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Mayrink J, Reis ZSN. Pre-eclampsia in low and middle-income settings: What are the barriers to improving perinatal outcomes and evidence-based recommendations? Int J Gynaecol Obstet 2024; 164:33-39. [PMID: 37329226 DOI: 10.1002/ijgo.14913] [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: 02/27/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To discuss the points that still challenge low- and middle-income countries (LMICs) and strategies that have been studied to help them overcome these issues. METHODS Narrative review addressing 20 years of articles concerning pre-eclampsia morbidity and mortality in LMICs. We summarized evidence-based strategies to overcome the challenges in order to reduce the pre-eclampsia impact on perinatal outcomes. RESULTS Pre-eclampsia is the first or second leading cause in the ranking of avoidable causes of maternal death, and approximately 16% of all maternal deaths are attributable to eclampsia and pre-eclampsia. Considering the social and economic contexts, it represents a major public health concern, and prevention and early detection of pre-eclampsia seem to be a major challenge. Reducing maternal mortality related to hypertensive disturbances depends on public policies to manage these preventable conditions. Early and continuous recognition of signs of severity related to hypertensive disorders during pregnancy and childbirth, self-monitoring of symptoms and blood pressure, as well as preventive approaches such as aspirin and calcium, and magnesium sulfate, are lifesaving procedures that have not yet reached a universal scale. CONCLUSION This review provides a vision of relevant points to support pregnant women in overcoming the constraints to healthcare access in LMICs, and strategies that can be applied in primary prenatal care units.
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Affiliation(s)
- Jussara Mayrink
- Federal University of Minas Gerais, Department of Obstetrics and Gynecology, Belo Horizonte, Brazil
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Thies SB, Bevan S, Wassall M, Shajan BK, Chowalloor L, Kenney L, Howard D. Evaluation of a novel biomechanics-informed walking frame, developed through a Knowledge Transfer Partnership between biomechanists and design engineers. BMC Geriatr 2023; 23:734. [PMID: 37957568 PMCID: PMC10642022 DOI: 10.1186/s12877-023-04443-7] [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: 02/12/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Walking aids such as walking frames offer support during walking, yet paradoxically, people who self-report using them remain more likely to fall than people who do not. Lifting of walking frames when crossing door thresholds or when turning has shown to reduce stability, and certain design features drive the need to lift (e.g. small, non-swivelling wheels at the front). To overcome shortfalls in design and provide better stability, biomechanists and industrial engineers engaged in a Knowledge Transfer Partnership to develop a novel walking frame that reduces the need for lifting during everyday tasks. This paper presents the results for the final prototype regarding stability, safety and other aspects of usability. METHODS Four studies were conducted that explored the prototype in relation to the current standard frame: a detailed gait lab study of 9 healthy older adults performing repeated trials for a range of everyday tasks provided mechanical measures of stability, a real-world study that involved 9 users of walking frames provided measures of body weight transfer and lifting events, two interview studies (5 healthcare professionals and 7 users of walking frames) elicited stakeholder perceptions regarding stability, safety and usability. RESULTS Analysis of healthy older adults using a standard walking frame and the prototype frame demonstrated that the prototype increases stability during performance of complex everyday tasks (p < 0.05). Similarly, gait assessments of walking frame users in their home environment showed that the prototype facilitated safer usage patterns and provided greater and more continuous body weight support. Interviews with healthcare professionals and users showed that the prototype was perceived to be safe and effective and hence more usable. CONCLUSIONS The outcomes of the separate studies all support the same conclusion: the prototype is an improvement on the status quo, the typical front-wheeled Zimmer frame for indoor use which has not changed in design for decades. The significance of this work lies in the success of the Knowledge Transfer Partnership and in biomechanics-informed design leading to improvements, which in future may be applied to other walking aids, to benefit walking aid users by promoting safer, more stable use of their aid.
