11 (17.2%). CONCLUSIONS The perinatal mortality surveillance system identified the causes of death in most of the cases in our observation. Prematurity was identified as the commonest cause of early neonatal deaths and preterm labor was the commonest cause responsible for perinatal deaths overall. The perinatal deaths should be investigated to establish exact causes of deaths which can be useful to develop prevention strategies.
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Affiliation(s)
- Nuwadatta Subedi
- Department of Forensic Medicine, Gandaki Medical College Teaching Hospital and Research Center, Gandaki Province, Pokhara, Nepal.
| | - Dipendra Kandel
- Green Pastures Hospital - International Nepal Fellowship, Gandaki Province, Pokhara, Nepal
| | - Tumaya Ghale
- Department of Anesthesiology, Gandaki Medical College Teaching Hospital and Research Center, Gandaki Province, Pokhara, Nepal
| | - Bandana Gurung
- Department of Obstetrics and Gynecology, Gandaki Medical College Teaching Hospital and Research Center, Gandaki Province, Pokhara, Nepal
| | - Bandana Shrestha
- Department of Pediatrics, Gandaki Medical College Teaching Hospital and Research Center, Gandaki Province, Pokhara, Nepal
| | - Sabita Paudel
- Department of Pharmacology, Gandaki Medical College Teaching Hospital and Research Center, Gandaki Province, Pokhara, Nepal
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22
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Jepkosgei J, Nzinga J, Adam MB, English M. Exploring healthcare workers' perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals' newborn units. BMC Health Serv Res 2022; 22:172. [PMID: 35144594 PMCID: PMC8832787 DOI: 10.1186/s12913-022-07572-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In many sub-Saharan African countries, including Kenya, the use of mortality and morbidity audits in maternal and perinatal/neonatal care as an avenue for learning and improving care delivery is sub-optimal due to structural, organizational, and human barriers. While attempts to address these barriers have been reported, lots of emphasis has been paid to addressing the role of tangible inputs (e.g., availing guidelines and training staff in the success of mortality and morbidity audits), while process-related factors (i.e., the role of the people, their experiences, relationships, and motivations) remain inadequately explored. We examined the processes of neonatal audits, their potential in promoting learning from gaps in care and improving care delivery, with a deliberate focus on process-related factors that generally influence mortality and morbidity (M&M) audits. METHODS This was an exploratory qualitative study, conducted in three hospitals, in Nairobi and Muranga counties. We employed a mix of in-depth interviews (17) and observation of 12 mortality and morbidity audit meetings. Our study participants included: nurses, doctors, trainee clinicians (i.e., junior doctors on internships), and nursing students involved in providing newborn care. These data were coded using NVivo12 employing a thematic content analysis approach. RESULTS Perceived shortcomings in the conduct of M&M audits such as unclear structure was reported to have contributed to its sub-optimal nature in promoting learning. These shortcomings, in addition to hierarchy and power dynamics, poor implementation of audit recommendations, and negative experiences, (e.g., blame) also demotivated health workers from attendance and participation in audits. Despite these, positive outcomes linked to audit recommendations, such as revision of care protocols, were reported. Overall, leadership and a blame-free culture enabled positive changes and promoted learning from audit-identified modifiable factors. CONCLUSION Our findings indicate that M&M audits provide a space for meaningful discussions, which may lead to learning and improvement in care delivery processes. However, a lack of participation, lack of observed positive outcomes, and negative experiences may reduce their usefulness. An enabling environment characterized by minimized effects of hierarchy and positive use of power and a blame-free culture may promote active participation, enhancing positive relationships and interactions thus promoting team learning.
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Affiliation(s)
- Joyline Jepkosgei
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya.
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
| | | | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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23
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Harsha Kumar HN, Baliga S, Kushtagi P, Kamath N, Rao S. Perinatal death auditing is necessary to identify preventable perinatal deaths. Int J Prev Med 2022; 13:48. [PMID: 35706869 PMCID: PMC9188881 DOI: 10.4103/ijpvm.ijpvm_65_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/21/2020] [Indexed: 11/30/2022] Open
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24
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Kinney MV, Day LT, Palestra F, Biswas A, Jackson D, Roos N, de Jonge A, Doherty P, Manu AA, Moran AC, George AS. Overcoming blame culture: key strategies to catalyse maternal and perinatal death surveillance and response. BJOG 2021; 129:839-844. [PMID: 34709701 PMCID: PMC9298870 DOI: 10.1111/1471-0528.16989] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/29/2022]
Affiliation(s)
- M V Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - L T Day
- Maternal Newborn Health Group, Maternal Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, UK.,Maternal Newborn Health Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - F Palestra
- World Health Organization, Geneva, Switzerland
| | | | - D Jackson
- School of Public Health, University of the Western Cape, Bellville, South Africa.,Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - N Roos
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Stockholm, Sweden
| | - A de Jonge
- Midwifery Science, AVAG (Academy Midwifery Amsterdam and Groningen), Amsterdam Public Health Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,University Medical Center Groningen, Groningen, The Netherlands
| | - P Doherty
- Options Consultancy Services Ltd, St Magnus House, London, UK
| | - A A Manu
- Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - A C Moran
- Department of Maternal, Newborn, Child, Adolescent Health & Ageing, World Health Organization, Geneva, Switzerland
| | - A S George
- School of Public Health, University of the Western Cape, Bellville, South Africa
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25
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Waiswa P, Wanduru P, Okuga M, Kajjo D, Kwesiga D, Kalungi J, Nambuya H, Mulowooza J, Tagoola A, Peterson S. Institutionalizing a Regional Model for Improving Quality of Newborn Care at Birth Across Hospitals in Eastern Uganda: A 4-Year Story. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:365-378. [PMID: 33956641 PMCID: PMC8324186 DOI: 10.9745/ghsp-d-20-00156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 03/02/2021] [Indexed: 12/03/2022]
Abstract
A locally developed, low-cost package of interventions implemented in a regional network of hospitals resulted in significant reductions in mortality for mothers and newborns as well as the institutionalization of the quality improvement initiative. This work demonstrates that it is possible to achieve the World Health Organization/United Nations Children's Fund Quality of Care targets in hospitals. Introduction: Despite the rapid increase in facility deliveries in Uganda, the number of adverse birth outcomes (e.g., neonatal and maternal deaths) has remained high. We aimed to codesign and co-implement a locally designed package of interventions to improve the quality of care in hospitals in the Busoga region. Design and Implementation: This project was designed and implemented in 3 phases in the 6 main hospitals in east-central Uganda from 2013 to 2016. First, the inception phase engaged health system managers to codesign the intervention. Second, the implementation phase involved training health providers, strengthening the data information system, and providing catalytic equipment and medicines to establish newborn care units (NCUs) within the existing infrastructure. Third, the hospital collaborative phase focused on clinical mentorship, maternal and perinatal death reviews (MPDRs), and collaborative learning sessions. Achievements: In all 6 participating hospitals, we achieved institutionalization of NCUs in maternity units by establishing kangaroo mother care areas, resuscitation corners, and routine MPDRs. These improvements were associated with reduced maternal and neonatal deaths. Facilitators of success included a simple, low-cost, and integrated package designed with local health managers; the emergence of local neonatal care champions; implementation and support over a reasonably long period; decentralization of newborn care services; and use of mainly existing local resources (e.g., physical space, human resources, and commodities). Barriers to success related to limited hospital resources, unstable electricity, and limited participation from doctors. More advanced NCUs have been established in 3 of the 6 hospitals, and 7 high-volume comprehensive health centers have been established with functional NCUs. Conclusion: The involvement of local health workers and leaders was the foundation for designing, sustaining, and scaling up feasible interventions by harnessing available resources. These findings are relevant for the quality of care improvement efforts in Uganda and other resource-restrained settings.
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Affiliation(s)
- Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda. .,Global Public Health, Karolinska Institute, Stockholm, Sweden.,Busoga Health Forum, Jinja, Uganda
| | - Phillip Wanduru
- Makerere University School of Public Health, Kampala, Uganda.,Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Monica Okuga
- Makerere University School of Public Health, Kampala, Uganda
| | - Darius Kajjo
- Makerere University School of Public Health, Kampala, Uganda
| | - Doris Kwesiga
- Makerere University School of Public Health, Kampala, Uganda.,Uppsala University, Uppsala, Sweden
| | - James Kalungi
- Makerere University School of Public Health, Kampala, Uganda
| | | | | | | | - Stefan Peterson
- Makerere University School of Public Health, Kampala, Uganda.,Global Public Health, Karolinska Institute, Stockholm, Sweden.,Uppsala University, Uppsala, Sweden
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26
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Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George A. Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors. Health Policy Plan 2021; 36:955-973. [PMID: 33712840 PMCID: PMC8227470 DOI: 10.1093/heapol/czab011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.
