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Ramos E, Piló Palax I, Serech Cuxil E, Sebaquijay Iquic E, Canú Ajqui A, Miller AC, Chandrasekeran S, Hall-Clifford R, Sameni R, Katebi N, Clifford GD, Rohloff P. Mobil Monitoring Doppler Ultrasound (MoMDUS) study: protocol for a prospective, observational study investigating the use of artificial intelligence and low-cost Doppler ultrasound for the automated quantification of hypertension, pre-eclampsia and fetal growth restriction in rural Guatemala. BMJ Open 2024; 14:e090503. [PMID: 39260859 PMCID: PMC11409237 DOI: 10.1136/bmjopen-2024-090503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2024] Open
Abstract
INTRODUCTION Undetected high-risk conditions in pregnancy are a leading cause of perinatal mortality in low-income and middle-income countries. A key contributor to adverse perinatal outcomes in these settings is limited access to high-quality screening and timely referral to care. Recently, a low-cost one-dimensional Doppler ultrasound (1-D DUS) device was developed that front-line workers in rural Guatemala used to collect quality maternal and fetal data. Further, we demonstrated with retrospective preliminary data that 1-D DUS signal could be processed using artificial intelligence and deep-learning algorithms to accurately estimate fetal gestational age, intrauterine growth and maternal blood pressure. This protocol describes a prospective observational pregnancy cohort study designed to prospectively evaluate these preliminary findings. METHODS AND ANALYSIS This is a prospective observational cohort study conducted in rural Guatemala. In this study, we will follow pregnant women (N =700) recruited prior to 18 6/7 weeks gestation until their delivery and early postpartum period. During pregnancy, trained nurses will collect data on prenatal risk factors and obstetrical care. Every 4 weeks, the research team will collect maternal weight, blood pressure and 1-D DUS recordings of fetal heart tones. Additionally, we will conduct three serial obstetric ultrasounds to evaluate for fetal growth restriction (FGR), and one postpartum visit to record maternal blood pressure and neonatal weight and length. We will compare the test characteristics (receiver operator curves) of 1-D DUS algorithms developed by deep-learning methods to two-dimensional fetal ultrasound survey and published clinical pre-eclampsia risk prediction algorithms for predicting FGR and pre-eclampsia, respectively. ETHICS AND DISSEMINATION Results of this study will be disseminated at scientific conferences and through peer-reviewed articles. Deidentified data sets will be made available through public repositories. The study has been approved by the institutional ethics committees of Maya Health Alliance and Emory University.
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Affiliation(s)
- Edlyn Ramos
- Center for Indigenous Health Research, Maya Health Alliance Wuqu' Kawoq, Tecpán, Guatemala
| | - Irma Piló Palax
- Center for Indigenous Health Research, Maya Health Alliance Wuqu' Kawoq, Tecpán, Guatemala
| | - Emily Serech Cuxil
- Center for Indigenous Health Research, Maya Health Alliance Wuqu' Kawoq, Tecpán, Guatemala
| | - Elsa Sebaquijay Iquic
- Center for Indigenous Health Research, Maya Health Alliance Wuqu' Kawoq, Tecpán, Guatemala
| | - Ana Canú Ajqui
- Center for Indigenous Health Research, Maya Health Alliance Wuqu' Kawoq, Tecpán, Guatemala
| | - Ann C Miller
- Department of Global Health and Social Medicinem, Blavatnik Institute, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Rachel Hall-Clifford
- Departments of Global Health and Sociology, Center for the Study of Human Health, Emory University, Atlanta, Georgia, USA
| | - Reza Sameni
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Nasim Katebi
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Gari D Clifford
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Peter Rohloff
- Center for Indigenous Health Research, Maya Health Alliance Wuqu' Kawoq, Tecpán, Guatemala
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Ekhaguere OA, Okonkwo IR, Batra M, Hedstrom AB. Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022. Front Pediatr 2022; 10:961509. [PMID: 35967574 PMCID: PMC9372546 DOI: 10.3389/fped.2022.961509] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023] Open
Abstract
The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.