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Affiliation(s)
- Sibylle Brunhilde Thies
- Centre for Health Sciences Research, School of Health & Society, University of Salford, Brian Blatchford Building Room PO28, Salford, Greater Manchester, UK.
| | - Susan Bevan
- NRS Healthcare, Coalville, LE67 1UB, Leicestershire, UK
| | - Matthew Wassall
- Centre for Health Sciences Research, School of Health & Society, University of Salford, Brian Blatchford Building Room PO28, Salford, Greater Manchester, UK
| | - Blessy Kurissinkal Shajan
- Centre for Health Sciences Research, School of Health & Society, University of Salford, Brian Blatchford Building Room PO28, Salford, Greater Manchester, UK
| | - Lydia Chowalloor
- Centre for Health Sciences Research, School of Health & Society, University of Salford, Brian Blatchford Building Room PO28, Salford, Greater Manchester, UK
| | - Laurence Kenney
- Centre for Health Sciences Research, School of Health & Society, University of Salford, Brian Blatchford Building Room PO28, Salford, Greater Manchester, UK
| | - Dave Howard
- Centre for Health Sciences Research, School of Health & Society, University of Salford, Brian Blatchford Building Room PO28, Salford, Greater Manchester, UK
- School of Science, Engineering and Environment, University of Salford, Salford, Greater Manchester, UK
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Louart S, Hedible GB, Ridde V. Assessing the acceptability of technological health innovations in sub-Saharan Africa: a scoping review and a best fit framework synthesis. BMC Health Serv Res 2023; 23:930. [PMID: 37649024 PMCID: PMC10469465 DOI: 10.1186/s12913-023-09897-4] [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: 04/11/2022] [Accepted: 08/10/2023] [Indexed: 09/01/2023] Open
Abstract
Acceptability is a key concept used to analyze the introduction of a health innovation in a specific setting. However, there seems to be a lack of clarity in this notion, both conceptually and practically. In low and middle-income countries, programs to support the diffusion of new technological tools are multiplying. They face challenges and difficulties that need to be understood with an in-depth analysis of the acceptability of these innovations. We performed a scoping review to explore the theories, methods and conceptual frameworks that have been used to measure and understand the acceptability of technological health innovations in sub-Saharan Africa. The review confirmed the lack of common definitions, conceptualizations and practical tools addressing the acceptability of health innovations. To synthesize and combine evidence, both theoretically and empirically, we then used the "best fit framework synthesis" method. Based on five conceptual and theoretical frameworks from scientific literature and evidence from 33 empirical studies, we built a conceptual framework in order to understand the acceptability of technological health innovations. This framework comprises 6 determinants (compatibility, social influence, personal emotions, perceived disadvantages, perceived advantages and perceived complexity) and two moderating factors (intervention and context). This knowledge synthesis work has also enabled us to propose a chronology of the different stages of acceptability.
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Affiliation(s)
- Sarah Louart
- Univ. Lille, CNRS, UMR 8019 - CLERSE - Centre Lillois d'Etudes Et de Recherches Sociologiques Et Economiques, 59000, Lille, France.
- ALIMA, the Alliance for International Medical Action, Dakar, Senegal.
| | | | - Valéry Ridde
- Université Paris Cité, IRD, INSERM, Ceped, 75006, Paris, France
- Institut de Santé Et Développement, Université Cheikh Anta Diop, Dakar, Sénégal
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Bright S, Moses F, Ridout A, Sam B, Momoh M, Goodhart V, Smart F, Mannah M, Issa S, Herm-Singh S, Reid F, Seed PT, Bunn J, Shennan A, Augustin K, Sandall J. Scale-up of a novel vital signs alert device to improve maternity care in Sierra Leone: a mixed methods evaluation of adoption. Reprod Health 2023; 20:6. [PMID: 36609353 PMCID: PMC9817393 DOI: 10.1186/s12978-022-01551-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/13/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The CRADLE (Community blood pressure monitoring in Rural Africa: Detection of underLying pre-Eclampsia) Vital Signs Alert device-designed specifically to improve maternity care in low resource settings-had varying impact when trialled in different countries. To better understand the contextual factors that may contribute to this variation, this study retrospectively evaluated the adoption of CRADLE, during scale-up in Sierra Leone. METHODS This was a mixed methods study. A quantitative indicator of adoption (the proportion of facilities trained per district) was calculated from existing training records, then focus groups were held with 'CRADLE Champions' in each district (n = 32), to explore adoption qualitatively. Template Analysis was used to deductively interpret qualitative data, guided by the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) Framework. FINDINGS Substantial but non-significant variation was found in the proportion of facilities trained in each district (range 59-90%) [X2 (7, N = 8) = 10.419, p = 0.166]. Qualitative data identified complexity in two NASSS domains that may have contributed to this variation: 'the technology' (for example, charging issues, difficulty interpreting device output and concerns about ongoing procurement) and 'the organisation' (for example, logistical barriers to implementing training, infighting and high staff turnover). Key strategies mentioned to mitigate against these issues included: transparent communication at all levels; encouraging localised adaptations during implementation (including the involvement of community leaders); and selecting Champions with strong soft skills (particularly conflict resolution and problem solving). CONCLUSIONS Complexity related to the technology and the organisational context were found to influence the adoption of CRADLE in Sierra Leone, with substantial inter-district variation. These findings emphasise the importance of gaining an in-depth understanding of the specific system and context in which a new healthcare technology is being implemented. This study has implications for the ongoing scale-up of CRADLE, and for those implementing or evaluating other health technologies in similar contexts.