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Affiliation(s)
- Mary V Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - David Roger Walugembe
- School of Health Studies and Faculty of Information and Media Studies, The University of Western Ontario, London, ON, Canada
| | - Phillip Wanduru
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter Waiswa
- Global Health Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Asha George
- School of Public Health, University of the Western Cape, Bellville, South Africa
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27
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Connolly M, Phung L, Farrington E, Scoullar MJL, Wilson AN, Comrie-Thomson L, Homer CSE, Vogel JP. Defining Preterm Birth and Stillbirth in the Western Pacific: A Systematic Review. Asia Pac J Public Health 2021; 33:489-501. [PMID: 34165364 DOI: 10.1177/10105395211026099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preterm birth and stillbirth are important global perinatal health indicators. Definitions of these indicators can differ between countries, affecting comparability of preterm birth and stillbirth rates across countries. This study aimed to document national-level adherence to World Health Organization (WHO) definitions of preterm birth and stillbirth in the WHO Western Pacific region. A systematic search of government health websites and 4 electronic databases was conducted. Any official report or published study describing the national definition of preterm birth or stillbirth published between 2000 and 2020 was eligible for inclusion. A total of 58 data sources from 21 countries were identified. There was considerable variation in how preterm birth and stillbirth was defined across the region. The most frequently used lower gestational age threshold for viability of preterm birth was 28 weeks gestation (range 20-28 weeks), and stillbirth was most frequently classified from 20 weeks gestation (range 12-28 weeks). High-income countries more frequently used earlier gestational ages for preterm birth and stillbirth compared with low- to middle-income countries. The findings highlight the importance of clear, standardized, internationally comparable definitions for perinatal indicators. Further research is needed to determine the impact on regional preterm birth and stillbirth rates.
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Affiliation(s)
- Mairead Connolly
- Burnet Institute, Melbourne, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Laura Phung
- Burnet Institute, Melbourne, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Elise Farrington
- Burnet Institute, Melbourne, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Michelle J L Scoullar
- Burnet Institute, Melbourne, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | | | - Liz Comrie-Thomson
- Burnet Institute, Melbourne, Australia.,University of Melbourne, Parkville, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia.,Ghent University, Ghent, Belgium
| | | | - Joshua P Vogel
- Burnet Institute, Melbourne, Australia.,University of Melbourne, Parkville, Victoria, Australia
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28
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Vallely LM, Smith R, Laman M, Riddell MA, Mengi A, Au L, Polomon C, Vogel JP, Pomat WS, Vallely AJ, Homer CS. Early neonatal death review from two provinces in Papua New Guinea: A retrospective analysis. J Paediatr Child Health 2021; 57:841-846. [PMID: 33450113 DOI: 10.1111/jpc.15333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/30/2020] [Accepted: 12/16/2020] [Indexed: 11/30/2022]
Abstract
AIM To determine the causes of early neonatal death and the avoidable factors associated with these deaths among women participating in a cluster-randomised crossover trial in Papua New Guinea. METHODS Early neonatal deaths were identified by retrospective chart review of the Women and Newborn Trial of Antenatal Interventions and Management study participants between July 2017 and January 2020. Causes of death and avoidable factors were identified using the Perinatal Problem Identification Program system. RESULTS There were 35 early neonatal deaths among 2499 livebirths (14 per 1000 births). Fifty-seven percent (20/35) of deaths occurred on the first day of life. Idiopathic preterm birth was the leading obstetric cause of perinatal death (29%; 10/35). Extreme multi-organ immaturity (23%; 8/35) and hypoxic ischaemic encephalopathy (17%; 6/35) were the most common final causes of neonatal death. Forty-six avoidable factors were identified among 26 deaths, including delays in care-seeking, insufficient resources at health facilities, poor intrapartum care and immediate care of the newborn, including neonatal resuscitation. CONCLUSION In this study, potentially preventable causes and avoidable factors were identified in the majority of early neonatal deaths. Addressing these factors will require health system strengthening, particularly the upskilling of primary level health staff, as well as targeted health education of women and the community.
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Affiliation(s)
- Lisa M Vallely
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Rachel Smith
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Moses Laman
- Infection and Immunity Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Michaela A Riddell
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Infection and Immunity Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Alice Mengi
- Infection and Immunity Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Lucy Au
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Cherolyn Polomon
- School of Nursing and Midwfery, Pacific Adventist University, Port Moresby, Papua New Guinea
| | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - William S Pomat
- Infection and Immunity Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew J Vallely
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Caroline Se Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
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29
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Alyahya MS, Khader YS, Al-Sheyab NA, Shattnawi KK, Altal OF, Batieha A. Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits. Am J Perinatol 2021; 40:731-740. [PMID: 34058760 DOI: 10.1055/s-0041-1730434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study employed the "three-delay" model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan. STUDY DESIGN A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected. RESULTS During the study period (August 1, 2019-February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths. CONCLUSION The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors. KEY POINTS · Death review committees play key roles in identifying critical delays and modifiable factors.. · The "three-delay" model was successful in identifying preventable neonatal deaths and stillbirths.. · Death review committees are central in developing actions to reduce preventable deaths..
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Affiliation(s)
- Mohammad S Alyahya
- Department of Health Management and Policy, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Yousef S Khader
- Medical Education and Biostatistics, Department of Public Health and Community Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Nihaya A Al-Sheyab
- Allied Medical Sciences Department, Faculty of Applied Medical Sciences, Department of Maternal and Child Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Khulood K Shattnawi
- Department of Maternal and Child Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Omar F Altal
- Department of Obstetrics and Gynecology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Anwar Batieha
- Department of Public Health and Community Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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30
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Serafim TC, Camilo BHN, Carizani MR, Gervasio MDG, Carlos DM, Salim NR. Attention to women in situation of intrauterine fetal death: experiences of health professionals. ACTA ACUST UNITED AC 2021; 42:e20200249. [PMID: 34037113 DOI: 10.1590/1983-1447.2021.20200249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/05/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Understand the experiences of health professionals in obstetric care in relation to the situation of intrauterine fetal death. METHOD Study of a qualitative approach, in which 11 health professionals participated. Data were collected through semi-open interviews and submitted to thematic content analysis. RESULTS The professionals' difficulty in dealing with the topic and its invisibility during the training proved to be challenging. The lack of ambience and the forms of organization of attention reflected in the care for women and families who are undergoing intrauterine fetal death. The lack of strategies and spaces for sharing among professionals was directly related to the suffering and feeling of helplessness in the cases. FINAL CONSIDERATIONS There is a need to develop strategies for changes in the model and organization of the service in the face of situations of fetal death, promoting spaces that are welcoming producers.
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Affiliation(s)
| | - Beatriz Helena Naddaf Camilo
- Santa Casa de Misericórdia de São Carlos. São Carlos, São Paulo, Brasil.,Universidade Federal de São Carlos (UFSCar), Departamento de Enfermagem. São Carlos, São Paulo, Brasil
| | - Mariana Rodrigues Carizani
- Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Residência em Enfermagem Obstétrica. Botucatu, São Paulo, Brasil
| | | | - Diene Monique Carlos
- Universidade Federal de São Carlos (UFSCar), Departamento de Enfermagem. São Carlos, São Paulo, Brasil
| | - Natália Rejane Salim
- Universidade Federal de São Carlos (UFSCar), Departamento de Enfermagem. São Carlos, São Paulo, Brasil
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31
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Mirbaha-Hashemi F, Tayefi B, Rampisheh Z, Tehrani-Banihashemi A, Ramezani M, Khalili N, Pournik O, Taghizadeh-Asl R, Habibelahi A, Heidarzadeh M, Moradi-Lakeh M. Progress towards Every Newborn Action Plan (ENAP) implementation in Iran: obstacles and bottlenecks. BMC Pregnancy Childbirth 2021; 21:379. [PMID: 34001015 PMCID: PMC8127274 DOI: 10.1186/s12884-021-03800-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 04/13/2021] [Indexed: 12/03/2022] Open
Abstract
Background Neonatal mortality accounts for more than 47% of deaths among children under five globally but proper care at and around the time of birth could prevent about two-thirds of these deaths. The Every Newborn Action Plan (ENAP) offers a plan and vision to improve and achieve equitable and high-quality care for mothers and newborns. We applied the bottleneck analysis tool offered by ENAP to identify obstacles and bottlenecks hindering the scale-up of newborn care across seven health system building blocks. Methods We applied the every newborn bottleneck analysis tool to identify obstacles hindering the scale-up of newborn care across seven health system building blocks. We used qualitative methods to collect data from five medical universities and their corresponding hospitals in three provinces. We also interviewed other national experts, key informants, and stakeholders in neonatal care. In addition, we reviewed and qualitatively analyzed the performance report of neonatal care and services from 16 medical universities around the country. Results We identified many challenges and bottlenecks in the scale-up of newborn care in Iran. The major obstacles included but were not limited to the lack of a single leading and governing entity for newborn care, insufficient financial resources for neonatal care services, insufficient number of skilled health professionals, and inadequate patient transfer. Conclusions To address identified bottlenecks in neonatal health care in Iran, some of our recommendations were as follows: establishing a single national authorizing and leading entity, allocating specific budget to newborn care, matching high-quality neonatal health care providers to the needs of all urban and rural areas, maintaining clear policies on the distribution of NICUs to minimize the need for patient transfer, and using the available and reliable private sector NICU ambulances for safe patient transfer. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03800-x.
