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Nabatanzi M, Harris JR, Namukanja P, Kabwama SN, Nabatanzi S, Nabunya P, Kwesiga B, Ario AR, Komakech P. Improving maternal and neonatal outcomes among pregnant women who are HIV-positive or HIV-negative through the Saving Mothers Giving Life initiative in Uganda: An analysis of population-based mortality surveillance data. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002801. [PMID: 38300894 PMCID: PMC10833525 DOI: 10.1371/journal.pgph.0002801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024]
Abstract
HIV infection is associated with poor maternal health outcomes. In 2016, the maternal mortality ratio (MMR) in Uganda was 336/100,000, and the neonatal mortality rate (NMR) was 19/1,000. Saving Mothers, Giving Life (SMGL) was a five-year maternal and neonatal health strengthening initiative launched in 2012 in Uganda. We extracted maternal and neonatal data for 2015-2016 from the initiative's population-based mortality surveillance system in 123 health facilities in Western Uganda. We collected data on the facilities, HIV status, antiretroviral drug (ARV) use, death, birth weight, delivery type, parity, Apgar scores, and complications. We compared mother and baby outcomes between HIV-positive or HIV-negative, computed risk ratios (RR) for adverse outcomes, and used the chi-square to test for significance in differences observed. Among 116,066 pregnant women who attended and gave birth at SMGL-implementing facilities during 2015-2016, 8,307 (7.7%) were HIV-positive, of whom 7,809 (94%) used antiretroviral drugs (ARVs) at the time of delivery. During birth, 23,993 (21%) women experienced ≥1 complications. Neonate Apgar scores <7 (8.8%) and maternal haemorrhage during birth (1.6%) were the most common outcomes. Overall facility MMR was 258/100,000 and NMR was 7.6/1,000. HIV infection increased risk of maternal death (RR = 3.6, 95% Confidence Interval (CI) = 2.4-5.5), maternal sepsis (RR = 2.1, 95% CI = 1.3-3.3), and infant birth weight <2,500g (RR = 1.2, 95% CI = 1.1-1.3), but was protective against maternal complications (RR = 0.92, 95% CI = 0.87-0.97) and perinatal death (RR = 0.78, 95% CI = 0.68-0.89). Among the HIV-positive, ARV non-use increased risk of maternal death (RR = 15, 95% CI = 7.1-31) and perinatal death (RR = 2.3, 95% CI = 1.6-3.4). SMGL reduced facility MMR and NMR below national rates. HIV-infection was associated with maternal sepsis and death. Failure to use ARVs among women living with HIV increased the risk of maternal and perinatal death. Use of the SMGL approach and complementary interventions that further strengthen HIV care, may continue to reduce MMR and NMR.
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Affiliation(s)
- Maureen Nabatanzi
- Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda
| | - Julie R. Harris
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Kampala, Uganda
| | - Phoebe Namukanja
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Kampala, Uganda
| | - Steven N. Kabwama
- Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Sandra Nabatanzi
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Kampala, Uganda
| | - Phoebe Nabunya
- Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda
| | - Benon Kwesiga
- Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda
| | - Alex R. Ario
- Uganda National Institute of Public Health, Ministry of Health, Kampala, Uganda
| | - Patrick Komakech
- Office of Health and HIV, US Agency for International Development, Kampala, Uganda
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Zakumumpa H, Paina L, Ssegujja E, Shroff ZC, Namakula J, Ssengooba F. The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21). Health Policy Plan 2024; 39:i21-i32. [PMID: 38253438 PMCID: PMC10803197 DOI: 10.1093/heapol/czad096] [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: 01/24/2023] [Revised: 09/19/2023] [Accepted: 10/20/2023] [Indexed: 01/24/2024] Open
Abstract
Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.
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Affiliation(s)
- Henry Zakumumpa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, P O Box 7062, Kampala, Uganda
| | - Eric Ssegujja
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Justin Namakula
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
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Wanyenze EW, Nalwadda GK, Tumwesigye NM, Byamugisha JK. Efficacy of midwife-led role orientation of birth companions on maternal satisfaction and birth outcomes: a randomized control trial in Uganda. BMC Pregnancy Childbirth 2023; 23:669. [PMID: 37723430 PMCID: PMC10506214 DOI: 10.1186/s12884-023-05978-8] [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: 04/03/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND The World Health Organization recommends birth companionship for all women in labor. There is insufficient evidence on birth companionship in low-income settings and it is not clear if role orientation impacts effectiveness. The aim of this study was to assess the efficacy of midwife-led role orientation of birth companions of on maternal satisfaction and birth outcomes in a sub-region in Uganda. METHODS A stepped wedge cluster randomized trial conducted (control n = 240), intervention n = 235) from 4 clusters. Women who had a birth companion, in spontaneously established labor and, expecting a vaginal delivery were eligible. The intervention was "midwife-provided orientation of birth companions". The admitting midwife provided an orientation session for the birth companion on supportive labor techniques. The primary outcome was the chance of having a spontaneous vaginal delivery. Assessors were not blinded. Independent t-test and Chi-Square tests were used to assess the differences by study period. RESULTS Mean maternal satisfaction rate was significantly higher in the intervention period compared to the control period (P > 0.001). High maternal satisfaction levels were noted among the women who were; at the regional referral hospital, younger, first-time mothers, and unmarried (P < 0.001). Satisfaction with pain management was rated lowest across study periods. Satisfaction with humaneness was rated highest with a higher score in the intervention period (93%) than the control (79.5%). There were no statistically significant differences in the mode of delivery, need to augment labor, length of labor and Apgar scores. CONCLUSION Midwife-led role orientation of birth companions increased maternal satisfaction. Nevertheless, no significant effect was noted in the mode of delivery, length of labor, Apgar score, and need to augment labor. Findings could inform the integration of birth companions in the admission process of the woman in labor in similar settings. TRIAL REGISTRATION NUMBER NCT04771325.
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Affiliation(s)
- Eva Wodeya Wanyenze
- Department of Nursing, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda.
| | - Gorrette K Nalwadda
- Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nazarius Mbona Tumwesigye
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Josaphat K Byamugisha
- Department of Obstetrics and Gynecology, College of Health Sciences, Makerere University, Kampala, Uganda
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Dynes MM, Daniel GA, Mac V, Picho B, Asiimwe A, Nalutaaya A, Opio G, Kamara V, Kaharuza F, Serbanescu F. A qualitative evaluation and conceptual framework on the use of the Birth weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) matrix for perinatal health in Uganda. BMC Pregnancy Childbirth 2023; 23:86. [PMID: 36726073 PMCID: PMC9890791 DOI: 10.1186/s12884-023-05402-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Perinatal mortality (newborn deaths in the first week of life and stillbirths) continues to be a significant global health threat, particularly in resource-constrained settings. Low-tech, innovative solutions that close the quality-of-care gap may contribute to progress toward the Sustainable Development Goals for health by 2030. From 2012 to 2018, the Saving Mothers, Giving Life Initiative (SMGL) implemented the Birth weight and Age-at-Death Boxes for Intervention and Evaluation System (BABIES) matrix in Western Uganda. The BABIES matrix provides a simple, standardized way to track perinatal health outcomes to inform evidence-based quality improvement strategies. METHODS In November 2017, a facility-based qualitative evaluation was conducted using in-depth interviews with 29 health workers in 16 health facilities implementing BABIES in Uganda. Data were analyzed using directed content analysis across five domains: 1) perceived ease of use, 2) how the matrix was used, 3) changes in behavior or standard operating procedures after introduction, 4) perceived value of the matrix, and 5) program sustainability. RESULTS Values in the matrix were easy to calculate, but training was required to ensure correct data placement and interpretation. Displaying the matrix on a highly visible board in the maternity ward fostered a sense of accountability for health outcomes. BABIES matrix reports were compiled, reviewed, and responded to monthly by interprofessional teams, prompting collaboration across units to fill data gaps and support perinatal death reviews. Respondents reported improved staff communication and performance appraisal, community engagement, and ability to track and link clinical outcomes with actions. Midwives felt empowered to participate in the problem-solving process. Respondents were motivated to continue using BABIES, although sustainability concerns were raised due to funding and staff shortages. CONCLUSIONS District-level health systems can use data compiled from the BABIES matrix to inform policy and guide implementation of community-centered health practices to improve perinatal heath. Future work may consider using the Conceptual Framework on Use of the BABIES Matrix for Perinatal Health as a model to operationalize concepts and test the impact of the tool over time.