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Affiliation(s)
- Sophie Bright
- grid.11835.3e0000 0004 1936 9262School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Francis Moses
- Reproductive Health and Family Planning, MoHS, Freetown, Sierra Leone.
| | - Alex Ridout
- grid.13097.3c0000 0001 2322 6764King’s College London (KCL), London, England
| | - Betty Sam
- Welbodi Partnership, Freetown, Sierra Leone
| | - Mariama Momoh
- grid.463455.50000 0004 1799 2069Ministry of Health and Sanitation (MoHS), Freetown, Sierra Leone
| | | | - Francis Smart
- Planning and Information, MoHS, Freetown, Sierra Leone
| | | | - Sattu Issa
- Reproductive Health and Family Planning, MoHS, Freetown, Sierra Leone
| | | | - Fiona Reid
- grid.13097.3c0000 0001 2322 6764Department of Population Health Sciences, KCL, London, England
| | - Paul T. Seed
- grid.13097.3c0000 0001 2322 6764Department of Women and Children’s Health, KCL, London, England
| | - James Bunn
- World Health Organization, Freetown, Sierra Leone
| | - Andrew Shennan
- grid.13097.3c0000 0001 2322 6764Department of Women and Children’s Health, KCL, London, England
| | - Katrin Augustin
- grid.13097.3c0000 0001 2322 6764School of Population Health and Environmental Sciences, KCL, London, England
| | - Jane Sandall
- grid.13097.3c0000 0001 2322 6764Women’s Health Academic Centre, KCL, London, England
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Dinh N, Agarwal S, Avery L, Ponnappan P, Chelangat J, Amendola P, Labrique A, Bartlett L. Implementation Outcomes Assessment of a Digital Clinical Support Tool for Intrapartum Care in Rural Kenya: Observational Analysis. JMIR Form Res 2022; 6:e34741. [PMID: 35723911 PMCID: PMC9253974 DOI: 10.2196/34741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/26/2022] Open
Abstract
Background iDeliver, a digital clinical support system for maternal and neonatal care, was developed to support quality of care improvements in Kenya. Objective Taking an implementation research approach, we evaluated the adoption and fidelity of iDeliver over time and assessed the feasibility of its use to provide routine Ministry of Health (MOH) reports. Methods We analyzed routinely collected data from iDeliver, which was implemented at the Transmara West Sub-County Hospital from December 2018 to September 2020. To evaluate its adoption, we assessed the proportion of actual facility deliveries that was recorded in iDeliver over time. We evaluated the fidelity of iDeliver use by studying the completeness of data entry by care providers during each stage of the labor and delivery workflow and whether the use reflected iDeliver’s envisioned function. We also examined the data completeness of the maternal and neonatal indicators prioritized by the Kenya MOH. Results A total of 1164 deliveries were registered in iDeliver, capturing 45.31% (1164/2569) of the facility’s deliveries over 22 months. This uptake of registration improved significantly over time by 6.7% (SE 2.1) on average in each quarter-year (P=.005), from 9.6% (15/157) in the fourth quarter of 2018 to 64% (235/367) in the third quarter of 2020. Across iDeliver’s workflow, the overall completion rate of all variables improved significantly by 2.9% (SE 0.4) on average in each quarter-year (P<.001), from 22.25% (257/1155) in the fourth quarter of 2018 to 49.21% (8905/18,095) in the third quarter of 2020. Data completion was highest for the discharge-labor summary stage (16,796/23,280, 72.15%) and lowest for the labor signs stage (848/5820, 14.57%). The completion rate of the key MOH indicators also improved significantly by 4.6% (SE 0.5) on average in each quarter-year (P<.001), from 27.1% (69/255) in the fourth quarter of 2018 to 83.75% (3346/3995) in the third quarter of 2020. Conclusions iDeliver’s adoption and data completeness improved significantly over time. The assessment of iDeliver’ use fidelity suggested that some features were more easily used because providers had time to enter data; however, there was low use during active childbirth, which is when providers are necessarily engaged with the woman and newborn. These insights on the adoption and fidelity of iDeliver use prompted the team to adapt the application to reflect the users’ culture of use and further improve the implementation of iDeliver.