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Affiliation(s)
- Fariba Mirbaha-Hashemi
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Batool Tayefi
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Rampisheh
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Tehrani-Banihashemi
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mozhdeh Ramezani
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Narjes Khalili
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Pournik
- Statistics and Information Technology Management, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Abbas Habibelahi
- Neonatal Health Office, Ministry of Health and Medical Education, Tehran, Iran
| | - Mohammad Heidarzadeh
- Neonatal Health Office, Ministry of Health and Medical Education, Tehran, Iran.,Department of Neonatology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maziar Moradi-Lakeh
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Hemmat Freeway, Next to Milad Tower, Tehran, Iran.
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32
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Mukinda FK, George A, Van Belle S, Schneider H. Practice of death surveillance and response for maternal, newborn and child health: a framework and application to a South African health district. BMJ Open 2021; 11:e043783. [PMID: 33958337 PMCID: PMC8103944 DOI: 10.1136/bmjopen-2020-043783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 04/07/2021] [Accepted: 04/11/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the functioning of maternal, perinatal, neonatal and child death surveillance and response (DSR) mechanisms at a health district level. DESIGN A framework of elements covering analysis of causes of death, and processes of review and response was developed and applied to the smallest unit of coordination (subdistrict) to evaluate DSR functioning. The evaluation design was a descriptive qualitative case study, based on observations of DSR practices and interviews. SETTING Rural South African health district (subdistricts and district office). PARTICIPANTS A purposive sample of 45 front-line health managers and providers involved with maternal, perinatal, neonatal and child DSR. The DSR mechanisms reviewed included a system of real-time death reporting (24 hours) and review (48 hours), a nationally mandated confidential enquiry into maternal death and regular facility and subdistrict mortality audit and response processes. PRIMARY OUTCOME MEASURES Functioning of maternal, perinatal, neonatal and child DSR. RESULTS While DSR mechanisms were integrated into the organisational routines of the district, their functioning varied across subdistricts and between forms of DSR. Some forms of DSR, notably those involving maternal deaths, with external reporting and accounting, were more likely to trigger reactive fault-finding and sanctioning than other forms, which were more proactive in supporting evidence-based actions to prevent future deaths. These actions occurred at provider and system level, and to a limited extent, in communities. CONCLUSIONS This study provides an empirical example of the everyday practice of DSR mechanisms at a district level. It assesses such practice based on a framework of elements and enabling organisational processes that may be of value in similar settings elsewhere.
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Affiliation(s)
- Fidele Kanyimbu Mukinda
- School of Public Health, University of the Western Cape, Faculty of Community and Health Sciences, Cape Town, South Africa
| | - Asha George
- School of Public Health, University of the Western Cape, Faculty of Community and Health Sciences, Cape Town, South Africa
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Helen Schneider
- School of Public Health, South African Medical Research Council (MRC)/Health Services and Systems Unit, Cape Town, South Africa
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Paul S, Tickell KD, Ojee E, Oduol C, Martin S, Singa B, Ickes S, Denno DM. Knowledge, attitudes, and perceptions of Kenyan healthcare workers regarding pediatric discharge from hospital. PLoS One 2021; 16:e0249569. [PMID: 33891601 PMCID: PMC8064546 DOI: 10.1371/journal.pone.0249569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/19/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess attitudes, perceptions, and practices of healthcare workers regarding hospital discharge and follow-up care for children under age five in Migori and Homa Bay, Kenya. METHODS This mixed-methods study included surveys and semi-structured telephone interviews with healthcare workers delivering inpatient pediatric care at eight hospitals between November 2017 and December 2018. RESULTS The survey was completed by 111 (85%) eligible HCWs. Ninety-seven of the surveyed HCWs were invited for interviews and 39 (40%) participated. Discharge tasks were reported to be "very important" to patient outcomes by over 80% of respondents, but only 37 (33%) perceived their hospital to deliver this care "very well" and 23 (21%) believed their facility provides sufficient resources for its provision. The vast majority (97%) of participants underestimated the risk of pediatric post-discharge mortality. Inadequate training, understaffing, stock-outs of take-home therapeutics, and user fees were commonly reported health systems barriers to adequate discharge care while poverty was seen as limiting caregiver adherence to discharge and follow-up care. Respondents endorsed the importance of follow-up care, but reported supportive mechanisms to be lacking. They requested enhanced guidelines on discharge and follow-up care. CONCLUSION Kenyan healthcare workers substantially underestimated the risk of pediatric post-discharge mortality. Pre- and in-service training should incorporate instruction on discharge and follow-up care. Improved post-discharge deaths tracking-e.g., through vital registry systems, child mortality surveillance studies, and community health worker feedback loops-is needed, alongside dissemination which could leverage platforms such as routine hospital-based mortality reports. Finally, further interventional trials are needed to assess the efficacy and cost-effectiveness of novel packages to improve discharge and follow-up care.
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Affiliation(s)
- Shadae Paul
- Department of Global Health, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Kirkby D. Tickell
- Department of Global Health, University of Washington School of Public Health, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Ednah Ojee
- The Childhood Acute Illness & Nutrition (CHAIN) Network, University of Washington School of Public Health, Seattle, Washington, United States of America
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Chris Oduol
- The Childhood Acute Illness & Nutrition (CHAIN) Network, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Sarah Martin
- Partners in Health, Boston, Massachusetts, United States of America
| | - Benson Singa
- The Childhood Acute Illness & Nutrition (CHAIN) Network, University of Washington School of Public Health, Seattle, Washington, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Scott Ickes
- Department of Global Health, University of Washington School of Public Health, Seattle, Washington, United States of America
- Department of Applied Health Sciences, Wheaton College, Wheaton, Illinois, United States of America
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Donna M. Denno
- Department of Global Health, University of Washington School of Public Health, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, University of Washington School of Public Health, Seattle, Washington, United States of America
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, United States of America
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Walk the Talk: The Transforming Journey of Facility-Based Death Review Committee from Stillbirths to Neonates. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8871287. [PMID: 33855086 PMCID: PMC8019367 DOI: 10.1155/2021/8871287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 03/06/2021] [Accepted: 03/23/2021] [Indexed: 12/04/2022]
Abstract
Background Facility-based death review committee (DRC) of neonatal deaths and stillbirths can encourage stakeholders to enhance the quality of care during the antenatal period and labour to improve birth outcomes. To understand the benefits and impact of the DRCs, this study was aimed at exploring the DRC members' perception about the role and benefits of the newly developed facility-based DRCs in five pilot hospitals in Jordan, to assess women empowerment, decision-making process, power dynamics, culture and genderism as contributing factors for deaths, and impact of COVID-19 lockdown on births. Methods A descriptive study of a qualitative design—using focus group discussions—was conducted after one year of establishing DRCs in 5 pilot large hospitals. The number of participants in each focus group ranged from 8 to10, and the total number of participants was 45 HCPs (nurses and doctors). Questions were consecutively asked in each focus group. The moderator asked the main questions from the guide and then used probing as needed. A second researcher observed the conversation and took field notes. Results Overall, there was an agreement among the majority of DRC members across all hospitals that the DRC was successful in identifying the exact cause of neonatal deaths and stillbirths as well as associated modifiable factors. There was also a consensus that the DRC contributed to an improvement in health services provided for pregnant women and newborns as well as protecting human rights and enabling women to be more interdependent in taking decisions related to family planning. Moreover, the DRC agreed that a proportion of the neonatal deaths and stillbirths occurring in the hospitals could have been prevented if adequate antenatal care was provided and some traditional harmful practices were avoided. Conclusions Facility-based neonatal death review audit is practical and can be used to identify exact causes of maternal and neonatal deaths and is a valuable tool for hospital quality indicators. It can also change the perception and practice of health care providers, which may be reflected in improving the quality of provided healthcare services.