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Affiliation(s)
- Michelle M. Dynes
- grid.416738.f0000 0001 2163 0069Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Gaea A. Daniel
- grid.189967.80000 0001 0941 6502Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA USA
| | - Valerie Mac
- grid.189967.80000 0001 0941 6502Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA USA
| | - Brenda Picho
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Alice Asiimwe
- grid.423308.e0000 0004 0397 2008Baylor College of Medicine Children’s Foundation, Kampala, Uganda
| | - Agnes Nalutaaya
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gregory Opio
- grid.423308.e0000 0004 0397 2008Baylor College of Medicine Children’s Foundation, Kampala, Uganda
| | | | - Frank Kaharuza
- grid.440478.b0000 0004 0648 1247Kampala International University, Western Campus, Ishaka Bushenyi, Uganda
| | - Florina Serbanescu
- grid.416738.f0000 0001 2163 0069Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA USA
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Odendaal W, Goga A, Chetty T, Schneider H, Pillay Y, Marshall C, Feucht U, Hlongwane T, Kauchali S, Makua M. Early Reflections on Mphatlalatsane, a Maternal and Neonatal Quality Improvement Initiative Implemented During COVID-19 in South Africa. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2200022. [PMID: 36316142 PMCID: PMC9622289 DOI: 10.9745/ghsp-d-22-00022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/20/2022] [Indexed: 08/02/2023]
Abstract
Despite global progress in reducing maternal and neonatal mortality and stillbirths, much work remains to be done to achieve the Sustainable Development Goals. Reports indicate that coronavirus disease (COVID-19) disrupts the provision and uptake of routine maternal and neonatal health care (MNH) services and negatively impacts cumulative pre-COVID-19 achievements. We describe a multipartnered MNH quality improvement (QI) initiative called Mphatlalatsane, which was implemented in South Africa before and during the COVID-19 pandemic. The initiative aimed to reduce the maternal mortality ratio, neonatal mortality rate, and stillbirth rate by 50% between 2018 and 2022. The multifaceted design comprises QI and other intervention activities across micro-, meso-, and macrolevels, and its area-based approach facilitates patients' access to MNH services. The initiative commenced 6 months pre-COVID-19, with subsequent adaptation necessitated by COVID-19. The initial focus on a plan-do-study-act QI model shifted toward meeting the immediate needs of health care workers (HCWs), the health system, and health care managers arising from COVID-19. Examples include providing emotional support to staff and streamlining supply chain management for infection control and personal protection materials. As these needs were addressed, Mphatlalatsane gradually refocused HCWs' and managers' attention to recognize the disruptions caused by COVID-19 to routine MNH services. This gradual reprioritization included the development of a risk matrix to help staff and managers identify specific risks to service provision and uptake and develop mitigating measures. Through this approach, Mphatlalatsane led to an optimization case using existing resources rather than requesting new resources to build an investment case, with a responsive design and implementation approach as the cornerstone of the initiative. Further, Mphatlalatsane demonstrates that agile and context-specific responses to crises such as the COVID-19 pandemic can mitigate such threats and maintain interventions to improve MNH services.
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Affiliation(s)
- Willem Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Ameena Goga
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Terusha Chetty
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Helen Schneider
- School of Public Health and the South African Medical Research Council Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South Africa
| | - Yogan Pillay
- Clinton Health Access Initiative, Pretoria, South Africa
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | | | - Ute Feucht
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria, South Africa
| | - Tsakane Hlongwane
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria, South Africa
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa
| | - Shuaib Kauchali
- Maternal, Adolescent and Child Health Institute, Durban, South Africa
| | - Manala Makua
- National Department of Health, Pretoria, South Africa
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Kanyesigye H, Kabakyenga J, Mulogo E, Fajardo Y, Atwine D, MacDonald NE, Bortolussi R, Migisha R, Ngonzi J. Improved maternal-fetal outcomes among emergency obstetric referrals following phone call communication at a teaching hospital in south western Uganda: a quasi-experimental study. BMC Pregnancy Childbirth 2022; 22:684. [PMID: 36064375 PMCID: PMC9442930 DOI: 10.1186/s12884-022-05007-0] [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: 11/03/2021] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency obstetric referrals develop adverse maternal-fetal outcomes partly due to delays in offering appropriate care at referral hospitals especially in resource limited settings. Referral hospitals do not get prior communication of incoming referrals leading to inadequate preparedness and delays of care. Phone based innovations may bridge such communication challenges. We investigated effect of a phone call communication prior to referral of mothers in labour as intervention to reduce preparation delays and improve maternal-fetal outcome at a referral hospital in a resource limited setting. METHODS This was a quasi-experimental study with non-equivalent control group conducted at Mbarara Regional Referral Hospital (MRRH) in South Western Uganda from September 2020 to March 2021. Adverse maternal-fetal outcomes included: early neonatal death, fresh still birth, obstructed labour, ruptured uterus, maternal sepsis, low Apgar score, admission to neonatal ICU and hysterectomy. Exposure variable for intervention group was a phone call prior maternal referral from a lower health facility. We compared distribution of clinical characteristics and adverse maternal-fetal outcomes between intervention and control groups using Chi square or Fisher's exact test. We performed logistic regression to assess association between independent variables and adverse maternal-fetal outcomes. RESULTS We enrolled 177 participants: 75 in intervention group and 102 in control group. Participants had similar demographic characteristics. Three quarters (75.0%) of participants in control group delayed on admission waiting bench of MRRH compared to (40.0%) in intervention group [p = < 0.001]. There were significantly more adverse maternal-fetal outcomes in control group than intervention group (obstructed labour [p = 0.026], low Apgar score [p = 0.013] and admission to neonatal high dependency unit [p = < 0.001]). The phone call intervention was protective against adverse maternal-fetal outcome [aOR = 0.22; 95%CI: 0.09-0.44, p = 0.001]. CONCLUSION The phone call intervention resulted in reduced delay to patient admission at a tertiary referral hospital in a resource limited setting, and is protective against adverse maternal-fetal outcomes. Incorporating the phone call communication intervention in the routine practice of emergency obstetric referrals from lower health facilities to regional referral hospitals may reduce both maternal and fetal morbidities. TRIAL REGISTRATION Pan African Clinical Trial Registry PACTR20200686885039.
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Affiliation(s)
- Hamson Kanyesigye
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edgar Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Yarine Fajardo
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Daniel Atwine
- Department of Clinical Research, SOAR Research Foundation, Mbarara, Uganda
| | - Noni E MacDonald
- Faculty of Medicine & MicroResearch International, Dalhouise University, Halifax, Canada
| | - Robert Bortolussi
- Faculty of Medicine & MicroResearch International, Dalhouise University, Halifax, Canada
| | - Richard Migisha
- Department of Physiology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Muwema M, Kaye DK, Edwards G, Nalwadda G, Nangendo J, Okiring J, Mwanja W, Ekong EN, Kalyango JN, Nankabirwa JI. Perinatal care in Western Uganda: Prevalence and factors associated with appropriate care among women attending three district hospitals. PLoS One 2022; 17:e0267015. [PMID: 35639711 PMCID: PMC9154186 DOI: 10.1371/journal.pone.0267015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/31/2022] [Indexed: 11/25/2022] Open
Abstract
Background Perinatal mortality remains high globally and remains an important indicator of the quality of a health care system. To reduce this mortality, it is important to provide the recommended care during the perinatal period. We assessed the prevalence and factors associated with appropriate perinatal care (antenatal, intrapartum, and postpartum) in Bunyoro region, Uganda. Results from this study provide valuable information on the perinatal care services and highlight areas of improvement for better perinatal outcomes. Methods A cross sectional survey was conducted among postpartum mothers attending care at three district hospitals in Bunyoro. Following consent, a questionnaire was administered to capture the participants’ demographics and data on care received was extracted from their antenatal, labour, delivery, and postpartum records using a pre-tested structured tool. The care received by women was assessed against the standard protocol established by World Health Organization (WHO). Poisson regression with robust standard errors was used to assess factors associated with appropriate postpartum care. Results A total of 872 mothers receiving care at the participating hospitals between March and June 2020 were enrolled in the study. The mean age of the mothers was 25 years (SD = 5.95). None of the mothers received appropriate antenatal or intrapartum care, and only 3.8% of the participants received appropriate postpartum care. Factors significantly associated with appropriate postpartum care included mothers being >35 years of age (adjusted prevalence ratio [aPR] = 11.9, 95% confidence interval [CI] 2.8–51.4) and parity, with low parity (2–3) and multiparous (>3) mothers less likely to receive appropriate care than prime gravidas (aPR = 0.3, 95% CI 0.1–0.9 and aPR = 0.3, 95% CI 0.1–0.8 respectively). Conclusions Antenatal, intrapartum, and postpartum care received by mothers in this region remains below the standard recommended by WHO, and innovative strategies across the continuum of perinatal care need to be devised to prevent mortality among the mothers. The quality of care also needs to be balanced for all mothers irrespective of the age and parity.
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Affiliation(s)
- Mercy Muwema
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Dan K. Kaye
- Department of Obstetrics and Gynecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grace Edwards
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda
| | - Gorrette Nalwadda
- Department of Nursing, School of Health Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joanita Nangendo
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Elizabeth N. Ekong
- Department of Nursing, Faculty of Health Sciences, Uganda Christian University, Uganda
| | - Joan N. Kalyango
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Pharmacy, School of Health Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joaniter I. Nankabirwa
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
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Agaba P, Magadi M, Orton B. Predictors of health facility childbirth among unmarried and married youth in Uganda. PLoS One 2022; 17:e0266657. [PMID: 35390079 PMCID: PMC8989320 DOI: 10.1371/journal.pone.0266657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/24/2022] [Indexed: 12/02/2022] Open
Abstract
Background Uganda has a high maternal mortality rate combined with poor use of health facilities at childbirth among youth. Improved use of maternal health services by the youth would help reduce maternal deaths in the country. Predictors of use of health facilities at childbirth among unmarried compared to married youth aged 15–24 years in Uganda between 2006 and 2016 are examined. Methodology Binary logistic regression was conducted on the pooled data of the 2006, 2011 and 2016 Uganda Demographic and Health Surveys among youth who had given birth within five years before each survey. This analysis was among a sample of 764 unmarried, compared to 5,176 married youth aged 15–24 years. Results Overall, unmarried youth were more likely to have a childbirth within the health facilities (79.3%) compared to married youth (67.6%). Higher odds of use of health facilities at childbirth were observed among youth with at least secondary education (OR = 2.915, 95%CI = 1.747–4.865 for unmarried vs OR = 1.633, 95%CI = 1.348–1.979 for married) and frequent antenatal care of at least four visits (OR = 1.758, 95%CI = 1.153–2.681 for unmarried vs OR = 1.792, 95%CI = 1.573–2.042 for married). Results further showed that youth with parity two or more, those that resided in rural areas and those who were engaged in agriculture had reduced odds of the use of health facilities at childbirth. In addition, among married youth, the odds of using health facilities at childbirth were higher among those with at least middle wealth index, and those with frequent access to the newspapers (OR = 1.699, 95%CI = 1.162–2.486), radio (OR = 1.290, 95%CI = 1.091–1.525) and television (OR = 1.568, 95%CI = 1.149–2.138) compared to those with no access to each of the media, yet these were not significant among unmarried youth. Conclusion and recommendations Frequent use of antenatal care and higher education attainment were associated with increased chances of use of health facilities while higher parity, rural residence and being employed in the agriculture sector were negatively associated with use of health facilities at childbirth among both unmarried and married youth. To enhance use of health facilities among youth, there is a need to encourage frequent antenatal care use, especially for higher parity births and for rural residents, and design policies that will improve access to mass media, youth’s education level and their economic status.