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Affiliation(s)
- Nhi Dinh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Lisa Avery
- Centre for Global Public Health, University of Manitoba, Winnipeg, MB, Canada
| | | | | | | | - Alain Labrique
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Linda Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
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Shahil Feroz A, Afzal N, Seto E. Exploring digital health interventions for pregnant women at high risk for pre-eclampsia and eclampsia in low-income and-middle-income countries: a scoping review. BMJ Open 2022; 12:e056130. [PMID: 35135777 PMCID: PMC8830260 DOI: 10.1136/bmjopen-2021-056130] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To explore digital health interventions that have been used to support pregnant women at high risk for pre-eclampsia/eclampsia (HRPE/E) in low-income and middle-income countries (LMICs). DESIGN Scoping review. DATA SOURCE EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were searched between 1 January 2000 and 20 October 2020. ELIGIBILITY CRITERIA The review included original research studies that were published in English, involved pregnant women at HRPE/E and implemented digital health interventions for PE/E in LMICs. DATA EXTRACTION AND SYNTHESIS Two reviewers independently completed the data extraction for each of the 19 final articles. An inductive approach was used to thematically organise and summarise the results from the included articles. RESULTS A total of 19 publications describing 7 unique studies and 9 different digital health interventions were included. Most studies were conducted in South Asia and sub-Saharan Africa (n=16). Of nine unique digital health interventions, two served the purpose of predicting risk for adverse maternal health outcomes while seven focused on monitoring high-risk pregnant women for PE/E. Both of these purposes used mobile phone applications as interface to facilitate data collection, decision making, and communication between health workers and pregnant women. The review identified key functions of interventions including data collection, prediction of adverse maternal outcomes, integrated diagnostic and clinical decision support, and personal health tracking. The review reported three major outcomes: maternal health outcomes including maternal and neonatal morbidity and mortality (n=4); usability and acceptability including ease-of-use, and perceived usefulness, (n=5); and intervention feasibility and fidelity including accuracy of device, and intervention implementation (n=7). CONCLUSION Although the current evidence base shows some potential for the use of digital health interventions for PE/E, more prospective experimental and longitudinal studies are needed prior to recommending the use of digital health interventions for PE/E.
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Affiliation(s)
- Anam Shahil Feroz
- Community Health Sciences, Aga Khan University, Karachi, Pakistan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Noreen Afzal
- Dean's Office, The Aga Khan University Medical College Pakistan, Karachi, Sindh, Pakistan
| | - Emily Seto
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Global eHealth Innovation, University Health Network, Toronto, Ontario, Canada
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7
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Smith V, Kenny LC, Sandall J, Devane D, Noonan M. Physiological track-and-trigger/early warning systems for use in maternity care. Cochrane Database Syst Rev 2021; 9:CD013276. [PMID: 34515991 PMCID: PMC8436732 DOI: 10.1002/14651858.cd013276.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND A considerable challenge for maternity care providers is recognising clinical deterioration early in pregnant women. Professional bodies recommend the use of clinical assessment protocols or evaluation tools, commonly referred to as physiological track-and-trigger systems (TTS) or early warning systems (EWS), as a means of helping maternity care providers recognise actual or potential clinical deterioration early. TTS/EWS are clinician-administered (midwife, obstetrician), bedside physiological assessment protocols, charts or tools designed to record routinely assessed clinical parameters; that is, blood pressure, temperature, heart rate, urine output and mental/neurological alertness. In general, these systems involve the application of scores or alert indicators to the observed physiological parameters based on their prespecified limits of normality. The overall system score or alert limit is then used to assist the maternity care provider identify a need to escalate care. This, in turn, may allow for earlier intervention(s) to alter the course of the emerging critical illness and ultimately reduce or avoid mortality and morbidity sequelae. OBJECTIVES To evaluate the clinical- and cost-effectiveness of maternal physiological TTS/EWS on pregnancy, labour and birth, postpartum (up to 42 days) and neonatal outcomes. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (28 May 2021), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 June 2021), OpenGrey, the ProQuest Dissertations and Theses database (7 June 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials (RCTs), including cluster-RCTs, comparing physiological TTS/EWS with no system or another system. Participants were women who were pregnant or had given birth within the previous 42 days, at high risk and low risk for pregnancy, labour and birth, and postpartum complications. DATA COLLECTION AND ANALYSIS Two review authors (VS and MN) independently assessed all identified papers for inclusion and performed risk of bias assessments. Any discrepancies were resolved through discussion and consensus. Data extraction was also conducted independently by two review authors (VS and MN) and checked for accuracy. We used the summary odds ratio (OR) with 95% confidence intervals (CIs) to present the results for dichotomous data and the mean difference (MD) with 