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Ssegujja E, Ddumba I, Andipartin M. Prioritization of interventions in pursuit of maternal health policy objectives to mitigate stillbirth risks. An exploratory qualitative study at subnational level in Uganda. BMC Health Serv Res 2021; 21:53. [PMID: 33430858 PMCID: PMC7802206 DOI: 10.1186/s12913-020-06046-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 12/26/2020] [Indexed: 12/04/2022] Open
Abstract
Background Global calls for renewed efforts to address stillbirth burden highlighted areas for policy and implementation resulting in national level translations. Information regarding adapted strategies to effect policy objectives into service delivery by frontline health workers remains scanty especially at subnational level. The study explored strategies prioritized to mitigate stillbirth risk in the context of operationalizing recommendations from the global campaigns at a subnational level in Uganda. Methods A cross-sectional qualitative exploratory study was conducted among a purposively selected sample of sixteen key informants involved in delivery of maternal and child health services in Mukono district. Analysis followed thematic content analysis deductively focusing on those policy priorities highlighted in the global stillbirth campaigns and reflected at the national level in the different guidelines. Results. Interventions to address stillbirth followed prioritization of service delivery aspects to respond to identified gaps. Efforts to increase uptake of family planning services for example included offering it at all entry points into care with counseling forming part of the package following stillbirth. Referrals were streamlined by focusing on addressing delays from the referring entity while antenatal care attendance was boosted through provision of incentives to encourage mothers to comply. Other prioritized aspects included perinatal death audits and improvements in data systems while differentiated care focused on aligning resources to support high risk mothers. This was in part influenced by the limited resources and skills which made health workers to adapt routine to fit implementation context. Conclusions The resource availability determined aspects of policy to prioritize while responding to stillbirth risk at subnational level by frontline health workers. Their understanding of risk, feasibility of implementation and the desire for optimal health systems performance worked to define the nature of services delivered calling for purposeful consideration of resource availability and implementation context while prioritizing stillbirth reduction at subnational level. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-06046-z.
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Affiliation(s)
- Eric Ssegujja
- Makerere University School of Public Health, Kampala, Uganda. .,University of the Western Cape, School of Public Health, Cape Town, South Africa.
| | - Isaac Ddumba
- Mukono District Local Government, Mukono Town, Uganda
| | - Michelle Andipartin
- Department of Psychology, University of the Western Cape, Cape Town, South Africa
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Malinga NS, du Preez A, Rabie T. Maternal and neonatal factors associated with perinatal deaths in a South African healthcare institution. Health SA 2020; 25:1332. [PMID: 33354353 PMCID: PMC7736659 DOI: 10.4102/hsag.v25i0.1332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/08/2020] [Indexed: 11/04/2022] Open
Abstract
Background Research indicated the prevalence of perinatal deaths of infants immediately or up to a week after birth and includes fresh and macerated stillbirths and neonatal deaths. Worldwide, there is a decline in perinatal deaths. However, in South Africa, it is not the case. Often the quality of maternity care is considered as the most important contributing factor for these deaths. However, maternal and neonatal factors can also contribute. Aim The aim of the study was to determine the maternal and neonatal factors associated with perinatal deaths in a single selected district hospital within the Free State Province of South Africa. Setting The maternity unit of the largest district hospital in the specific district in the Free State Province of South Africa. Method A clinical audit design was used. Units of analysis comprised the Perinatal Problem Identification Programme (PPIP) database of neonates born during 2015, and their mothers. A random sample of 384 alive neonates and an all-inclusive sample of 43 deceased neonates were taken from a total of 2319. Descriptive statistics were reported and Cohen’s effect sizes, d, were calculated to identify practically significant differences between the neonates in the alive and the deceased group, respectively. Results Cohen’s effect sizes and logistical regression analyses indicate that the Apgar score recorded 10 min after birth, gestational age, birth weight of neonate and the parity of the mother were the most practically significant factors influencing a neonate’s chances of survival. Conclusion Quality maternity care is not the only cause of perinatal mortality rates; maternal and neonatal factors are also contributors.
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Affiliation(s)
- Nthabiseng S Malinga
- NuMIQ Research Focus Area, School of Nursing Science, North-West University, Potchefstroom, South Africa
| | - Antoinette du Preez
- NuMIQ Research Focus Area, School of Nursing Science, North-West University, Potchefstroom, South Africa
| | - Tinda Rabie
- NuMIQ Research Focus Area, School of Nursing Science, North-West University, Potchefstroom, South Africa
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Kinney MV, Ajayi G, de Graft-Johnson J, Hill K, Khadka N, Om’Iniabohs A, Mukora-Mutseyekwa F, Tayebwa E, Shittu O, Lipingu C, Kerber K, Nyakina JD, Ibekwe PC, Sayinzoga F, Madzima B, George AS, Thapa K. "It might be a statistic to me, but every death matters.": An assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan African countries. PLoS One 2020; 15:e0243722. [PMID: 33338039 PMCID: PMC7748147 DOI: 10.1371/journal.pone.0243722] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 11/29/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Maternal and perinatal death surveillance and response (MPDSR) systems aim to understand and address key contributors to maternal and perinatal deaths to prevent future deaths. From 2016-2017, the US Agency for International Development's Maternal and Child Survival Program conducted an assessment of MPDSR implementation in Nigeria, Rwanda, Tanzania, and Zimbabwe. METHODS A cross-sectional, mixed-methods research design was used to assess MPDSR implementation. The study included a desk review, policy mapping, semistructured interviews with 41 subnational stakeholders, observations, and interviews with key informants at 55 purposefully selected facilities. Using a standardised tool with progress markers defined for six stages of implementation, each facility was assigned a score from 0-30. Quantitative and qualitative data were analysed from the 47 facilities with a score above 10 ('evidence of MPDSR practice'). RESULTS The mean calculated MPDSR implementation progress score across 47 facilities was 18.98 out of 30 (range: 11.75-27.38). The team observed variation across the national MPDSR guidelines and tools, and inconsistent implementation of MPDSR at subnational and facility levels. Nearly all facilities had a designated MPDSR coordinator, but varied in their availability and use of standardised forms and the frequency of mortality audit meetings. Few facilities (9%) had mechanisms in place to promote a no-blame environment. Some facilities (44%) could demonstrate evidence that a change occurred due to MPDSR. Factors enabling implementation included clear support from leadership, commitment from staff, and regular occurrence of meetings. Barriers included lack of health worker capacity, limited staff time, and limited staff motivation. CONCLUSION This study was the first to apply a standardised scoring methodology to assess subnational- and facility-level MPDSR implementation progress. Structures and processes for implementing MPDSR existed in all four countries. Many implementation gaps were identified that can inform priorities and future research for strengthening MPDSR in low-capacity settings.