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Affiliation(s)
- Peninah Agaba
- Department of Population Studies, School of Statistics and Planning, College of Business and Management Sciences, Makerere University, Kampala, Uganda
- * E-mail: ,
| | - Monica Magadi
- Department of Criminology and Sociology, Faculty of Arts, Cultures and Education, University of Hull, Hull, United Kingdom
| | - Bev Orton
- Department of Criminology and Sociology, Faculty of Arts, Cultures and Education, University of Hull, Hull, United Kingdom
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Balla S, Sk MIK, Ambade M, Hossain B. Distress financing in coping with out-of-pocket expenditure for maternity care in India. BMC Health Serv Res 2022; 22:288. [PMID: 35241077 PMCID: PMC8892690 DOI: 10.1186/s12913-022-07656-5] [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: 09/10/2021] [Accepted: 02/21/2022] [Indexed: 12/01/2022] Open
Abstract
Background The cost of maternity care is seen as the barrier in utilizing maternity care, resulting in high maternal deaths. This study focuses on the distress financing and its coping mechanisms associated with maternity care expenditure in India so that corrective measures can be taken to reduce the burden of maternity care. Methods This study used the National Sample Survey (NSS) data conducted in 20,014–15 (71st round of NSS) and 2017–18(75th round of NSS). We define distress financing as use of formal borrowing, borrowing from friends or family or sale of asser to finance maternity care. Percentage of pregnant/delivered females using distress financing were calculated.. The present study also used multinomial logistic regression with 95% to understand the impact of socio-economic variables on distress financing and concentration index to measure the inequality in maternity care expenditure. Results This study found that the maternity care expenditure has decreased from the INR. 9379 in 2014–15 to INR. 7835 in 2017–18. The percentage of households using distress financing is higher among the poorest (13.2%). Almost 14% of the SC households experience distress financing. Among EAG + A states, particularly in Madhya Pradesh and Uttarakhand, the percentage of households are which experience a high level of distress financing increased from 8.9 to 18.3 and 0.7 to 8.1 from 2014–15 to 2017–18 respectively. The study finds that more urban households (37%) utilized insurance than rural households (26%). Among EAG + A states, 67.9 percent of households were dependent upon household savings, and it was 63.6 percent in the non-EAG states. The households with a high burden of maternity care expenditure were at higher risk of borrowing money to finance the cost of maternity as compared to use of savings/income for the same (relative risk (RR) (R: 2.59; P < 0.01; 95% CI: 2.15–3.13). Mothers belonging to the SC caste were at significantly higher risk (RR: 1.43; P < 0.1; 95% CI: 1.07–1.91). of using borrowings as compared to the use of income/savings. Mothers with college education were 50% more likely to use health insurance as compared to those with primary education. Conclusions The study found that even though many programs for maternity care services are there, the maternity care expenditure, particularly the delivery care expenses, is very high in many states. The study recommends that India should increase subsidized maternity care facilities to decrease catastrophic maternity expenditure among households.
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Affiliation(s)
- Shalem Balla
- International Institute for Population Sciences, Mumbai, 400 088, India
| | | | - Mayanka Ambade
- International Institute for Population Sciences, Mumbai, 400 088, India
| | - Babul Hossain
- International Institute for Population Sciences, Mumbai, 400 088, India
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Namagembe I, Nakimuli A, Byamugisha J, Moffett A, Aiken A, Aiken C. Preventing death following unsafe abortion: a case series from urban Uganda. AJOG GLOBAL REPORTS 2022; 2:100039. [PMID: 35252906 PMCID: PMC8883508 DOI: 10.1016/j.xagr.2021.100039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Maternal deaths from unsafe abortion continue to occur globally, with particularly high rates in Sub-Saharan Africa where most abortions are classified as unsafe. Maternal death reviews are an effective part of cohesive strategies to prevent future deaths while abortion remains illegal. OBJECTIVE This study aimed to conduct maternal death reviews for all deaths occurring following unsafe abortion during the study period, to assess preventability, and to synthesize key learning points that may help to prevent future maternal deaths following unsafe abortions. STUDY DESIGN Full case reviews of all maternal deaths (350 cases from Jan 2016 to Dec 2018) at the study center (a national referral hospital in urban Uganda) were conducted by specially trained multidisciplinary panels of obstetricians and midwives. We extracted the reviews of women who died following unsafe abortions (13 [2.6%]) for further analysis. RESULTS Most maternal deaths owing to unsafe abortion were found to be preventable. The key recommendations that emerged from the reviews were (1) that clinicians should maintain a high index of suspicion for delayed presentation and rapid decompensation in cases where unsafe abortion has occurred, (2) that a low threshold for early intravenous antibiotic therapy should be applied, and (3) that any admission with complications following an unsafe abortion merits review by an experienced clinician as soon as possible. CONCLUSION Postabortion care is part of essential emergency medical care and should be provided with high standards, especially in areas where there is limited or no legal access to abortion care. Implementing the recommended learning points is likely to be feasible even in low-resource obstetrical settings and, given the high rates of preventability found in maternal deaths owing to unsafe abortion, is likely to be effective.
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11
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Karamagi HC, Ben Charif A, Ngusbrhan Kidane S, Yohanes T, Kariuki D, Titus M, Batungwanayo C, Seydi ABW, Berhane A, Nzinga J, Njuguna D, Kipruto HK, Andrews Annan E, Droti B. Investments for effective functionality of health systems towards Universal Health Coverage in Africa: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001076. [PMID: 36962623 PMCID: PMC10021830 DOI: 10.1371/journal.pgph.0001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/18/2022]
Abstract
The health challenges in Africa underscore the importance of effectively investing in health systems. Unfortunately, there is no information on systems investments adequate for an effective functional health system. We aimed to address this by conducting a scoping review of existing evidence following the Joanna Briggs Institute Manual for Evidence Synthesis and preregistered with the Open Science Framework (https://osf.io/bvg4z). We included any empirical research describing interventions that contributed to the functionality of health systems in Africa or any low-income or lower-middle-income regions. We searched Web of Science, MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL, and ERIC from their inception, and hand-searched other relevant sources. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. We identified 554 unique reports describing 575 interventions, of which 495 reported evidence of effectiveness. Most interventions were undertaken in Africa (80.9%), covered multiple elements of health systems (median: 3), and focused on service delivery (77.4%) and health workforce (65.6%). Effective interventions contributed to improving single (35.6%) or multiple (64.4%) capacities of health systems: access to essential services (75.6%), quality of care (70.5%), demand for essential services (38.6%), or health systems resilience (13.5%). For example, telemedicine models which covered software (technologies) and hardware (health workers) elements were used as a strategy to address issues of access to essential services. We inventoried these effective interventions for improving health systems functionality in Africa. Further analyses could deepen understanding of how such interventions differ in their incorporation of evidence for potential scale across African countries.
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Affiliation(s)
- Humphrey Cyprian Karamagi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | | | - Solyana Ngusbrhan Kidane
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Tewelde Yohanes
- Division of Policy and Planning, Ministry of Health, Asmara, Eritrea
| | | | | | | | - Aminata Binetou-Wahebine Seydi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Araia Berhane
- Conmmunicable Diseases Control Division, Ministry of Health, Asmara, Eritrea
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - David Njuguna
- Health Economist, Ministry of Health, Nairobi, Kenya
| | - Hillary Kipchumba Kipruto
- Essential Drugs and Medicines, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Edith Andrews Annan
- Essential Drugs and Medicines, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Benson Droti
- Health Information Systems, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Congo
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Rokicki S, Mwesigwa B, Waiswa P, Cohen J. Impact of Solar Light and Electricity on the Quality and Timeliness of Maternity Care: A Stepped-Wedge Cluster-Randomized Trial in Uganda. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:777-792. [PMID: 34933975 PMCID: PMC8691890 DOI: 10.9745/ghsp-d-21-00205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/10/2021] [Indexed: 01/02/2023]
Abstract
Lack of access to reliable energy is a major neglected health system challenge to maternal and child health. We found that installing a solar energy system intervention in rural Ugandan maternity facilities led to modest increases in the quality of maternity care and reductions in delays in care. Background: We evaluated the impact of solar light installation in Ugandan maternity facilities on implementation processes, reliability of light, and quality of intrapartum care. Methods: We conducted a stepped-wedge cluster-randomized trial of the We Care Solar Suitcase, a complete solar electric system providing lighting and power for charging phones and small medical devices, in 30 rural Ugandan maternity facilities with unreliable lighting. Facilities were randomly assigned to receive the intervention in the first or second sequence in a 1:1 ratio. We collected data from June 2018 to April 2019. The intervention was installed in September 2018 (first sequence) and in December 2018 (second sequence). The primary effectiveness outcomes were a 20-item and a 36-item index of quality of intrapartum care, a 6-item index of delays in care provision, and the percentage of deliveries with bright light, satisfactory light, and adequate light. Results: We observed 1,118 births across 30 facilities. The intervention was successfully installed in 100% of facilities. After installation, the intervention was used in 83% of nighttime deliveries. Before the intervention, providers on average performed 42% of essential care actions and accumulated 76 minutes of delays during nighttime deliveries. After installation, quality increased by 4 percentage points (95% confidence interval [CI]=1,8) and delays in care decreased by 10 minutes (95% CI=−16,−3), with the largest impacts on infection control, prevention of postpartum hemorrhage, and newborn care practices. One year after the end of the trial, 90% of facilities had LED lights in operation and 60% of facilities had all components in operation. Conclusions: Reliable light is an important driver of timely and adequate health care. Policy makers should invest in renewable energy systems for health facilities; however, even when reliable lighting is present, quality of care may remain low without a broader approach to quality improvements.