95% CI to present the results for continuous data. MAIN RESULTS We included two studies, a parallel RCT involving 700 women and a stepped-wedge cluster trial involving 536,233 women. Both studies were published in 2019, and both were conducted in low-resource settings. The interventions were the 'Saving Mothers Score' (SMS) and the CRADLE Vital Sign Alert (VSA) device, and both interventions were compared with standard care. Both studies had low or unclear risk of bias on all seven risk of bias criteria. Evidence certainty, assessed using GRADE, ranged from very low to moderate certainty, mainly due to other bias as well as inconsistency and imprecision. For women randomised to TTS/EWS compared to standard care there is probably little to no difference in maternal death (OR 0.80, 95% CI 0.30 to 2.11; 1 study, 536,233 participants; moderate-certainty evidence). Use of TTS/EWS compared to standard care may reduce total haemorrhage (OR 0.36, 95% CI 0.19 to 0.69; 1 study, 700 participants; low-certainty evidence). For women randomised to TTS/EWS compared to standard care there may be little to no difference in sepsis (OR 0.21, 95% CI 0.02 to 1.80; 1 study, 700 participants; low-certainty evidence), eclampsia (OR 1.50, 95% CI 0.74 to 3.03; 2 studies, 536,933 participants; low-certainty evidence) and HELLP (OR 0.21, 95% CI 0.01 to 4.40; 1 study, 700 participants; very low-certainty evidence), and probably little to no difference in maternal admission to the intensive care unit (ICU) (OR 0.78, 95% CI 0.53 to 1.15; 2 studies, 536,933 participants; moderate-certainty evidence). Use of TTS/EWS compared to standard care may reduce a woman's length of hospital stay (MD -1.21, 95% CI -1.78 to -0.64; 1 study, 700 participants; low-certainty evidence) but may result in little to no difference in neonatal death (OR 1.06, 95% CI 0.62 to 1.84; 1 study, 700 participants; low-certainty evidence). Cost-effectiveness measures were not measured in either of the two studies. AUTHORS' CONCLUSIONS: Use of TTS/EWS in maternity care may be helpful in reducing some maternal outcomes such as haemorrhage and maternal length of hospital stay, possibly through early identification of clinical deterioration and escalation of care. The evidence suggests that the use of TTS/EWS compared to standard care probably results in little to no difference in maternal death and may result in little to no difference in neonatal death. Both of the included studies were conducted in low-resource settings where the use of TTS/EWS might potentially confer a different effect to TTS/EWS use in high-resource settings. Further high-quality trials in high- and middle-resource settings, as well as in discrete populations of high- and low-risk women, are required.
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Affiliation(s)
- Valerie Smith
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Louise C Kenny
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Maria Noonan
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
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Giblin L, Vousden N, Nathan H, Gidiri F, Goudar S, Charantimath U, Sandall J, Seed PT, Chappell LC, Shennan AH. Effect of the CRADLE vital signs alert device intervention on referrals for obstetric haemorrhage in low-middle income countries: a secondary analysis of a stepped- wedge cluster-randomised control trial. BMC Pregnancy Childbirth 2021; 21:317. [PMID: 33882864 PMCID: PMC8061003 DOI: 10.1186/s12884-021-03796-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Obstetric haemorrhage is the leading cause of maternal death worldwide, 99% of which occur in low and middle income countries. The majority of deaths and adverse events are associated with delays in identifying compromise and escalating care. Management of severely compromised pregnant women may require transfer to tertiary centres for specialised treatment, therefore early recognition is vital for efficient management. The CRADLE vital signs alert device accurately measures blood pressure and heart rate, calculates the shock index (heart rate divided by systolic blood pressure) and alerts the user to compromise through a traffic light system reflecting previously validated shock index thresholds. METHODS This is a planned secondary analysis of data from the CRADLE-3 trial from ten clusters across Africa, India and Haiti where the device and training package were randomly introduced. Referral data were prospectively collected for a 4-week period before, and a 4-week period 3 months after implementation. Referrals from primary or secondary care facilities to higher level care for any cause were recorded. The denominator was the number of women seen for maternity care in these facilities. RESULTS Between April 1 2016 and Nov 30th, 2017 536,223 women attended maternity care facilities. Overall, 3.7% (n = 2784/74,828) of women seen in peripheral maternity facilities were referred to higher level care in the control period compared to 4.4% (n = 3212/73,371) in the intervention period (OR 0.89; 0.39-2.05) (data for nine sites that were able to collect denominator). Of these 0.29% (n = 212) pre-intervention and 0.16% (n = 120) post-intervention were referred to higher-level facilities for maternal haemorrhage. Although overall referrals did not significantly reduce there was a significant reduction in referrals for obstetric haemorrhage (OR 0.56 (0.39-0.65) following introduction of the device with homogeneity (i-squared 26.1) between sites. There was no increase in any bleeding-related morbidity (maternal death or emergency hysterectomy). CONCLUSIONS Referrals for obstetric haemorrhage reduced following implementation of the CRADLE Vital Signs Alert Device, occurring without an increase in maternal death or emergency hysterectomy. This demonstrates the potential benefit of shock index in management pathways for obstetric haemorrhage and targeting limited resources in low- middle- income settings. TRIAL REGISTRATION This study is registered with the ISRCTN registry, number ISRCTN41244132 (02/02/2016).