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Affiliation(s)
- Mary V. Kinney
- Save the Children US, Washington, DC, United States of America
- University of the Western Cape, Cape Town, South Africa
| | - Gbaike Ajayi
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
| | - Joseph de Graft-Johnson
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | - Kathleen Hill
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
| | - Neena Khadka
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | - Alyssa Om’Iniabohs
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | | | | | | | | | - Kate Kerber
- Save the Children US, Washington, DC, United States of America
| | | | - Perpetus Chudi Ibekwe
- Maternal and perinatal death surveillance and response, Abakaliki, Ebonyi State, Nigeria
| | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Bernard Madzima
- Family Health Directorate, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Kusum Thapa
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
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Vallely LM, Smith R, Bolnga JW, Babona D, Riddell MA, Mengi A, Au L, Polomon C, Vogel JP, Pomat WS, Vallely AJ, Homer CSE. Perinatal death audit and classification of stillbirths in two provinces in Papua New Guinea: A retrospective analysis. Int J Gynaecol Obstet 2020; 153:160-168. [PMID: 33098672 DOI: 10.1002/ijgo.13431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To undertake a retrospective perinatal death audit and assessment of avoidable factors associated with stillbirths among a cohort of women in two provinces in Papua New Guinea. METHODS We used data from an ongoing cluster-randomized crossover trial in 10 sites among 4600 women in Papua New Guinea (from 2017 to date). The overarching aim is to improve birth outcomes. All stillbirths from July 2017 to January 2020 were identified. The Perinatal Problem Identification Program was used to analyze each stillbirth and review associated avoidable factors. RESULTS There were 59 stillbirths among 2558 births (23 per 1000 births); 68% (40/59) were classified "fresh" and 32% as "macerated". Perinatal cause of death was identified for 63% (37/59): 30% (11/37) were due to intrapartum asphyxia and traumatic breech birth and 19% (7/37) were the result of pre-eclampsia. At least one avoidable factor was identified for 95% (56/59) of stillbirths. Patient-associated factors included lack of response to reduced fetal movements and delay in seeking care during labor. Health personnel-associated factors included poor intrapartum care, late diagnosis of breech presentation, and prolonged second stage with no intervention. CONCLUSION Factors associated with stillbirths in this setting could be avoided through a package of interventions at both the community and health-facility levels.
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Affiliation(s)
- Lisa M Vallely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Rachel Smith
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | | | - Delly Babona
- St Mary's Hospital Vunapope, East New Britain Province, Papua New Guinea
| | - Michaela A Riddell
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Alice Mengi
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Lucy Au
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | | | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - William S Pomat
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew J Vallely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Caroline S E Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
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Wasim T, Bushra N, Iqbal HI, Mumtaz A, Khan KS. Maternal condition as an underlying cause of perinatal mortality: Prospective cohort study. J Obstet Gynaecol Res 2020; 47:544-550. [PMID: 33145865 DOI: 10.1111/jog.14551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/04/2020] [Accepted: 10/16/2020] [Indexed: 11/27/2022]
Abstract
AIM To compare the distribution of various causes of perinatal mortality in a public hospital in low-middle-income country setting. METHODS A prospective cohort study was conducted from January 2016 to December 2018 at a large public hospital, Services Institute of Medical Sciences, Services Hospital, in Lahore, Pakistan. We applied the World Health Organization's perinatal mortality coding in the International Classification of Diseases. All stillbirths after 28 weeks' gestation weighing more than 1 kg were identified and followed up till delivery. All live births were followed up till discharge or early neonatal death. A multidisciplinary group of obstetricians, pediatricians, midwife and related healthcare professionals was established to assess each case of fatality. The associated maternal conditions were identified for each of the antepartum, intrapartum and neonatal deaths. RESULTS Of 11 850 births, there were 690 perinatal deaths, with 240 stillbirths (antepartum 167, intrapartum 73) and 450 early neonatal deaths (perinatal mortality rate 58.2/1000 births). Among antepartum deaths, hypoxia accounted for 70 (42%) cases. Among intrapartum deaths, an acute event was responsible for 50 (68%) cases. Among neonatal deaths (450, 65% of total), low birthweight and prematurity contributed to 152 (34%) cases. A maternal condition was found in 183 (76%) of stillbirths and 355 (79%) patients with neonatal death. CONCLUSION In our study, the most important causes of perinatal deaths were maternal in origin. There was an excess in the distribution of neonatal causes of perinatal deaths. These data should inform policy and practice.
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Affiliation(s)
- Tayyiba Wasim
- Department of Obstetrics and Gynaecology, Services Institute of Medical Sciences, Services Hospital, Lahore, Pakistan
| | - Natasha Bushra
- Department of Obstetrics and Gynaecology, Services Institute of Medical Sciences, Services Hospital, Lahore, Pakistan
| | - Hafiza I Iqbal
- Department of Obstetrics and Gynaecology, Services Institute of Medical Sciences, Services Hospital, Lahore, Pakistan
| | - Anila Mumtaz
- Department of Obstetrics and Gynaecology, Services Institute of Medical Sciences, Services Hospital, Lahore, Pakistan
| | - Khalid S Khan
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Granada, Granada, Spain
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Crehan C, Kesler E, Chikomoni IA, Sun K, Dube Q, Lakhanpaul M, Heys M. Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App: Digital Perinatal Outcome Audit. JMIR Mhealth Uhealth 2020; 8:e16485. [PMID: 33084581 PMCID: PMC7641784 DOI: 10.2196/16485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 11/28/2022] Open
Abstract
Background Mobile health (mHealth) is showing increasing potential to address health outcomes in underresourced settings as smartphone coverage increases. The NeoTree is an mHealth app codeveloped in Malawi to improve the quality of newborn care at the point of admission to neonatal units. When collecting vital demographic and clinical data, this interactive platform provides clinical decision support and training for the end users (health care professionals [HCPs]), according to evidence-based national and international guidelines. Objective This study aims to examine 1 month’s data collected using NeoTree in an outcome audit of babies admitted to a district-level neonatal nursery in Malawi and to demonstrate proof of concept of digital outcome audit data in this setting. Methods Using a phased approach over 1 month (November 21-December 19, 2016), frontline HCPs were trained and supported to use NeoTree to admit newborns. Discharge data were collected by the research team using a discharge form within NeoTree, called NeoDischarge. We conducted a descriptive analysis of the exported pseudoanonymized data and presented it to the newborn care department as a digital outcome audit. Results Of 191 total admissions, 134 (70.2%) admissions were completed using NeoTree, and 129 (67.5%) were exported and analyzed. Of 121 patients for whom outcome data were available, 102 (84.3%) were discharged alive. The overall case fatality rate was 93 per 1000 admitted babies. Prematurity with respiratory distress syndrome, birth asphyxia, and neonatal sepsis contributed to 25% (3/12), 58% (7/12), and 8% (1/12) of deaths, respectively. Data were more than 90% complete for all fields. Deaths may have been underreported because of phased implementation and some families of babies with imminent deaths self-discharging home. Detailed characterization of the data enabled departmental discussion of modifiable factors for quality improvement, for example, improved thermoregulation of infants. Conclusions This digital outcome audit demonstrates that data can be captured digitally at the bedside by HCPs in underresourced newborn facilities, and these data can contribute to a meaningful review of the quality of care, outcomes, and potential modifiable factors. Coverage may be improved during future implementation by streamlining the admission process to be solely via digital format. Our results present a new methodology for newborn audits in low-resource settings and are a proof of concept for a novel newborn data system in these settings.
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Affiliation(s)
- Caroline Crehan
- UCL-Great Ormond Street Hospital Institute of Child Health, University College London, London, United Kingdom
| | - Erin Kesler
- UCL-Great Ormond Street Hospital Institute of Child Health, University College London, London, United Kingdom
| | | | - Kristi Sun
- Whittington Hospital, London, United Kingdom
| | - Queen Dube
- Paediatric Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Monica Lakhanpaul
- UCL-Great Ormond Street Hospital Institute of Child Health, University College London, London, United Kingdom.,Whittington Hospital, London, United Kingdom
| | - Michelle Heys
- UCL-Great Ormond Street Hospital Institute of Child Health, University College London, London, United Kingdom.,East London NHS Foundation Trust, London, United Kingdom
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Squires F, Martin Hilber A, Cordero JP, Boydell V, Portela A, Lewis Sabin M, Steyn P. Social accountability for reproductive, maternal, newborn, child and adolescent health: A review of reviews. PLoS One 2020; 15:e0238776. [PMID: 33035242 PMCID: PMC7546481 DOI: 10.1371/journal.pone.0238776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022] Open
Abstract
Globally, increasing efforts have been made to hold duty-bearers to account for their commitments to improve reproductive, maternal, newborn, child and adolescent health (RMNCAH) over the past two decades, including via social accountability approaches: citizen-led, collective processes for holding duty-bearers to account. There have been many individual studies and several reviews of social accountability approaches but the implications of their findings to inform future accountability efforts are not clear. We addressed this gap by conducting a review of reviews in order to summarise the current evidence on social accountability for RMNCAH, identify factors contributing to intermediary outcomes and health impacts, and identify future research and implementation priorities. The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42019134340). We searched eight databases and systematic review repositories and sought expert recommendations for published and unpublished reviews, with no date or language restrictions. Six reviews were analysed using narrative synthesis: four on accountability or social accountability approaches for RMNCAH, and two specifically examining perinatal mortality audits, from which we extracted information relating to community involvement in audits. Our findings confirmed that there is extensive and growing evidence for social accountability approaches, particularly community monitoring interventions. Few documented social accountability approaches to RMNCAH achieve transformational change by going beyond information-gathering and awareness-raising, and attention to marginalised and vulnerable groups, including adolescents, has not been well documented. Drawing generalisable conclusions about results was difficult, due to inconsistent nomenclature and gaps in reporting, particularly regarding objectives, contexts, and health impacts. Promising approaches for successful social accountability initiatives include careful tailoring to the social and political context, strategic planning, and multi-sectoral/multi-stakeholder approaches. Future primary research could advance the evidence by describing interventions and their results in detail and in their contexts, focusing on factors and processes affecting acceptability, adoption, and effectiveness.