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Affiliation(s)
- Slawa Rokicki
- Rutgers School of Public Health, Piscataway, NJ, USA. .,University College Dublin, Dublin, Ireland
| | | | - Peter Waiswa
- Maternal, Newborn and Child Health Centre of Excellence, Makerere University School of Public Health, Kampala, Uganda.,Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Busoga Health Forum, Jinja, Uganda
| | - Jessica Cohen
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
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He Z, Zhang C, Wang S, Bishwajit G, Yang X. Socioeconomic Determinants of Maternal HealthCare Utilisation in Zambia: 1997-2014. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2021; 58:469580211067480. [PMID: 34911372 PMCID: PMC8689614 DOI: 10.1177/00469580211067480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This study aims at exploring the trends and socioeconomic inequalities in the use of maternal healthcare utilization between 1997 and 2014. Data were analyzed using descriptive and multivariate regression methods. Women in the higher wealth quintiles (Q4 and Q5) generally had higher prevalence of using health facility delivery and postnatal care services compared with those in the lower wealth quintiles (Q1 and Q2), whereas the prevalence of timely and adequate antenatal care visit was comparatively higher among those in the lower wealth quintiles. Findings indicated important sociodemographic inequalities in using maternal healthcare services, addressing which may help promote the utilization of these services.
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Affiliation(s)
- Zhifei He
- School of Politics and Public Administration, Southwest University of Political Science and Law, Chongqing, China
| | - Caihua Zhang
- School of International Development and Global Studies, University of Ottawa, Ottawa, ON, Canada
| | - Shiming Wang
- School of International Development and Global Studies, University of Ottawa, Ottawa, ON, Canada
| | - Ghose Bishwajit
- School of International Law, Southwest University of Political Science and Law, Chongqing, China
| | - Xinglong Yang
- School of International Law, Southwest University of Political Science and Law, Chongqing, China
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Beneath the Surface: A Comparison of Methods for Assessment of Quality of Care for Maternal and Neonatal Health Care in Rural Uganda. Matern Child Health J 2020; 24:328-339. [PMID: 31894511 DOI: 10.1007/s10995-019-02862-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Efforts to improve access to healthcare in low-income countries will not achieve the maternal and child health (MCH) Sustainable Development Goals unless a concomitant improvement in the quality of care (QoC) occurs. This study measures infrastructure and QoC indicators in rural Ugandan health facilities. Valid measure of the quality of current clinical practices in resource-limited settings are critical for effectively intervening to reduce adverse maternal and neonatal outcomes. METHODS Facility-based assessments of infrastructure and clinical quality during labor and delivery were conducted in six primary care health facilities in the greater Masaka area, Uganda in 2017. Data were collected using direct observation of clinical encounters and facility checklists. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum hemorrhage, neonatal resuscitation). Health providers were assessed on their adherence to best practice standards of care. RESULTS The quality of facility infrastructure was relatively high in facilities, with little variation in availability of equipment and supplies. However, heterogeneity in adherence to best clinical practices was noted across procedure type and facility. Adherence to crude measures of clinical quality were relatively high but more sensitive measures of the same clinical practice were found to be much lower. CONCLUSIONS FOR PRACTICE Standard indicators of clinical practice may be insufficient to validly measure clinical quality for maternal and newborn care if we want to document evidence of impact.
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Robinson T, Santorino D, Dube M, Twine M, Najjuma JN, Cherop M, Kyakwera C, Brenner J, Singhal N, Bajunirwe F, Wishart I, Lin Y, Lorentzen H, Lutnæs DE, Cheng A. Sim for Life: Foundations-A Simulation Educator Training Course to Improve Debriefing Quality in a Low Resource Setting: A Pilot Study. Simul Healthc 2020; 15:326-334. [PMID: 33003188 DOI: 10.1097/sih.0000000000000445] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Despite the importance of debriefing, little is known about the effectiveness of training programs designed to teach debriefing skills. In this study, we evaluated the effectiveness of a faculty development program for new simulation educators at Mbarara University of Science and Technology in Uganda, Africa. METHODS Healthcare professionals were recruited to attend a 2-day simulation educator faculty development course (Sim for Life: Foundations), covering principles of scenario design, scenario execution, prebriefing, and debriefing. Debriefing strategies were contextualized to local culture and focused on debriefing structure, conversational strategies, and learner centeredness. A debriefing worksheet was used to support debriefing practice. Trained simulation educators taught simulation sessions for 12 months. Debriefings were videotaped before and after initial training and before and after 1-day refresher training at 12 months. The quality of debriefing was measured at each time point using the Objective Structured Assessment of Debriefing (OSAD) tool by trained, calibrated, and blinded raters. RESULTS A total of 13 participants were recruited to the study. The mean (95% confidence interval) OSAD scores pretraining, posttraining, and at 12 months before and after refresher were 18.2 (14.3-22.1), 26.7 (22.8-30.6), 25.5 (21.2-29.9), and 27.0 (22.4-31.6), respectively. There was a significant improvement from pretraining to posttraining (P < 0.001), with no significant decay from posttraining to 12 months (P = 0.54). There was no significant difference in OSAD scores pre- versus post-refresher training at 12 months (P = 0.49). CONCLUSIONS The Sim for Life Foundations program significantly improves debriefing skills with retention of debriefing skills at 12 months.
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Affiliation(s)
- Traci Robinson
- From the Department of Pediatrics (J.B., N.S., A.C.), Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada, Global Health Unit (T.R.), University of Calgary, Calgary, Alberta, Canada; Mbarara University of Science and Technology (D.S., M.T., J.N.N., M.C., C.K., F.B.), Mbarara, Uganda; eSIM Provincial Program (M.D.), Alberta Health Services; Department of Emergency Medicine (I.W.), University of Calgary; KidSIM Simulation Program (Y.L.), Alberta Children's Hospital, Calgary, Alberta, Canada; Operations Training, Oceaneering (H.L.), Sandnes; Formerly of: SAFER (D.E.L.); and The Norwegian Healthcare Investigation Board (D.E.L.), Stavanger, Norway
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Varela C, Young S, Groen RS, Banza L, Mkandawire N, Moen BE, Viste A. Deaths from surgical conditions in Malawi - a randomised cross-sectional Nationwide household survey. BMC Public Health 2020; 20:1456. [PMID: 32977777 PMCID: PMC7519556 DOI: 10.1186/s12889-020-09575-8] [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: 01/23/2020] [Accepted: 09/21/2020] [Indexed: 12/21/2022] Open
Abstract
Background Relatively little is known about deaths from surgical conditions in low- and middle- income African countries. The prevalence of untreated surgical conditions in Malawi has previously been estimated at 35%, with 24% of the total deaths associated with untreated surgical conditions. In this study, we wished to analyse the causes of deaths related to surgical disease in Malawi and where the deaths took place; at or outside a health facility. Methods The study is based on data collected in a randomised multi-stage cross-sectional national household survey, which was carried out using the Surgeons Overseas Assessment of Surgical Need (SOSAS) tool. Randomisation was done on 48,233 settlements, using 55 villages from each district as data collection sites. Two to four households were randomly selected from each village. Two members from each household were interviewed. A total of 1479 households (2909 interviewees) across the whole country were visited as part of the survey. Results The survey data showed that in 2016, the total number of reported deaths from all causes was 616 in the 1479 households visited. Data related to cause of death were available for 558 persons (52.7% male). Surgical conditions accounted for 26.9% of these deaths. The conditions mostly associated with the 150 surgical deaths were body masses, injuries, and acute abdominal distension (24.3, 21.5 and 18.0% respectively). 12 women died from child delivery complications. Significantly more deaths from surgical conditions or injuries (55.3%) occurred outside a health facility compared to 43.6% of deaths from other medical conditions, (p = 0.0047). 82.3% of people that died sought formal health care and 12.9% visited a traditional healer additionally prior to their death. 17.7% received no health care at all. Of 150 deaths from potentially treatable surgical conditions, only 21.3% received surgical care. Conclusion In Malawi, a large proportion of deaths from possible surgical conditions occur outside a health facility. Conditions associated with surgical death were body masses, acute abdominal distention and injuries. These findings indicate an urgent need for scale up of surgical services at all health care levels in Malawi.
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Affiliation(s)
- Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Surgery, University of Malawi, College of Medicine, Lilongwe, Malawi.,Department of Clinical Medicine, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Surgery, University of Malawi, College of Medicine, Lilongwe, Malawi.,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Reinou S Groen
- Department of Obstetrics and Gynaecology, Johns Hopkins Medicine, Baltimore, USA.,Department of Obstetrics and Gynaecology, Alaska Native Medical Centre, Anchorage, USA
| | - Leonard Banza
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Surgery, University of Malawi, College of Medicine, Lilongwe, Malawi.,Department of Clinical Medicine, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Nyengo Mkandawire
- Department of Surgery, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Bente Elisabeth Moen
- Department of Clinical Medicine, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Asgaut Viste
- Department of Clinical Medicine, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway. .,Department of Research and Development, Haukeland University Hospital, Bergen, Norway.