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Affiliation(s)
- Lucie Giblin
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Nicola Vousden
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Hannah Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shivaprasad Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Umesh Charantimath
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK.
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Abstract
OBJECTIVES This survey aimed to review aspects of clinical decision support (CDS) that contribute to burnout and identify key themes for improving the acceptability of CDS to clinicians, with the goal of decreasing said burnout. METHODS We performed a survey of relevant articles from 2018-2019 addressing CDS and aspects of clinician burnout from PubMed and Web of Science™. Themes were manually extracted from publications that met inclusion criteria. RESULTS Eighty-nine articles met inclusion criteria, including 12 review articles. Review articles were either prescriptive, describing how CDS should work, or analytic, describing how current CDS tools are deployed. The non-review articles largely demonstrated poor relevance and acceptability of current tools, and few studies showed benefits in terms of efficiency or patient outcomes from implemented CDS. Encouragingly, multiple studies highlighted steps that succeeded in improving both acceptability and relevance of CDS. CONCLUSIONS CDS can contribute to clinician frustration and burnout. Using the techniques of improving relevance, soliciting feedback, customization, measurement of outcomes and metrics, and iteration, the effects of CDS on burnout can be ameliorated.
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Affiliation(s)
- Ivana Jankovic
- Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan H. Chen
- Center for Biomedical Informatics Research and Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Nagraj S, Kennedy SH, Norton R, Jha V, Praveen D, Hinton L, Hirst JE. Cardiometabolic Risk Factors in Pregnancy and Implications for Long-Term Health: Identifying the Research Priorities for Low-Resource Settings. Front Cardiovasc Med 2020; 7:40. [PMID: 32266293 PMCID: PMC7099403 DOI: 10.3389/fcvm.2020.00040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/03/2020] [Indexed: 12/17/2022] Open
Abstract
Cardiometabolic disorders (CMDs), including ischemic heart disease, stroke and type 2 diabetes are the leading causes of mortality and morbidity in women worldwide. The burden of CMDs falls disproportionately on low and middle-income countries (LMICs), placing substantial demands on already pressured health systems. Cardiometabolic disorders may present up to a decade earlier in some LMIC settings, and are associated with high-case fatality rates. Early identification and ongoing postpartum follow-up of women with pregnancy complications such as hypertensive disorders of pregnancy (HDPs), and gestational diabetes mellitus (GDM) may offer opportunities for prevention, or help delay onset of CMDs. This mini-review paper presents an overview of the key challenges faced in the early identification, referral and management of pregnant women at increased risk of CMDs, in low-resource settings worldwide. Evidence-based strategies, including novel diagnostics, technology and innovations for early detection, screening and management for pregnant women at high-risk of CMDs are presented. The review highlights the key research priorities for addressing cardiometabolic risk in pregnancy in low-resource settings.