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Affiliation(s)
| | - Adriane Martin Hilber
- Novametrics, Duffield, Derbyshire, United Kingdom
- Swiss Centre for International Health, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Joanna Paula Cordero
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP Research), World Health Organization, Geneva, Switzerland
| | - Victoria Boydell
- Global Health Centre, The Graduate Institute Geneva, Geneva, Switzerland
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Miriam Lewis Sabin
- The Partnership for Maternal, Newborn, Child & Adolescent Health, Geneva, Switzerland
| | - Petrus Steyn
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP Research), World Health Organization, Geneva, Switzerland
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Webbe JWH, Duffy JMN, Afonso E, Al-Muzaffar I, Brunton G, Greenough A, Hall NJ, Knight M, Latour JM, Lee-Davey C, Marlow N, Noakes L, Nycyk J, Richard-Löndt A, Wills-Eve B, Modi N, Gale C. Core outcomes in neonatology: development of a core outcome set for neonatal research. Arch Dis Child Fetal Neonatal Ed 2020; 105:425-431. [PMID: 31732683 PMCID: PMC7363790 DOI: 10.1136/archdischild-2019-317501] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 10/01/2019] [Accepted: 10/30/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND Neonatal research evaluates many different outcomes using multiple measures. This can prevent synthesis of trial results in meta-analyses, and selected outcomes may not be relevant to former patients, parents and health professionals. OBJECTIVE To define a core outcome set (COS) for research involving infants receiving neonatal care in a high-income setting. DESIGN Outcomes reported in neonatal trials and qualitative studies were systematically reviewed. Stakeholders were recruited for a three-round international Delphi survey. A consensus meeting was held to confirm the final COS, based on the survey results. PARTICIPANTS Four hundred and fourteen former patients, parents, healthcare professionals and researchers took part in the eDelphi survey; 173 completed all three rounds. Sixteen stakeholders participated in the consensus meeting. RESULTS The literature reviews identified 104 outcomes; these were included in round 1. Participants proposed 10 additional outcomes; 114 outcomes were scored in rounds 2 and 3. Round 1 scores showed different stakeholder groups prioritised contrasting outcomes. Twelve outcomes were included in the final COS: survival, sepsis, necrotising enterocolitis, brain injury on imaging, general gross motor ability, general cognitive ability, quality of life, adverse events, visual impairment/blindness, hearing impairment/deafness, retinopathy of prematurity and chronic lung disease/bronchopulmonary dysplasia. CONCLUSIONS AND RELEVANCE A COS for clinical trials and other research studies involving infants receiving neonatal care in a high-income setting has been identified. This COS for neonatology will help standardise outcome selection in clinical trials and ensure these are relevant to those most affected by neonatal care.
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Affiliation(s)
| | - James M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Elsa Afonso
- Neonatal Unit, Rosie Hospital, Cambridge, Cambridgeshire, UK
| | - Iyad Al-Muzaffar
- The Neonatal Unit, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taf, UK
| | - Ginny Brunton
- UCL Institute of Education Centre for Longitudinal Studies, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Nigel J Hall
- Paediatric Surgery, Southampton General Hospital, Southampton, UK
| | | | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, Education and Society, Plymouth University, Plymouth, Devon, UK
- School of Nursing and Midwifery, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | | | - Neil Marlow
- Institute for Women's Health, University College London, London, UK
| | | | - Julie Nycyk
- Neonatal Unit, Birmingham City Hospital, Birmingham, UK
| | | | | | - Neena Modi
- Neonatal Medicine, Imperial College London, London, UK
| | - Chris Gale
- Academic Neonatal Medicine, Imperial College London, London, UK
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Anggraini D, Abdollahian M, Marion K, Asmu'i, Meilania GT, Annisa AS. Improving the Information Availability and Accessibility of Antenatal Measurements to Ensure Safe Delivery: A Research-Based Policy Recommendation to Reduce Neonatal Mortality in Indonesia. Int J Womens Health 2020; 12:369-380. [PMID: 32440231 PMCID: PMC7212777 DOI: 10.2147/ijwh.s247213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/30/2020] [Indexed: 01/14/2023] Open
Abstract
Purpose Assessing the risks and preventable causes of maternal and neonatal mortality requires the availability of good-quality antenatal information. In Indonesia, however, access to reliable information on pregnancy-related results remains challenging. This research has proposed a research-based policy recommendation to improve availability and accessibility to vital information on antenatal examinations. Patients and Methods Descriptive statistics were used to characterize midwives’ capabilities in routinely gathering and recording antenatal information during pregnancy. The investigation was carried out among 19 midwives in South Kalimantan, Indonesia, from April 2016 to October 2017. Antenatal data on 4946 women (retrospective study) and 381 women (prospective study) have been accessed through a scientific and technical training program. Results To date, lack of timely access to antenatal information has hampered the process of reducing neonatal mortality in Indonesia. The post-training statistical analysis showed that the training has significantly improved midwives’ scientific knowledge and technical abilities in providing more reliable data on antenatal measurements. Conclusion Consistent scientific and technical training among midwives is required to update their knowledge and skills, particularly those relating to documenting the results of antenatal examinations at different stages of pregnancy and using that information to assess potential risks and identify necessary interventions. This should also be followed by routine monitoring on the quality of collected antenatal data. This can be one of the enabling actions to achieve the 2030 Sustainable Development Goals target in reducing neonatal mortality in Indonesia.
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Affiliation(s)
- Dewi Anggraini
- Study Program of Statistics, Faculty of Mathematics and Natural Sciences, Lambung Mangkurat University, Banjarbaru, South Kalimantan, Indonesia
| | - Mali Abdollahian
- School of Science, College of Science, Engineering, and Health, RMIT University, Melbourne, VIC, Australia
| | - Kaye Marion
- School of Science, College of Science, Engineering, and Health, RMIT University, Melbourne, VIC, Australia
| | - Asmu'i
- Study Program of Public Administration, Faculty of Social and Political Sciences, Lambung Mangkurat University, Banjarmasin, South Kalimantan, Indonesia
| | - Gusti Tasya Meilania
- Study Program of Statistics, Faculty of Mathematics and Natural Sciences, Lambung Mangkurat University, Banjarbaru, South Kalimantan, Indonesia
| | - Auliya Syifa Annisa
- Study Program of Statistics, Faculty of Mathematics and Natural Sciences, Lambung Mangkurat University, Banjarbaru, South Kalimantan, Indonesia
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Horwood C, Haskins L, Luthuli S, McKerrow N. Communication between mothers and health workers is important for quality of newborn care: a qualitative study in neonatal units in district hospitals in South Africa. BMC Pediatr 2019; 19:496. [PMID: 31842824 PMCID: PMC6913017 DOI: 10.1186/s12887-019-1874-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background There is a high global burden of neonatal mortality, with many newborn babies dying of preventable and treatable conditions, particularly in low and middle-income countries. Improving quality of newborn care could save the lives of many thousands of babies. Quality of care (QoC) is a complex and multifaceted construct that is difficult to measure, but patients’ experiences of care are an important component in any measurement of QoC. We report the findings of a qualitative study exploring observations and experiences of health workers (HWs) and mothers of babies in neonatal units in South Africa. Methods A qualitative case study approach was adopted to explore care of newborn babies admitted to neonatal units in district hospitals. Observation data were collected by a registered nurse during working hours over a continuous five-day period. Doctors and nurses working in the neonatal unit and mothers of babies admitted during the observation period were interviewed using a semi-structured interview guide. All interviews were audio recorded. Observation data were transcribed from hand written notes. Audiotapes of interviews were transcribed verbatim and, where necessary, translated into English. A thematic content analysis was used to analyse the data. Results Observations and interviews were conducted in seven participating hospitals between November 2015 and May 2016. Our findings highlight the importance of information sharing between HWs and mothers of babies, contrasting the positive communication reported by many mothers which led to them feeling empowered and participating actively in the care of their babies, with incidents of poor communication. Poor communication, rudeness and disrespectful behaviour of HWs was frequently described by mothers, and led to mothers feeling anxious, unwilling to ask questions and excluded from their baby’s care. In some cases poor communication and misunderstandings led to serious mismanagement of babies with HWs delaying or withholding care, or to mothers putting their babies at risk by not following instructions. Conclusion Good communication between mothers and HWs is critical for building mothers’ confidence, promoting bonding and participation of mothers in the care of their baby and may have long term benefits for the health and well-being of the mother and her baby.