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Willcox ML, Price J, Scott S, Nicholson BD, Stuart B, Roberts NW, Allott H, Mubangizi V, Dumont A, Harnden A. Death audits and reviews for reducing maternal, perinatal and child mortality. Cochrane Database Syst Rev 2020; 3:CD012982. [PMID: 32212268 PMCID: PMC7093891 DOI: 10.1002/14651858.cd012982.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under five years of age, in every country, by 2030. Maternal and perinatal death audit and review is widely recommended as an intervention to reduce maternal and perinatal mortality, and to improve quality of care, and could be key to attaining the SDGs. However, there is uncertainty over the most cost-effective way of auditing and reviewing deaths: community-based audit (verbal and social autopsy), facility-based audits (significant event analysis (SEA)) or a combination of both (confidential enquiry). OBJECTIVES To assess the impact and cost-effectiveness of different types of death audits and reviews in reducing maternal, perinatal and child mortality. SEARCH METHODS We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and searched reference lists of included articles. SELECTION CRITERIA Cluster-randomised trials, cluster non-randomised trials, controlled before-and-after studies and interrupted time series studies of any form of death audit or review that involved reviewing individual cases of maternal, perinatal or child deaths, identifying avoidable factors, and making recommendations. To be included in the review, a study needed to report at least one of the following outcomes: perinatal mortality rate; stillbirth rate; neonatal mortality rate; mortality rate in children under five years of age or maternal mortality rate. DATA COLLECTION AND ANALYSIS We used standard Cochrane Effective Practice and Organisation of Care (EPOC) group methodological procedures. Two review authors independently extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. We planned to perform a meta-analysis using a random-effects model but included studies were not homogeneous enough to make pooling their results meaningful. MAIN RESULTS We included two cluster-randomised trials. Both introduced death review and audit as part of a multicomponent intervention, and compared this to current care. The QUARITE study (QUAlity of care, RIsk management, and TEchnology) concerned maternal death reviews in hospitals in West Africa, which had very high maternal and perinatal mortality rates. In contrast, the OPERA trial studied perinatal morbidity/mortality conferences (MMCs) in maternity units in France, which already had very low perinatal mortality rates at baseline. The OPERA intervention in France started with an outreach visit to brief obstetricians, midwives and anaesthetists on the national guidelines on morbidity/mortality case management, and was followed by a series of perinatal MMCs. Half of the intervention units were randomised to receive additional support from a clinical psychologist during these meetings. The OPERA intervention may make little or no difference to overall perinatal mortality (low certainty evidence), however we are uncertain about the effect of the intervention on perinatal mortality related to suboptimal care (very low certainty evidence).The intervention probably reduces perinatal morbidity related to suboptimal care (unadjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95; 165,353 births; moderate-certainty evidence). The effect of the intervention on stillbirth rate, neonatal mortality, mortality rate in children under five years of age, maternal mortality or adverse effects was not reported. The QUARITE intervention in West Africa focused on training leaders of hospital obstetric teams using the ALARM (Advances in Labour And Risk Management) course, which included one day of training about conducting maternal death reviews. The leaders returned to their hospitals, established a multidisciplinary committee and started auditing maternal deaths, with the support of external facilitators. The intervention probably reduces inpatient maternal deaths (adjusted OR 0.85, 95% CI 0.73 to 0.98; 191,167 deliveries; moderate certainty evidence) and probably also reduces inpatient neonatal mortality within 24 hours following birth (adjusted OR 0.74, 95% CI 0.61 to 0.90; moderate certainty evidence). However, QUARITE probably makes little or no difference to the inpatient stillbirth rate (moderate certainty evidence) and may make little or no difference to the inpatient neonatal mortality rate after 24 hours, although the 95% confidence interval includes both benefit and harm (low certainty evidence). The QUARITE intervention probably increases the percent of women receiving high quality of care (OR 1.87, 95% CI 1.35 - 2.57, moderate-certainty evidence). The effect of the intervention on perinatal mortality, mortality rate in children under five years of age, or adverse effects was not reported. We did not find any studies that evaluated child death audit and review or community-based death reviews or costs. AUTHORS' CONCLUSIONS A complex intervention including maternal death audit and review, as well as development of local leadership and training, probably reduces inpatient maternal mortality in low-income country district hospitals, and probably slightly improves quality of care. Perinatal death audit and review, as part of a complex intervention with training, probably improves quality of care, as measured by perinatal morbidity related to suboptimal care, in a high-income setting where mortality was already very low. The WHO recommends that maternal and perinatal death reviews should be conducted in all hospitals globally. However, conducting death reviews in isolation may not be sufficient to achieve the reductions in mortality observed in the QUARITE trial. This review suggests that maternal death audit and review may need to be implemented as part of an intervention package which also includes elements such as training of a leading doctor and midwife in each hospital, annual recertification, and quarterly outreach visits by external facilitators to provide supervision and mentorship. The same may also apply to perinatal and child death reviews. More operational research is needed on the most cost-effective ways of implementing maternal, perinatal and paediatric death reviews in low- and middle-income countries.
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Affiliation(s)
- Merlin L Willcox
- University of Southampton, Aldermoor Health CentreDepartment of Primary Care and Population SciencesAldermoor CloseSouthamptonHampshireUKSO16 5ST
| | - Jessica Price
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Sophie Scott
- University of Southampton, Aldermoor Health CentreDepartment of Primary Care and Population SciencesAldermoor CloseSouthamptonHampshireUKSO16 5ST
| | - Brian D Nicholson
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Beth Stuart
- University of SouthamptonPrimary Care and Population Sciences, Faculty of MedicineSouthamptonUKSO16 5ST
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Helen Allott
- Liverpool School of Tropical MedicineCentre for Maternal and Newborn HealthPembroke PlLiverpoolUKL3 5QA
| | - Vincent Mubangizi
- Mbarara University of Science and Technology (MUST)Family medicine and community practiceMUST, PLOT 10‐18, KABALE ROADMbararaUganda1410, Mbarara
| | - Alexandre Dumont
- Institut de recherche pour le développement, Paris Descartes UniversityUMR 196 CEPEDFaculté de Pharmacie, 4 avenue de l?ObservatoireParisFrance75006
| | - Anthony Harnden
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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Kimario FF, Festo C, Shabani J, Mrisho M. Determinants of Home Delivery among Women Aged 15-24 Years in Tanzania. Int J MCH AIDS 2020; 9:191-199. [PMID: 32431962 PMCID: PMC7226705 DOI: 10.21106/ijma.361] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The United Nation's Sustainable Development Goal number 3 aims at reducing the maternal mortality rate by less than 70/100,000 live births globally and 216/100,000 live births in developing regions by 2030. Despite several interventions in Tanzania, maternal mortality has increased from 454/100,000 live births in 2010 to 556/100,000 live births in 2015. Home delivery and maternal young age contribute to maternal deaths. Reducing home deliveries among women aged 15-24 years may likely decrease the prevalence of maternal deaths in Tanzania. This study investigated the determinants of home delivery among women aged 15- 24 years in rural and mainland districts of Tanzania. METHODS This study uses a mixed-methods approach using data collected as part of the evaluation of government and UNICEF interventions in 13 districts of Tanzania mainland from October and November 2011. Results from the secondary analysis were supplemented by qualitative data collected between February and April 2019 from four rural districts: Bagamoyo, Tandahimba, Magu, and Moshi. RESULTS A total of 409 adolescents and young women who delivered one year before the quantitative data collection were included in the final analysis. A quarter of them gave birth at home. Having at least four antenatal care (ANC) visits (OR=0.23, 95% CI: 0.12-0.41, p<0.01), planning place of delivery (OR=0.22, 95% CI: 0.14-0.36 p<0.01), and knowledge of the danger signs during pregnancy (OR=0.36, 95% CI: 0.22-0.57, p<0.01) were significantly associated with the place of delivery. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS Maternal level of education, number of ANC visits attended, planned place of delivery, and knowledge of danger signs during pregnancy were the determinants of the choice of place of delivery among women aged 15-24 years in Tanzania. Understanding these risk factors is important in designing programs and interventions to reduce maternal deaths from women of this age group which contributes about 18% of all maternal deaths in Tanzania.
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Affiliation(s)
- Florence F Kimario
- Nelson Mandela African Institute of Science and Technology in Collaboration with Ifakara Health Institute. P.O. Box 447, Arusha, Tanzania.,Kilimanjaro Christian Medical Centre, (KCMC), P.O. BOX 3010, Moshi, Tanzania
| | - Charles Festo
- Ifakara Health Institute, Department of Health System and Impact Evaluation and Policy, P.O. Box 78373 Dar es Salaam, Tanzania
| | - Josephine Shabani
- Ifakara Health Institute, Department of Health System and Impact Evaluation and Policy, P.O. Box 78373 Dar es Salaam, Tanzania
| | - Mwifadhi Mrisho
- Ifakara Health Institute, Department of Health System and Impact Evaluation and Policy, P.O. Box 78373 Dar es Salaam, Tanzania
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Iverson KR, Svensson E, Sonderman K, Barthélemy EJ, Citron I, Vaughan KA, Powell BL, Meara JG, Shrime MG. Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries. Int J Health Policy Manag 2019; 8:521-537. [PMID: 31657175 PMCID: PMC6815989 DOI: 10.15171/ijhpm.2019.43] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services. Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates. Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study. Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.