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Affiliation(s)
- Shobhana Nagraj
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom.,The George Institute for Global Health, Oxford, United Kingdom
| | - Stephen H Kennedy
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Robyn Norton
- The George Institute for Global Health, Oxford, United Kingdom.,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Vivekananda Jha
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom.,The George Institute for Global Health, New Delhi, India.,Manipal Academy of Higher Education, Manipal, India
| | | | - Lisa Hinton
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.,THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, United Kingdom
| | - Jane E Hirst
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom.,The George Institute for Global Health, Oxford, United Kingdom
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Vousden N, Lawley E, Seed PT, Gidiri MF, Charantimath U, Makonyola G, Brown A, Yadeta L, Best R, Chinkoyo S, Vwalika B, Nakimuli A, Ditai J, Greene G, Chappell LC, Sandall J, Shennan AH. Exploring the effect of implementation and context on a stepped-wedge randomised controlled trial of a vital sign triage device in routine maternity care in low-resource settings. Implement Sci 2019; 14:38. [PMID: 30999963 PMCID: PMC6471783 DOI: 10.1186/s13012-019-0885-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Interventions aimed at reducing maternal mortality are increasingly complex. Understanding how complex interventions are delivered, to whom, and how they work is key in ensuring their rapid scale-up. We delivered a vital signs triage intervention into routine maternity care in eight low- and middle-income countries with the aim of reducing a composite outcome of morbidity and mortality. This was a pragmatic, hybrid effectiveness-implementation stepped-wedge randomised controlled trial. In this study, we present the results of the mixed-methods process evaluation. The aim was to describe implementation and local context and integrate results to determine whether differences in the effect of the intervention across sites could be explained. METHODS The duration and content of implementation, uptake of the intervention and its impact on clinical management were recorded. These were integrated with interviews (n = 36) and focus groups (n = 19) at 3 months and 6-9 months after implementation. In order to determine the effect of implementation on effectiveness, measures were ranked and averaged across implementation domains to create a composite implementation strength score and then correlated with the primary outcome. RESULTS Overall, 61.1% (n = 2747) of health care providers were trained in the intervention (range 16.5% to 89.2%) over a mean of 10.8 days. Uptake and acceptability of the intervention was good. All clusters demonstrated improved availability of vital signs equipment. There was an increase in the proportion of women having their blood pressure measured in pregnancy following the intervention (79.2% vs. 97.6%; OR 1.30 (1.29-1.31)) and no significant change in referral rates (3.7% vs. 4.4% OR 0.89; (0.39-2.05)). Availability of resources and acceptable, effective referral systems influenced health care provider interaction with the intervention. There was no correlation between process measures within or between domains, or between the composite score and the primary outcome. CONCLUSIONS This process evaluation has successfully described the quantity and quality of implementation. Variation in implementation and context did not explain differences in the effectiveness of the intervention on maternal mortality and morbidity. We suggest future trials should prioritise in-depth evaluation of local context and clinical pathways. TRIAL REGISTRATION Trial registration: ISRCTN41244132 . Registered on 2 Feb 2016.
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Affiliation(s)
- Nicola Vousden
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Elodie Lawley
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Paul T. Seed
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Muchabayiwa Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Umesh Charantimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka 590010 India
| | - Grace Makonyola
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG UK
| | - Adrian Brown
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG UK
| | - Lomi Yadeta
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG UK
| | - Rebecca Best
- Welbodi Partnership, Ola During Childrens Hospital, Freetown, Sierra Leone
| | - Sebastian Chinkoyo
- Department of Obstetrics and Gynaecology, Ndola Teaching Hospital, Ndola, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia, Lusaka, Zambia
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, Mulago Hospital, Makerere University, Kampala, Uganda
| | - James Ditai
- Sanyu Africa Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Grace Greene
- Hope Health Action, Hopital Convention Baptiste d’Haiti, Cap Haitien, Haiti
| | - Lucy C. Chappell
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Jane Sandall
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
| | - Andrew H. Shennan
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH UK
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12