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Affiliation(s)
- Christiane Horwood
- Centre for Rural Health, University of KwaZulu-Natal, George Campbell Building, Howard College Campus, Durban, South Africa
| | - Lyn Haskins
- Centre for Rural Health, University of KwaZulu-Natal, George Campbell Building, Howard College Campus, Durban, South Africa.
| | - Silondile Luthuli
- Centre for Rural Health, University of KwaZulu-Natal, George Campbell Building, Howard College Campus, Durban, South Africa
| | - Neil McKerrow
- KwaZulu-Natal Department of Health, Durban, South Africa.,Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
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Mersha A, Shibiru S, Gultie T, Degefa N, Bante A. Training and well-equipped facility increases the odds of skills of health professionals on helping babies breathe in public hospitals of Southern Ethiopia: cross-sectional study. BMC Health Serv Res 2019; 19:946. [PMID: 31818292 PMCID: PMC6902403 DOI: 10.1186/s12913-019-4772-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/22/2019] [Indexed: 11/19/2022] Open
Abstract
Background Health professionals equipped with the adequate skills of helping baby breath remain the backbone in the health system in improving neonatal outcomes. However, there is a great controversy between studies to show the proximate factors of the skills of health care providers in helping babies breathe. In Ethiopia, there is a paucity of evidence on the current status of health care provider’s skills of helping babies breathe despite the improvement in neonatal health care services. Therefore, this study intends to fill those gaps in assessing the skills of helping babies breathe and its associated factors among health professionals in public hospitals in Southern Ethiopia. Methods A facility-based cross-sectional study was conducted among 441 health professionals from March 10 to 30, 2019. A simple random sampling method was used to select the study participants. The data were collected through pre-tested interviewer-administered questionnaire and observational checklist. A binary logistic regression model was used to identify significant factors for the skills of helping babies breathe by using SPSS version 25. The P-value < 0.05 used to declare statistical significance. Results Overall, 71.1% (95%CI: 66.2, 75.4%) of health professionals had good skills in helping babies breathe. Age group from 25 to 34 (AOR = 2.24; 95%CI: 1.04, 4.81), training on helping babies breathe (AOR = 2.69; 95%CI: 1.49, 4.87), well-equipped facility (AOR = 2.15; 95%CI: 1.09, 4.25), and adequate knowledge on helping babies breathe (AOR = 2.21; 95%CI: 1.25, 3.89) were significantly associated with a health professionals good skill on helping babies breathe. Conclusions Even though a significant number of care providers had good skills in helping babies breathe, yet there is a need to further improve the skills of the provider in helping babies breathe. Hence, health facilities should be equipped with adequate materials and facilitate frequent training to the provider.
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Affiliation(s)
- Abera Mersha
- Department of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia.
| | - Shitaye Shibiru
- Department of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Teklemariam Gultie
- Department of Midwifery, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Nega Degefa
- Department of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Agegnehu Bante
- Department of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
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Understanding cause of stillbirth: a prospective observational multi-country study from sub-Saharan Africa. BMC Pregnancy Childbirth 2019; 19:470. [PMID: 31801488 PMCID: PMC6894270 DOI: 10.1186/s12884-019-2626-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 11/22/2019] [Indexed: 11/15/2022] Open
Abstract
Background Every year, an estimated 2.6 million stillbirths occur worldwide, with up to 98% occurring in low- and middle-income countries (LMIC). There is a paucity of primary data on cause of stillbirth from LMIC, and particularly from sub-Saharan Africa to inform effective interventions. This study aimed to identify the cause of stillbirths in low- and middle-income settings and compare methods of assessment. Methods This was a prospective, observational study in 12 hospitals in Kenya, Malawi, Sierra Leone and Zimbabwe. Stillbirths (28 weeks or more) were reviewed to assign the cause of death by healthcare providers, an expert panel and by using computer-based algorithms. Agreement between the three methods was compared using Kappa (κ) analysis. Cause of stillbirth and level of agreement between the methods used to assign cause of death. Results One thousand five hundred sixty-three stillbirths were studied. The stillbirth rate (per 1000 births) was 20.3 in Malawi, 34.7 in Zimbabwe, 38.8 in Kenya and 118.1 in Sierra Leone. Half (50.7%) of all stillbirths occurred during the intrapartum period. Cause of death (range) overall varied by method of assessment and included: asphyxia (18.5–37.4%), placental disorders (8.4–15.1%), maternal hypertensive disorders (5.1–13.6%), infections (4.3–9.0%), cord problems (3.3–6.5%), and ruptured uterus due to obstructed labour (2.6–6.1%). Cause of stillbirth was unknown in 17.9–26.0% of cases. Moderate agreement was observed for cause of stillbirth as assigned by the expert panel and by hospital-based healthcare providers who conducted perinatal death review (κ = 0.69; p < 0.0005). There was only minimal agreement between expert panel review or healthcare provider review and computer-based algorithms (κ = 0.34; 0.31 respectively p < 0.0005). Conclusions For the majority of stillbirths, an underlying likely cause of death could be determined despite limited diagnostic capacity. In these settings, more diagnostic information is, however, needed to establish a more specific cause of death for the majority of stillbirths. Existing computer-based algorithms used to assign cause of death require revision.
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Serra G, Miceli V, Albano S, Corsello G. Perinatal and newborn care in a two years retrospective study in a first level peripheral hospital in Sicily (Italy). Ital J Pediatr 2019; 45:152. [PMID: 31783883 PMCID: PMC6884854 DOI: 10.1186/s13052-019-0751-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/21/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Two hundred seventy-five thousand maternal deaths, 2.7 million neonatal deaths, and 2.6 million stillbirths have been estimated in 2015 worldwide, almost all in low-income countries (LICs). Moreover, more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. A significant decrease of mortality/morbidity rates could be achieved by providing effective perinatal and newborn care also in high-income countries (HICs), especially in peripheral hospitals and/or rural areas, where the number of childbirths per year is often under the minimal threshold recognized by the reference legislation. We report on a 2 years retrospective cohort study, conducted in a first level peripheral hospital in Cefalù, a small city in Sicily (Italy), to evaluate care provided and mortality/morbidity rates. The proposed goal is to improve the quality of care, and the services that peripheral centers can offer. METHODS We collected data from maternity and neonatal records, over a 2-year period from January 2017 to December 2018. The informations analyzed were related to demographic features (age, ethnicity/origin area, residence, educational level, marital status), diagnosis at admission (attendance of birth training courses, parity, type of pregnancy, gestational age, fetal presentation), mode of delivery, obstetric complications, the weight of the newborns, their feeding and eventual transfer to II level hospitals, also through the Neonatal Emergency Transport Service, if the established criteria were present. RESULTS Eight hundred sixteen women were included (age 18-48 years). 179 (22%) attended birth training courses. 763 (93%) were Italian, 53 foreign (7%). 175 (21%) came from outside the province of Palermo. Eight hundred ten were single pregnancies, 6 bigeminal; 783 were at term (96%), 33 preterm (4%, GA 30-41 WG); 434 vaginal deliveries (53%), 382 caesarean sections (47%). One maternal death and 28 (3%) obstetric complications occurred during the study period. The total number of children born to these women was 822, 3 of which stillbirths (3.6‰). 787 (96%) were born at term (>37WG), 35 preterm (4%), 31 of which late preterm. Twenty-one newborns (2.5%) were transferred to II level hospitals. Among them, 3 for moderate/severe prematurity, 18 for mild prematurity/other pathology. The outcome was favorable for all women (except 1 hysterectomy) and the newborns transferred, and no neonatal deaths occurred in the biennium under investigation. Of the remaining 798 newborns, 440 were breastfed at discharge (55%), 337 had a mixed feeding (breastfed/formula fed, 42%) and 21 were formula fed (3%). CONCLUSIONS Although the minimal standard of adequate perinatal care in Italy is >500 childbirths/year, the aims of the Italian legislation concern the rationalization of birth centers as well as the structural, technological and organizational improvement of health facilities. Therefore, specific contexts and critical areas need to be identified and managed. Adequate resources and intervention strategies should be addressed not only to perinatal emergencies, but also to the management of mild prematurity/pathology, especially in vulnerable populations for social or orographic reasons. The increasing availability and spread of health care offers, even in HICs, cannot be separated from the goal of quality of care, which is an ethic and public health imperative.