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Affiliation(s)
- Katherine R Iverson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,General Surgery Department, University of California Davis Medical Center, Sacramento, CA, USA
| | - Emma Svensson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Lund University, Lund, Sweden
| | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Kerry A Vaughan
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany L Powell
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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20
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Atuheire EB, Opio DN, Kadobera D, Ario AR, Matovu JKB, Harris J, Bulage L, Nakiganda B, Tumwesigye NM, Zhu BP, Kaharuza F. Spatial and temporal trends of cesarean deliveries in Uganda: 2012-2016. BMC Pregnancy Childbirth 2019; 19:132. [PMID: 30991975 PMCID: PMC6469217 DOI: 10.1186/s12884-019-2279-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 04/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background Cesarean section (CS) is an important intervention in complicated births when the safety of the mother or baby is compromised. Despite worldwide concerns about the overutilization of CS in recent years, many African women and their newborns still die because of limited or no access to CS services. We evaluated temporal and spatial trends in CS births in Uganda and modeled future trends to inform programming. Methods We performed secondary analysis of total births data from the Uganda National Health Management Information System (HMIS) reports during 2012–2016. We reviewed data from 3461 health facilities providing basic, essential obstetric and emergency obstetric care services in all 112 districts. We defined facility-based CS rate as the proportion of cesarean deliveries among total live births in facilities, and estimated the population-based CS rate using the total number of cesarean deliveries as a proportion of annual expected births (including facility-based and non-facility-based) for each district. We predicted CS rates for 2021 using Generalised Linear Models with Poisson family, Log link and Unbiased Sandwich Standard errors. We used cesarean deliveries as the dependent variable and calendar year as the independent variable. Results Cesarean delivery rates increased both at facility and population levels in Uganda. Overall, the CS rate for live births at facilities was 9.9%, increasing from 8.5% in 2012 to 11% in 2016. The overall population-based CS rate was 4.7%, and increased from 3.2 to 5.9% over the same period. Health Centre IV level facilities had the largest annual rate of increase in CS rate between 2012 and 2016. Among all 112 districts, 80 (72%) had a population CS rate below 5%, while 38 (34%) had a CS rate below 1% over the study period. Overall, Uganda’s facility-based CS rate is projected to increase by 36% (PRR 1.36, 95% CI 1.35–1.36) in 2021 while the population-based CS rate is estimated to have doubled (PRR 2.12, 95% CI 2.11–2.12) from the baseline in 2016. Conclusion Cesarean deliveries are increasing in Uganda. Health center IVs saw the largest increases in CS, and while there was regional heterogeneity in changes in CS rates, utilization of CS services is inadequate in most districts. We recommend expansion of CS services to improve availability.
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Affiliation(s)
- Emily B Atuheire
- Uganda Public Health Fellowship Program, P.O. Box 7272, Kampala, Uganda. .,Reproductive Health Division, Ministry of Health, Kampala, Uganda.
| | - Denis Nixon Opio
- Uganda Public Health Fellowship Program, P.O. Box 7272, Kampala, Uganda
| | - Daniel Kadobera
- Uganda Public Health Fellowship Program, P.O. Box 7272, Kampala, Uganda
| | - Alex R Ario
- Uganda Public Health Fellowship Program, P.O. Box 7272, Kampala, Uganda
| | | | - Julie Harris
- US Centers for Disease Control and Prevention, Atlanta, USA
| | - Lilian Bulage
- Uganda Public Health Fellowship Program, P.O. Box 7272, Kampala, Uganda.,African Field Epidemiology Network, Kampala, Uganda
| | | | | | - Bao-Ping Zhu
- US Centers for Disease Control and Prevention, Kampala, Uganda
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21
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Yorlets RR, Iverson KR, Leslie HH, Gage AD, Roder-DeWan S, Nsona H, Shrime MG. Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi. BMJ Glob Health 2019; 4:e000930. [PMID: 30997159 PMCID: PMC6441245 DOI: 10.1136/bmjgh-2018-000930] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 11/14/2018] [Accepted: 12/13/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women's choice of delivery facility. METHODS A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion. RESULTS Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women. CONCLUSION For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.
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Affiliation(s)
- Rachel R Yorlets
- Department of Plastic & Oral Surgery, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine R Iverson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Anna Davies Gage
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Sanam Roder-DeWan
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Humphreys Nsona
- Integrated Management of Childhood Illnesses (IMCI), Ministry of Health, Lilongwe, Malawi
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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22
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Conlon CM, Serbanescu F, Marum L, Healey J, LaBrecque J, Hobson R, Levitt M, Kekitiinwa A, Picho B, Soud F, Spigel L, Steffen M, Velasco J, Cohen R, Weiss W. Saving Mothers, Giving Life: It Takes a System to Save a Mother (Republication). GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:20-40. [PMID: 30926736 PMCID: PMC6538123 DOI: 10.9745/ghsp-d-19-00092] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/11/2018] [Indexed: 11/21/2022]
Abstract
A multi-partner effort in Uganda and Zambia employed a districtwide health systems strengthening approach, with supply- and demand-side interventions, to address timely use of appropriate, quality maternity care. Between 2012 and 2016, maternal mortality declined by approximately 40% in both partnership-supported facilities and districts in each country. This experience has useful lessons for other low-resource settings. Background: Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public–private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. Implementation: The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. Results: Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (−13% in Uganda and −36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. Conclusion: A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.
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Affiliation(s)
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence Marum
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired
| | - Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia
| | - Jonathan LaBrecque
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Reeti Hobson
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
| | - Marta Levitt
- Bureau for Global Health, U.S. Agency for International Development and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria
| | | | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fatma Soud
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now an independent consultant, Gainesville, FL, USA
| | - Lauren Spigel
- ICF, Fairfax, VA, USA. Now with Ariadne Labs, Boston, MA, USA
| | - Mona Steffen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
| | - Jorge Velasco
- U.S. Agency for International Development, Papua, New Guinea
| | - Robert Cohen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - William Weiss
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
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23
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Serbanescu F, Clark TA, Goodwin MM, Nelson LJ, Boyd MA, Kekitiinwa AR, Kaharuza F, Picho B, Morof D, Blanton C, Mumba M, Komakech P, Carlosama F, Schmitz MM, Conlon CM. Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S27-S47. [PMID: 30867208 PMCID: PMC6519676 DOI: 10.9745/ghsp-d-18-00428] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/28/2019] [Indexed: 01/09/2023]
Abstract
Through district system strengthening, integrated services, and community engagement interventions, the Saving Mothers, Giving Life initiative increased emergency obstetric care coverage and access to, and demand for, improved quality of care that led to rapid declines in district maternal and perinatal mortality. Significant reductions in intrapartum stillbirth rate and maternal mortality ratios around the time of birth attest to the success of the initiative. Background: Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions. Methods: SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities. Results: Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country. Conclusions: MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths.
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Affiliation(s)
- Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Thomas A Clark
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mary M Goodwin
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lisa J Nelson
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Mary Adetinuke Boyd
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Frank Kaharuza
- HIV Health Office, U.S. Agency for International Development, Kampala, Uganda
| | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Diane Morof
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.,U.S. Public Health Service Commissioned Corps, Rockville, MD, USA
| | - Curtis Blanton
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Maybin Mumba
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Patrick Komakech
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Fernando Carlosama
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michelle M Schmitz
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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24
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Johns B, Hangoma P, Atuyambe L, Faye S, Tumwine M, Zulu C, Levitt M, Tembo T, Healey J, Li R, Mugasha C, Serbanescu F, Conlon CM. The Costs and Cost-Effectiveness of a District-Strengthening Strategy to Mitigate the 3 Delays to Quality Maternal Health Care: Results From Uganda and Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S104-S122. [PMID: 30867212 PMCID: PMC6519668 DOI: 10.9745/ghsp-d-18-00429] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/27/2019] [Indexed: 11/15/2022]
Abstract
A comprehensive district-strengthening approach to address maternal and newborn health was estimated to cost US$177 per life-year gained in Uganda and $206 per life-year gained in Zambia. The approach represents a very cost-effective health investment compared to GDP per capita. The primary objective of this study was to estimate the costs and the incremental cost-effectiveness of maternal and newborn care associated with the Saving Mothers, Giving Life (SMGL) initiative—a comprehensive district-strengthening approach addressing the 3 delays associated with maternal mortality—in Uganda and Zambia. To assess effectiveness, we used a before-after design comparing facility outcome data from 2012 (before) and 2016 (after). To estimate costs, we used unit costs collected from comparison districts in 2016 coupled with data on health services utilization from 2012 in SMGL-supported districts to estimate the costs before the start of SMGL. We collected data from health facilities, ministerial health offices, and implementing partners for the year 2016 in 2 SMGL-supported districts in each country and in 3 comparison non-SMGL districts (2 in Zambia, 1 in Uganda). Incremental costs for maternal and newborn health care per SMGL-supported district in 2016 was estimated to be US$845,000 in Uganda and $760,000 in Zambia. The incremental cost per delivery was estimated to be $38 in Uganda and $95 in Zambia. For the districts included in this study, SMGL maternal and newborn health activities were associated with approximately 164 deaths averted in Uganda and 121 deaths averted in Zambia in 2016 compared to 2012. In Uganda, the cost per death averted was $10,311, or $177 per life-year gained. In Zambia, the cost per death averted was $12,514, or $206 per life-year gained. The SMGL approach can be very cost-effective, with the cost per life-year gained as a percentage of the gross domestic product (GDP) being 25.6% and 16.4% in Uganda and Zambia, respectively. In terms of affordability, the SMGL approach could be paid for by increasing health spending from 7.3% to 7.5% of GDP in Uganda and from 5.4% to 5.8% in Zambia.
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Affiliation(s)
- Benjamin Johns
- International Development Division, Abt Associates Inc., Bethesda, MD, USA.