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Affiliation(s)
- Osayame A. Ekhaguere
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ikechukwu R. Okonkwo
- Department of Pediatrics, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Maneesh Batra
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
| | - Anna B. Hedstrom
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
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Kleinhout MY, Stevens MM, Osman KA, Adu-Bonsaffoh K, Groenendaal F, Biza Zepro N, Rijken MJ, Browne JL. Evidence-based interventions to reduce mortality among preterm and low-birthweight neonates in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Glob Health 2021; 6:bmjgh-2020-003618. [PMID: 33602687 PMCID: PMC7896575 DOI: 10.1136/bmjgh-2020-003618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/23/2020] [Accepted: 12/25/2020] [Indexed: 01/21/2023] Open
Abstract
Background Preterm birth is the leading cause of under-five-mortality worldwide, with the highest burden in low-income and middle-income countries (LMICs). The aim of this study was to synthesise evidence-based interventions for preterm and low birthweight (LBW) neonates in LMICs, their associated neonatal mortality rate (NMR), and barriers and facilitators to their implementation. This study updates all existing evidence on this topic and reviews evidence on interventions that have not been previously considered in current WHO recommendations. Methods Six electronic databases were searched until 3 March 2020 for randomised controlled trials reporting NMR of preterm and/or LBW newborns following any intervention in LMICs. Risk ratios for mortality outcomes were pooled where appropriate using a random effects model (PROSPERO registration number: CRD42019139267). Results 1236 studies were identified, of which 49 were narratively synthesised and 9 contributed to the meta-analysis. The studies included 39 interventions in 21 countries with 46 993 participants. High-quality evidence suggested significant reduction of NMR following antenatal corticosteroids (Pakistan risk ratio (RR) 0.89; 95% CI 0.80 to 0.99|Guatemala 0.74; 0.68 to 0.81), single cord (0.65; 0.50 to 0.86) and skin cleansing with chlorhexidine (0.72; 0.55 to 0.95), early BCG vaccine (0.64; 0.48 to 0.86; I2 0%), community kangaroo mother care (OR 0.73; 0.55 to 0.97; I2 0%) and home-based newborn care (preterm 0.25; 0.14 to 0.48|LBW 0.42; 0.27 to 0.65). No effects on perinatal (essential newborn care 1.02; 0.91 to 1.14|neonatal resuscitation 0.95; 0.84 to 1.07) or 7-day NMR (essential newborn care 1.03; 0.83 to 1.27|neonatal resuscitation 0.92; 0.77 to 1.09) were observed after training birth attendants. Conclusion The findings of this study encourage the implementation of additional, evidence-based interventions in the current (WHO) guidelines and to be selective in usage of antenatal corticosteroids, to reduce mortality among preterm and LBW neonates in LMICs. Given the global commitment to end all preventable neonatal deaths by 2030, continuous evaluation and improvement of the current guidelines should be a priority on the agenda.
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Affiliation(s)
- Mirjam Y Kleinhout
- Department of Neonatology, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Department of Neonatology, Wilhelmina Children's Hospital University Medical Center Utrecht, Utrecht, The Netherlands
| | - Merel M Stevens
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Kwame Adu-Bonsaffoh
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Obstetrics and Gynaecology, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nejimu Biza Zepro
- College of Health Sciences, Samara University, Semera, Afar, Ethiopia.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joyce L Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Mwita S, Jande M, Katabalo D, Kamala B, Dewey D. Reducing neonatal mortality and respiratory distress syndrome associated with preterm birth: a scoping review on the impact of antenatal corticosteroids in low- and middle-income countries. World J Pediatr 2021; 17:131-140. [PMID: 33389692 DOI: 10.1007/s12519-020-00398-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The most common cause of death among preterm infants in low- and middle-income countries is respiratory distress syndrome. The purpose of this review was to assess whether antenatal corticosteroids given to women at risk of preterm birth at ≤ 34 weeks of gestation reduce rates of neonatal mortality and respiratory distress syndrome in low- and middle-income countries. METHODS Two reviewers independently searched four databases including MEDLINE (through PubMed), CINAHL, Embase, and Cochrane Libraries. We did not apply any language or date restrictions. All publications up to April 2020 were included in this search. RESULTS The search yielded 71 articles, 10 of which were included in this review (3 randomized controlled trials, 7 observational studies, 36,773 neonates). The majority of studies reported associations between exposure to antenatal corticosteroids and lower rates of neonatal mortality and respiratory distress syndrome. However, a few studies reported that antenatal corticosteroids were not associated with improved preterm birth outcomes. CONCLUSIONS Most of the studies in low- and middle-income countries showed that use of antenatal corticosteroids in hospitals with high levels of neonatal care was associated with lower rates of neonatal mortality and respiratory distress syndrome. However, the findings are inconclusive because some studies in low-resource settings reported that antenatal corticosteroids had no benefit in reducing rates of neonatal mortality or respiratory distress syndrome. Further research on the impact of antenatal corticosteroids in resource-limited settings in low-income countries is a priority.