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Affiliation(s)
- Gregorio Serra
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, Italy. .,"G. Giglio" Hospital Institute Foundation, Cefalù, Italy.
| | | | | | - Giovanni Corsello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, Italy
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Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George AS. Implementation of maternal and perinatal death reviews: a scoping review protocol. BMJ Open 2019; 9:e031328. [PMID: 31780590 PMCID: PMC6886965 DOI: 10.1136/bmjopen-2019-031328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 10/09/2019] [Accepted: 10/28/2019] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Maternal and perinatal death surveillance and response (MPDSR), or any related form of audit, is a systematic process used to prevent future maternal and perinatal deaths. While the existence of MPDSR policies is routinely measured, measurement and understanding of policy implementation has lagged behind. In this paper, we present a theory-based conceptual framework for understanding MPDSR implementation as well as a scoping review protocol to understand factors influencing MPDSR implementation in low/ middle-income countries (LMIC). METHODS AND ANALYSIS The Consolidated Framework for Implementation Research will inform the development of a theory-based conceptual framework for MPDSR implementation. The methodology for the scoping review will be guided by an adapted Arksey and O'Malley approach. Documents will include published and grey literature sourced from electronic databases (PubMed, CINAHL, SCOPUS, Web of Science, JSTOR, LILACS), the WHO Library, Maternal Death Surveillance and Response Action Network, Google, the reference lists of key studies and key experts. Two reviewers will independently screen titles, abstracts and full studies for inclusion. All discrepancies will be resolved by an independent third party. We will include studies published in English from 2004 to July 2018 that present results on factors influencing implementation of MPDSR, or any related form. Qualitative content and thematic analysis will be applied to extracted data according to the theory-based conceptual framework. Stakeholders will be consulted at various stages of the process. ETHICS AND DISSEMINATION The scoping review will synthesise implementation factors relating to MPDSR in LMIC as described in the literature. This review will contribute to the work of the Countdown to 2030 Drivers Group, which seeks to explore key contextual drivers for equitable and effective coverage of maternal and child health interventions. Ethics approval is not required. The results will be disseminated through various channels, including a peer-reviewed publication.
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Affiliation(s)
- Mary V Kinney
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, Bellville, South Africa
| | - David Roger Walugembe
- School of Health Studies, Faculty of Information and Media Studies, University of Western Ontario, London, Ontario, Canada
| | - Phillip Wanduru
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter Waiswa
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
- Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Asha S George
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, Bellville, South Africa
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Bandali S, Thomas C, Wamalwa P, Mahendra S, Kaimenyi P, Warfa O, Fulton N. Strengthening the "P" in Maternal and Perinatal Death Surveillance and Response in Bungoma county, Kenya: implications for scale-up. BMC Health Serv Res 2019; 19:611. [PMID: 31470854 PMCID: PMC6716884 DOI: 10.1186/s12913-019-4431-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/14/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND This paper examines perinatal death reporting and reviews in Bungoma county, Kenya, where substantial progress has been made, providing important insights for wider scale up to other contexts. METHODS Quantitative methods were used to analyse trends in perinatal death reporting and reviews between 2014 and 2017 throughout Kenya based on data from the District Health Information System. Qualitative methods helped further understand the success of perinatal death reporting and review in Bungoma county through focus group discussions and individual interviews at 5 hospitals and 1 health centre. Thematic analysis was used to draw out codes for the analysis. RESULTS Only 13 of the 47 counties in Kenya conduct perinatal death reviews. In 2017, the year after the perinatal death review system was introduced, only 3.6% of perinatal deaths were reviewed in Kenya. Bungoma county has made the greatest strides in Kenya, reviewing 59% of the perinatal deaths that occurred within the county in 2017. Bungoma accounted for 51% of all the perinatal deaths reviewed in Kenya. Factors contributing to the success in Bungoma include harmonisation of facility based perinatal reporting tools with the national level; prioritising the need to document and report mortalities; tailoring continual medical education and supportive supervision visits to needs identified from the review; and better documentation and referral processes. Supportive management and administrative staff have also helped drive forward implementation of actions and increased health staff motivation to reduce perinatal deaths and improve quality of care. CONCLUSIONS Successful implementation of perinatal death reviews requires clear delineation of roles and responsibilities for action, which are routinely monitored to track implementation progress. As in other low-income settings, Bungoma county has demonstrated that in Kenya, perinatal death reviews can be effectively implemented and sustained, through a focus on learning, solution-oriented responses, influencing those in a power to act, accountability for results, and observable quality of care improvements.
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Affiliation(s)
- Sarah Bandali
- Options Consultancy Services, 2nd Floor, St Magnus House, 3 Lower Thames Street, London, EC3R 6HD UK
| | - Camille Thomas
- Options Consultancy Services, 2nd Floor, St Magnus House, 3 Lower Thames Street, London, EC3R 6HD UK
| | - Phidelis Wamalwa
- Options Consultancy Services, 2nd Floor, St Magnus House, 3 Lower Thames Street, London, EC3R 6HD UK
| | - Shanti Mahendra
- Options Consultancy Services, 2nd Floor, St Magnus House, 3 Lower Thames Street, London, EC3R 6HD UK
| | - Peter Kaimenyi
- Options Consultancy Services, 2nd Floor, St Magnus House, 3 Lower Thames Street, London, EC3R 6HD UK
| | - Osman Warfa
- Kenya Ministry of Health, Afya House, Cathedral Road, P.O. Box:30016–00100, Nairobi, Kenya
| | - Nicole Fulton
- Options Consultancy Services, 2nd Floor, St Magnus House, 3 Lower Thames Street, London, EC3R 6HD UK
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Ebenezer ED, Londhe V, Rathore S, Benjamin S, Ross B, Jeyaseelan L, Mathews JE. Peripartum interventions resulting in reduced perinatal mortality rates, and birth asphyxia rates, over 18 years in a tertiary centre in South India: a retrospective study. BJOG 2019; 126 Suppl 4:21-26. [PMID: 31257695 DOI: 10.1111/1471-0528.15848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the changes in the rates of perinatal mortality, birth asphyxia, and caesarean sections in relation to interventions implemented over the past 18 years, in a tertiary centre in South India. DESIGN Retrospective study. SETTING Labour and maternity unit of a tertiary centre in South India. POPULATION OR SAMPLE Women who gave birth between 2000 and 2018. METHODS Information from perinatal audits, chart reviews, and data retrieved from the electronic database were used. Interventions implemented during this time period were audits and training, obstetric re-organisation, and minor changes in staffing and infrastructure. MAIN OUTCOME MEASURES Main outcome measures were perinatal mortality rate, birth asphyxia rate, and caesarean section rate. RESULTS Perinatal mortality rate decreased from 44 per 1000 births in 2000 to 16.4 per 1000 births in 2018 (P < 0.001). The rates of babies born with birth asphyxia requiring admission to the neonatal unit decreased from 24 per 1000 births in 2001 to 0.7 per 1000 births in 2018 (P < 0.00001). The overall caesarean section rate was maintained close to 30%. CONCLUSION In a large tertiary hospital in South India, with 14 000 deliveries per year, a policy of rigorous audits of stillbirths and birth asphyxia, electronic fetal monitoring, and the introduction of standardised criteria for trial of scar, reduced the perinatal mortality and the rate of babies born with birth asphyxia over the past 18 years, without an increase in the caesarean section rate. TWEETABLE ABSTRACT Rigorous perinatal audits with training in fetal cardiotocography, decreased birth asphyxia, without a major increase in caesarean rates.
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Affiliation(s)
- E D Ebenezer
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamilnadu, India
| | - V Londhe
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamilnadu, India
| | - S Rathore
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamilnadu, India
| | - S Benjamin
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamilnadu, India
| | - B Ross
- Department of Neonatology, Christian Medical College, Vellore, Tamilnadu, India
| | - L Jeyaseelan
- Department of Biostatistics, Christian Medical College, Vellore, Tamilnadu, India
| | - J E Mathews
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamilnadu, India
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