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Lynn Atuyambe
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sophie Faye
- International Development Division, Abt Associates Inc., Bethesda, MD, USA
| | - Mark Tumwine
- Uganda Country Office, U.S. Centers for Disease Control and Prevention, Entebbe, Uganda
| | - Collen Zulu
- U.S. Agency for International Development, Lusaka, Zambia
| | - Marta Levitt
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA, and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria
| | - Tannia Tembo
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia
| | - Rui Li
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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25
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Serbanescu F, Goodwin MM, Binzen S, Morof D, Asiimwe AR, Kelly L, Wakefield C, Picho B, Healey J, Nalutaaya A, Hamomba L, Kamara V, Opio G, Kaharuza F, Blanton C, Luwaga F, Steffen M, Conlon CM. Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S48-S67. [PMID: 30867209 PMCID: PMC6519679 DOI: 10.9745/ghsp-d-18-00343] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 01/29/2019] [Indexed: 11/24/2022]
Abstract
The Saving Mothers, Giving Life initiative used 3 coordinated approaches to reduce
maternal deaths resulting from a delay in deciding to seek health care, known as the
“first delay”: (1) promoting safe motherhood messages and facility delivery
using radio, theater, and community engagement; (2) encouraging birth preparedness and
increasing demand for facility delivery through community outreach worker visits; and (3)
providing clean delivery kits and transportation vouchers to reduce financial barriers for
facility delivery. These approaches can be adapted in other low-resource settings to
reduce maternal and perinatal mortality. Saving Mothers, Giving Life (SMGL), a 5-year initiative implemented in selected districts
in Uganda and Zambia, was designed to reduce deaths related to pregnancy and childbirth by
targeting the 3 delays to receiving appropriate care at birth. While originally the
“Three Delays” model was designed to focus on curative services that
encompass emergency obstetric care, SMGL expanded its application to primary and secondary
prevention of obstetric complications. Prevention of the “first delay”
focused on addressing factors influencing the decision to seek delivery care at a health
facility. Numerous factors can contribute to the first delay, including a lack of birth
planning, unfamiliarity with pregnancy danger signs, poor perceptions of facility care,
and financial or geographic barriers. SMGL addressed these barriers through community
engagement on safe motherhood, public health outreach, community workers who identified
pregnant women and encouraged facility delivery, and incentives to deliver in a health
facility. SMGL used qualitative and quantitative methods to describe intervention
strategies, intervention outcomes, and health impacts. Partner reports, health facility
assessments (HFAs), facility and community surveillance, and population-based mortality
studies were used to document activities and measure health outcomes in SMGL-supported
districts. SMGL's approach led to unprecedented community outreach on safe motherhood
issues in SMGL districts. About 3,800 community health care workers in Uganda and 1,558 in
Zambia were engaged. HFAs indicated that facility deliveries rose significantly in SMGL
districts. In Uganda, the proportion of births that took place in facilities rose from
45.5% to 66.8% (47% increase); similarly, in Zambia SMGL districts,
facility deliveries increased from 62.6% to 90.2% (44% increase). In
both countries, the proportion of women delivering in facilities equipped to provide
emergency obstetric and newborn care also increased (from 28.2% to 41.0% in
Uganda and from 26.0% to 29.1% in Zambia). The districts documented declines
in the number of maternal deaths due to not accessing facility care during pregnancy,
delivery, and the postpartum period in both countries. This reduction played a significant
role in the decline of the maternal mortality ratio in SMGL-supported districts in Uganda
but not in Zambia. Further work is needed to sustain gains and to eliminate preventable
maternal and perinatal deaths.
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Affiliation(s)
- Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Mary M Goodwin
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Susanna Binzen
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Diane Morof
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.,U.S. Public Health Service Commissioned Corps, Rockville, MD, USA
| | - Alice R Asiimwe
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Laura Kelly
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA. Now with Deloitte Consulting, LLP, Atlanta, GA, USA
| | | | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia
| | - Agnes Nalutaaya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Leoda Hamomba
- Division of Global HIV and TB, Centers for Disease Control and Prevention-Zambia, Lusaka, Zambia
| | - Vincent Kamara
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Gregory Opio
- Infectious Diseases Institute, Makerere University, Kibaale, Uganda
| | - Frank Kaharuza
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Curtis Blanton
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Fredrick Luwaga
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Mona Steffen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
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Schmitz MM, Serbanescu F, Kamara V, Kraft JM, Cunningham M, Opio G, Komakech P, Conlon CM, Goodwin MM. Did Saving Mothers, Giving Life Expand Timely Access to Lifesaving Care in Uganda? A Spatial District-Level Analysis of Travel Time to Emergency Obstetric and Newborn Care. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S151-S167. [PMID: 30867215 PMCID: PMC6519675 DOI: 10.9745/ghsp-d-18-00366] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 11/13/2018] [Indexed: 12/31/2022]
Abstract
A spatial analysis of facility accessibility, taking into account road networks and environmental constraints on travel, suggests that the Saving Mothers, Giving Life (SMGL) initiative increased access to emergency obstetric and neonatal care in SMGL-supported districts in Uganda. Spatial travel-time analyses can inform policy and program efforts targeting underserved populations in conjunction with the geographic distribution of maternity services. Introduction: Interventions for the Saving Mothers, Giving Life (SMGL) initiative aimed to ensure all pregnant women in SMGL-supported districts have timely access to emergency obstetric and newborn care (EmONC). Spatial travel-time analyses provide a visualization of changes in timely access. Methods: We compared travel-time estimates to EmONC health facilities in SMGL-supported districts in western Uganda in 2012, 2013, and 2016. To examine EmONC access, we analyzed a categorical variable of travel-time duration in 30-minute increments. Data sources included health facility assessments, geographic coordinates of EmONC facilities, geolocated population estimates of women of reproductive age (WRA), and other road network and geographic sources. Results: The number of EmONC facilities almost tripled between 2012 and 2016, increasing geographic access to EmONC. Estimated travel time to EmONC facilities declined significantly during the 5-year period. The proportion of WRA able to access any EmONC and comprehensive EmONC (CEmONC) facility within 2 hours by motorcycle increased by 18% (from 61.3% to 72.1%, P < .01) and 37% (from 51.1% to 69.8%, P < .01), respectively from baseline to 2016. Similar increases occurred among WRA accessing EmONC and CEmONC respectively if 4-wheeled vehicles (14% and 31% increase, P < .01) could be used. Increases in timely access were also substantial for nonmotorized transportation such as walking and/or bicycling. Conclusions: Largely due to the SMGL-supported expansion of EmONC capability, timely access to EmONC significantly improved. Our analysis developed a geographic outline of facility accessibility using multiple types of transportation. Spatial travel-time analyses, along with other EmONC indicators, can be used by planners and policy makers to estimate need and target underserved populations to achieve further gains in EmONC accessibility. In addition to increasing the number and geographic distribution of EmONC facilities, complementary efforts to make motorized transportation available are necessary to achieve meaningful increases in EmONC access.
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Affiliation(s)
- Michelle M Schmitz
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Vincent Kamara
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Joan Marie Kraft
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Marc Cunningham
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Gregory Opio
- Infectious Diseases Institute, Makerere University, Kibaale, Uganda
| | - Patrick Komakech
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | | | - Mary M Goodwin
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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Ngoma-Hazemba A, Hamomba L, Silumbwe A, Munakampe MN, Soud F. Community Perspectives of a 3-Delays Model Intervention: A Qualitative Evaluation of Saving Mothers, Giving Life in Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S139-S150. [PMID: 30867214 PMCID: PMC6519671 DOI: 10.9745/ghsp-d-18-00287] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 10/25/2018] [Indexed: 11/16/2022]
Abstract
While the Saving Mothers, Giving Life's health systems strengthening approach reduced maternal mortality, respondents still reported significant barriers accessing maternal health services. More research is needed to understand the necessary intervention package to affect system-wide change. Background: Saving Mothers, Giving Life (SMGL), a health systems strengthening approach based on the 3-delays model, aimed to reduce maternal and perinatal mortality in 6 districts in Zambia between 2012 and 2017. By 2016, the maternal mortality ratio in SMGL-supported districts declined by 41% compared to its level at the beginning of SMGL—from 480 to 284 deaths per 100,000 live births. The 10.5% annual reduction between the baseline and 2016 was about 4.5 times higher than the annual reduction rate for sub-Saharan Africa and about 2.6 times higher than the annual reduction estimated for Zambia as a whole. Objectives: While outcome measures demonstrate reductions in maternal and perinatal mortality, this qualitative endline evaluation assessed community perceptions of the SMGL intervention package, including (1) messaging about use of maternal health services, (2) access to maternal health services, and (3) quality improvement of maternal health services. Methods: We used purposive sampling to conduct semistructured in-depth interviews with women who delivered at home (n=20), women who delivered in health facilities (n=20), community leaders (n=8), clinicians (n=15), and public health stakeholders (n=15). We also conducted 12 focus group discussions with a total of 93 men and women from the community and Safe Motherhood Action Group members. Data were coded and analyzed using NVivo version 10. Results: Delay 1: Participants were receptive to SMGL's messages related to early antenatal care, health facility-based deliveries, and involving male partners in pregnancy and childbirth. However, top-down pressure to increase health facility deliveries led to unintended consequences, such as community-imposed penalty fees for home deliveries. Delay 2: Community members perceived some improvements, such as refurbished maternity waiting homes and dedicated maternity ambulances, but many still had difficulty reaching the health facilities in time to deliver. Delay 3: SMGL's clinician trainings were considered a strength, but the increased demand for health facility deliveries led to human resource challenges, which affected perceived quality of care. Conclusion and Lessons Learned: While SMGL's health systems strengthening approach aimed to reduce challenges related to the 3 delays, participants still reported significant barriers accessing maternal and newborn health care. More research is needed to understand the necessary intervention package to affect system-wide change.