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Vousden N, Lawley E, Nathan HL, Seed PT, Gidiri MF, Goudar S, Sandall J, Chappell LC, Shennan AH. Effect of a novel vital sign device on maternal mortality and morbidity in low-resource settings: a pragmatic, stepped-wedge, cluster-randomised controlled trial. Lancet Glob Health 2019; 7:e347-e356. [PMID: 30784635 PMCID: PMC6379820 DOI: 10.1016/s2214-109x(18)30526-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/19/2018] [Accepted: 11/07/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND In 2015, an estimated 303 000 women died in pregnancy and childbirth. Obstetric haemorrhage, sepsis, and hypertensive disorders of pregnancy account for more than 50% of maternal deaths worldwide. There are effective treatments for these pregnancy complications, but they require early detection by measurement of vital signs and timely administration to save lives. The primary aim of this trial was to determine whether implementation of the CRADLE Vital Sign Alert and an education package into community and facility maternity care in low-resource settings could reduce a composite of all-cause maternal mortality or major morbidity (eclampsia and hysterectomy). METHODS We did a pragmatic, stepped-wedge, cluster-randomised controlled trial in ten clusters across Africa, India, and Haiti, introducing the device into routine maternity care. Each cluster contained at least one secondary or tertiary hospital and their main referral facilities. Clusters crossed over from existing routine care to the CRADLE intervention in one of nine steps at 2-monthly intervals, with CRADLE devices replacing existing equipment at the randomly allocated timepoint. A computer-generated randomly allocated sequence determined the order in which the clusters received the intervention. Because of the nature of the intervention, this trial was not masked. Data were gathered monthly, with 20 time periods of 1 month. The primary composite outcome was at least one of eclampsia, emergency hysterectomy, and maternal death. This study is registered with the ISRCTN registry, number ISRCTN41244132. FINDINGS Between April 1, 2016, and Nov 30, 2017, among 536 223 deliveries, the primary outcome occurred in 4067 women, with 998 maternal deaths, 2692 eclampsia cases, and 681 hysterectomies. There was an 8% decrease in the primary outcome from 79·4 per 10 000 deliveries pre-intervention to 72·8 per 10 000 deliveries post-intervention (odds ratio [OR] 0·92, 95% CI 0·86-0·97; p=0·0056). After planned adjustments for variation in event rates between and within clusters over time, the unexpected degree of variability meant we were unable to judge the benefit or harms of the intervention (OR 1·22, 95% CI 0·73-2·06; p=0·45). INTERPRETATION There was an absolute 8% reduction in primary outcome during the trial, with no change in resources or staffing, but this reduction could not be directly attributed to the intervention due to variability. We encountered unanticipated methodological challenges with this trial design, which can provide valuable learning for future research and inform the trial design of future international stepped-wedge trials. FUNDING Newton Fund Global Research Programme: UK Medical Research Council; Department of Biotechnology, Ministry of Science & Technology, Government of India; and UK Department of International Development.
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Affiliation(s)
- Nicola Vousden
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Elodie Lawley
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Muchabayiwa Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shivaprasad Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Nathan HL, Vousden N, Lawley E, de Greeff A, Hezelgrave NL, Sloan N, Tanna N, Goudar SS, Gidiri MF, Sandall J, Chappell LC, Shennan AH. Development and evaluation of a novel Vital Signs Alert device for use in pregnancy in low-resource settings. BMJ INNOVATIONS 2018; 4:192-198. [PMID: 30319784 PMCID: PMC6173817 DOI: 10.1136/bmjinnov-2017-000235] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/15/2018] [Accepted: 08/17/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Haemorrhage, hypertension, sepsis and abortion complications (often from haemorrhage or sepsis) contribute to 60% of all maternal deaths. Each is associated with vital signs (blood pressure (BP) and pulse) abnormalities, and the majority of deaths are preventable through simple and timely intervention. This paper presents the development and evaluation of the CRADLE Vital Signs Alert (VSA), an accurate, low-cost and easy-to-use device measuring BP and pulse with an integrated traffic light early warning system. The VSA was designed to be used by all cadres of healthcare providers for pregnant women in low-resource settings with the aim to prevent avoidable maternal mortality and morbidity. METHODS The development and the mixed-methods clinical evaluation of the VSA are described. RESULTS Preliminary fieldwork identified that introduction of BP devices to rural clinics improved antenatal surveillance of BP in pregnant women. The aesthetics of the integrated traffic light system were developed through iterative qualitative evaluation. The traffic lights trigger according to evidence-based vital sign thresholds in hypertension and haemodynamic compromise from haemorrhage and sepsis. The VSA can be reliably used as an auscultatory device, as well as its primary semiautomated function, and is suitable as a self-monitor used by pregnant women. CONCLUSION The VSA is an accurate device incorporating an evidence-based traffic light early warning system. It is designed to ensure suitability for healthcare providers with limited training and may improve care for women in pregnancy, childbirth and in the postnatal period.
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Affiliation(s)
- Hannah L Nathan
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Nicola Vousden
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Elodie Lawley
- Department of Women and Children’s Health, King’s College London, London, UK
| | | | | | - Nicola Sloan
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Nina Tanna
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Shivaprasad S Goudar
- JNMC Women’s and Children’s Health Research Unit, KLE University, Belagavi, India
| | | | - Jane Sandall
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Andrew H Shennan
- Department of Women and Children’s Health, King’s College London, London, UK
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