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Affiliation(s)
- Alice Ngoma-Hazemba
- Department of Community and Family Medicine, School of Public Health, University of Zambia, Lusaka, Zambia.
| | - Leoda Hamomba
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Adam Silumbwe
- Department of Community and Family Medicine, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Margarate Nzala Munakampe
- Department of Community and Family Medicine, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Fatma Soud
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now an independent consultant, Gainesville, FL, USA
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Sensalire S, Isabirye P, Karamagi E, Byabagambi J, Rahimzai M, Calnan J. Saving Mothers, Giving Life Approach for Strengthening Health Systems to Reduce Maternal and Newborn Deaths in 7 Scale-up Districts in Northern Uganda. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S168-S187. [PMID: 30867216 PMCID: PMC6519678 DOI: 10.9745/ghsp-d-18-00263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/21/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Uganda's maternal and newborn mortality remains high at 336 maternal deaths per 100,000 live births and 27 newborn deaths per 1,000 live births. The Saving Mothers, Giving Life (SMGL) initiative launched in 2012 by the U.S. government and partners, with funding from the U.S. President's Emergency Plan for AIDS Relief, focused on reducing maternal and newborn deaths in Uganda and Zambia by addressing the 3 major delays associated with maternal and newborn deaths. In Uganda, SMGL was implemented in 2 phases. Phase 1 was a proof-of-concept demonstration in 4 districts of Western Uganda (2012 to 2014). Phase 2 involved scaling up best practices from Phase 1 to new sites in Northern Uganda (2014 to 2017). PROGRAM DESCRIPTION The SMGL project used a systems-strengthening approach with quality improvement (QI) methods applied in targeted facilities with high client volume and high maternal and perinatal deaths. A QI team was formed in each facility to address the building blocks of the World Health Organization's health systems framework. A community component was integrated within the facility-level QI work to create demand for services. Above-site health systems functions were strengthened through engagement with district management teams. RESULTS The institutional maternal mortality ratio in the intervention facilities decreased by 20%, from 138 to 109 maternal deaths per 100,000 live births between December 2014 and December 2016. The institutional neonatal mortality rate was reduced by 30%, while the fresh stillbirth rate declined by 47% and the perinatal mortality rate by 26%. During this period, over 90% of pregnant women were screened for hypertension and 70% for syphilis during antenatal care services. All women received a uterotonic drug to prevent postpartum hemorrhage during delivery, and about 90% of the women were monitored using a partograph during labor. CONCLUSIONS Identifying barriers at each step of delivering care and strengthening health systems functions using QI teams increase partcipation, resulting in improved care for mothers and newborns.
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Conlon CM, Serbanescu F, Marum L, Healey J, LaBrecque J, Hobson R, Levitt M, Kekitiinwa A, Picho B, Soud F, Spigel L, Steffen M, Velasco J, Cohen R, Weiss W. Saving Mothers, Giving Life: It Takes a System to Save a Mother. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S6-S26. [PMID: 30867207 PMCID: PMC6519673 DOI: 10.9745/ghsp-d-18-00427] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/11/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public-private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. IMPLEMENTATION The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. RESULTS Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (-13% in Uganda and -36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. CONCLUSION A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.
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Affiliation(s)
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence Marum
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired
| | - Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia
| | - Jonathan LaBrecque
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Reeti Hobson
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
| | - Marta Levitt
- Bureau for Global Health, U.S. Agency for International Development and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria
| | | | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fatma Soud
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now an independent consultant, Gainesville, FL, USA
| | - Lauren Spigel
- ICF, Fairfax, VA, USA. Now with Ariadne Labs, Boston, MA, USA
| | - Mona Steffen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
| | - Jorge Velasco
- U.S. Agency for International Development, Papua, New Guinea
| | - Robert Cohen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - William Weiss
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
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Scott NA, Henry EG, Kaiser JL, Mataka K, Rockers PC, Fong RM, Ngoma T, Hamer DH, Munro-Kramer ML, Lori JR. Factors affecting home delivery among women living in remote areas of rural Zambia: a cross-sectional, mixed-methods analysis. Int J Womens Health 2018; 10:589-601. [PMID: 30349403 PMCID: PMC6181475 DOI: 10.2147/ijwh.s169067] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Access to skilled care and facilities with capacity to provide emergency obstetric and newborn care is critical to reducing maternal mortality. In rural areas of Zambia, 42% of women deliver at home, suggesting persistent challenges for women in seeking, reaching, and receiving quality maternity care. This study assessed the determinants of home delivery among remote women in rural Zambia. METHODS A household survey was administered to a random selection of recently delivered women living 10 km or more from their catchment area health facility in 40 sites. A subset of respondents completed an in-depth interview. Multiple regression and content analysis were used to analyze the data. RESULTS The final sample included 2,381 women, of which 240 also completed an interview. Households were a median of 12.8 km (interquartile range 10.9, 16.2) from their catchment area health facility. Although 1% of respondents intended to deliver at home, 15.3% of respondents actually delivered at home and 3.2% delivered en route to a facility. Respondents cited shorter than expected labor, limited availability and high costs of transport, distance, and costs of required supplies as reasons for not delivering at a health facility. After adjusting for confounders, women with a first pregnancy (adjusted OR [aOR]: 0.1, 95% CI: 0.1, 0.2) and who stayed at a maternity waiting home (MWH) while awaiting delivery were associated with reduced odds of home delivery (aOR 0.1, 95% CI: 0.1, 0.2). Being over 35 (aOR 1.3, 95% CI: 0.9, 1.9), never married (aOR 2.1, 95% CI: 1.2, 3.7), not completing the recommended four or more antenatal visits (aOR 2.0, 95% CI: 1.5, 2.5), and not living in districts exposed to a large-scale maternal health program (aOR 3.2, 95% CI: 2.3, 4.5) were significant predictors of home delivery. After adjusting for confounders, living nearer to the facility (9.5-10 km) was not associated with reduced odds of home delivery, though the CIs suggest a trend toward significance (aOR 0.7, 95% CI: 0.4, 1.1). CONCLUSION Findings highlight persistent challenges facing women living in remote areas when it comes to realizing their intentions regarding delivery location. Interventions to reduce home deliveries should potentially target not only those residing farthest away, but multigravida women, those who attend fewer antenatal visits, and those who do not utilize MWHs.
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Affiliation(s)
- Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Elizabeth G Henry
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | | | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Michelle L Munro-Kramer
- Department of Health Behavior & Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Jody R Lori
- Department of Health Behavior & Biological Sciences, University of Michigan, School of Nursing, Ann Arbor, MI USA
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Thomas LM, D'Ambruoso L, Balabanova D. Verbal autopsy in health policy and systems: a literature review. BMJ Glob Health 2018; 3:e000639. [PMID: 29736271 PMCID: PMC5935163 DOI: 10.1136/bmjgh-2017-000639] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/18/2018] [Accepted: 02/08/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction Estimates suggest that one in two deaths go unrecorded globally every year in terms of medical causes, with the majority occurring in low and middle-income countries (LMICs). This can be related to low investment in civil registration and vital statistics (CRVS) systems. Verbal autopsy (VA) is a method that enables identification of cause of death where no other routine systems are in place and where many people die at home. Considering the utility of VA as a pragmatic, interim solution to the lack of functional CRVS, this review aimed to examine the use of VA to inform health policy and systems improvements. Methods A literature review was conducted including papers published between 2010 and 2017 according to a systematic search strategy. Inclusion of papers and data extraction were assessed by three reviewers. Thereafter, thematic analysis and narrative synthesis were conducted in which evidence was critically examined and key themes were identified. Results Twenty-six papers applying VA to inform health policy and systems developments were selected, including studies in 15 LMICs in Africa, Asia, the Middle East and South America. The majority of studies applied VA in surveillance sites or programmes actively engaging with decision makers and governments in different ways and to different degrees. In the papers reviewed, the value of continuous collection of cause of death data, supplemented by social and community-based investigations and underpinned by electronic data innovations, to establish a robust and reliable evidence base for health policies and programmes was clearly recognised. Conclusion VA has considerable potential to inform policy, planning and measurement of progress towards goals and targets. Working collaboratively at sub-national, national and international levels facilitates data collection, aggregation and dissemination linked to routine information systems. When used in partnerships between researchers and authorities, VA can help to close critical information gaps and guide policy development, implementation, evaluation and investment in health systems.
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Affiliation(s)
- Lisa-Marie Thomas
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Lucia D'Ambruoso
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
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Newell R, Spillman I, Newell ML. The Use of Facilities for Labor and Delivery: The Views of Women in Rural Uganda. J Public Health Afr 2017; 8:592. [PMID: 28890773 PMCID: PMC5585585 DOI: 10.4081/jphia.2017.592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 06/13/2017] [Accepted: 06/14/2017] [Indexed: 11/23/2022] Open
Abstract
The aim of the paper is to explore factors associated with home or hospital delivery in rural Uganda. Qualitative interviews with recently-delivered women in rural Uganda and statistical analysis of data from the 2011 Ugandan Demographic and Health Survey (DHS) to assess the association between socio-demographic and cultural factors and delivery location in multivariable regression models. In the DHS, 61.7% (of 4907) women had a facility-based delivery (FBD); in adjusted analyses, FBD was associated with an urban setting [adjusted odds ratio (aOR) 3.38, 95% confidence interval (CI) 2.66 to 4.28)], the upper wealth quintile (aOR: 3.69, 95%CI 2.79 to 3.87) and with secondary education (aOR: 3.07, 95%CI 2.37 to 3.96). In interviews women quoted costs and distance as barriers to FBD. Other factors reported in interviews to be associated with FBD included family influence, perceived necessity of care (weak women needed FBD), and the reputation of the facility (women bypassed local facilities to deliver at better hospitals). Choosing a FBD is a complex decision and education around the benefits of FBD should be combined with interventions designed to remove barriers to FBD.
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