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Affiliation(s)
- Stanley Mwita
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania.
| | - Mary Jande
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Deogratias Katabalo
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Benjamin Kamala
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Deborah Dewey
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
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Affiliation(s)
- Dwight J Rouse
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI (D.J.R.); and the Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill (J.S.A.S.)
| | - Jeffrey S A Stringer
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI (D.J.R.); and the Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill (J.S.A.S.)
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Valcin J, Jean-Charles S, Malfa A, Tucker R, Dorcélus L, Gautier J, Koster MP, Lechner BE. Mortality, morbidity and clinical care in a referral neonatal intensive care unit in Haiti. PLoS One 2020; 15:e0240465. [PMID: 33052937 PMCID: PMC7556516 DOI: 10.1371/journal.pone.0240465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/26/2020] [Indexed: 12/03/2022] Open
Abstract
Background Neonatal mortality rates in Haiti are among the highest in the Western hemisphere. Few mothers deliver with a skilled birth attendant present, and there is a significant lack of pediatricians. The neonatal intensive care unit (NICU) at St. Damien Pediatric Hospital, a national referral center, is one of only five neonatology departments in Haiti. In order to target limited resources toward improving outcomes, this study seeks to describe clinical care in the St. Damien NICU. Methods A retrospective medical record review was performed on available medical records on all admissions to the NICU between April 2016 and April 2017. Results 220 neonates were admitted to the NICU within the study epoch. The mortality rate was 14.5%. Death was associated with a maternal diagnosis of hypertension (p = 0.03) and neonatal diagnoses of lower gestational age (p<0.0001), lower birth weight (p<0.0001), prematurity (p = 0.002), RDS p = 0.01), sepsis (p<0.0001) and kernicterus (p = 0.04). The most common diagnoses were sepsis, chorioamnionitis, respiratory distress syndrome, jaundice, prematurity and perinatal asphyxia. Conclusions This study demonstrates that preterm birth, sepsis, RDS and kernicterus are key contributors to neonatal mortality in a Haitian national pediatric referral center NICU and as such are promising interventional targets for reducing the neonatal mortality rate in Haiti.
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Affiliation(s)
- Josie Valcin
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Skenda Jean-Charles
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Ana Malfa
- Brown University, Providence, Rhode Island, United States of America
| | - Richard Tucker
- Department of Neonatology, Women & Infants Hospital, Providence, Rhode Island, United States of America
| | | | | | - Michael P. Koster
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- Department of Pediatrics, Hasbro Children’s Hospital, Providence, Rhode Island, United States of America
| | - Beatrice E. Lechner
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- Department of Neonatology, Women & Infants Hospital, Providence, Rhode Island, United States of America
- * E-mail:
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Rohwer AC, Oladapo OT, Hofmeyr GJ. Strategies for optimising antenatal corticosteroid administration for women with anticipated preterm birth. Cochrane Database Syst Rev 2020; 5:CD013633. [PMID: 32452555 PMCID: PMC7387231 DOI: 10.1002/14651858.cd013633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Preterm birth is a serious and common pregnancy complication. The burden is particularly high in low- and middle-income countries where available care is often inadequate to ensure preterm newborn survival. Administration of antenatal corticosteroids (ACS) is recommended as the standard care for the management of women at risk of imminent preterm birth but its coverage varies globally. Efforts to improve preterm newborn survival have largely been focused on optimising the coverage of ACS use. However, the benefits and harms of such strategies are unclear. OBJECTIVES To determine the relative benefits and risks of individual patient protocols, health service policies, educational interventions or other strategies which aim to optimise the use of ACS for anticipated preterm birth. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs), randomised at individual or cluster level, and quasi-randomised trials that assessed strategies to optimise (either by increasing or restricting) the administration of ACS compared with usual care amongst women at risk of preterm birth. Our primary outcomes were perinatal death and a composite outcome of offspring mortality and early or late neurodevelopmental morbidity. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion. All three review authors independently extracted data and assessed risk of bias. We used narrative synthesis to analyse results, as we were unable to pool data from the included studies. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included three cluster-RCTs, all assessing the effects of a multifaceted strategy aiming to promote the use of ACS among women at risk of preterm birth. We did not identify any trials assessing strategies to restrict the use of ACS versus usual care. Two of the included trials assessed use of ACS in high-resource hospital settings. The third trial, the Antenatal Corticosteroid Trial (ACT) was a multi-site trial conducted in rural and semi-urban settings of six low- and middle-income countries in South Asia, sub-Saharan Africa and Central and South America. In two trials, promoting the use of ACS resulted in increased use of ACS, whereas one trial did not find a difference in the rate of ACS administration compared to usual care. Whilst we included three studies, we were unable to pool the data in meta-analysis due to outcomes not being reported across all studies, or outcome results being reported in different ways. The main source of data in this review is from the ACT trial. We assessed the ACT trial as high risk for performance and selective reporting bias. In the protocol for this review, we planned to report all settings and subgroup by low-middle versus high-income countries; these planned analyses were not possible in this version of the review, although adding further studies in future updates may allow us to carry out planned subgroup analyses. The ACT trial was conducted in low-resource settings and reported data on appropriate ACS treatment and inappropriate ACS treatment. Although a strategy of promoting the administration of ACS compared to routine care may increase appropriate ACS treatment (RR 4.34, 95%CI 3.59 to 5.25; 1 study; n = 4389; low-certainty evidence), it may also increase inappropriate ACS treatment (RR 9.11 95%CI 8.04 to 10.33, 1 study, n = 89,237; low-certainty evidence). In low-resource settings, a strategy of promoting the administration of ACS probably increases population level perinatal death by 3 per 1000 infants (risk ratio (RR) 1.11, 95% confidence interval (CI) 1.04 to 1.19; 1 study; n = 100,705; moderate-certainty evidence); stillbirth by 2 per 1000 infants (RR 1.11, 95% CI 1.02 to 1.21; 1 study; n = 100,705; moderate-certainty evidence); and neonatal death before 28 days by 2 per 1000 infants (RR 1.12, 95% CI 1.02 to 1.23; 1 study; n = 100,705; moderate-certainty evidence); may increase the risk for 'suspected' maternal infection or inflammation (RR 1.49, 95% CI 1.32 to 1.68; 1 study; n = 99,742; low-certainty evidence); and make little or no difference to the risk of maternal mortality (RR 1.11, 95% CI 0.64 to 1.92; 1 study; n = 99,742; low-certainty evidence) compared to routine care. Included trials did not report on the composite outcomes offspring mortality, early neurodevelopmental morbidity or late neurodevelopmental morbidity; and offspring mortality or severe neonatal morbidity. AUTHORS' CONCLUSIONS In low-resource settings, a strategy of actively promoting the use of ACS in women at risk of preterm birth may increase ACS use in the target population, but may also carry a substantial risk of unnecessary exposure of ACS to women in whom ACS is not indicated. At the population level, these effects are probably associated with increased risks of stillbirth, perinatal death, neonatal death before 28 days, and maternal infection. The findings of this review support a more conservative approach to clinical protocols and clinical decision-making particularly in low-resource settings, along the lines of the World Health Organization's ACS 2015 recommendations, which take into account both the established clinical efficacy of ACS when used in the correct situation and context, and the possibility of important adverse effects when certain conditions are not met. Given the unanticipated results of the ACT trial, further research on strategies to optimise the use of ACS in low-resource settings is justified.
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Affiliation(s)
- Anke C Rohwer
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - G Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, East London, South Africa; Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; and, University of Botswana, Gaborone, Botswana
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Juarez M, Juarez Y, Coyote E, Nguyen T, Shaw C, Hall-Clifford R, Clifford G, Rohloff P. Working with lay midwives to improve the detection of neonatal complications in rural Guatemala. BMJ Open Qual 2020. [PMCID: PMC7011902 DOI: 10.1136/bmjoq-2019-000775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Globally most neonatal deaths occur within the first week of life and in low-income and middle-income countries. Strengthening health system linkages for frontline providers—such as lay midwives providing home-based obstetrical care—may improve neonatal outcomes in these settings. Here, we conducted a quality improvement study to increase the detection of neonatal complications by lay midwives in rural Guatemala, thereby increasing referrals to a higher level of care. Methods A quality improvement team in Guatemala reviewed drivers of neonatal health services provided by lay midwives. Improvement interventions included training on neonatal warning signs, optimised mobile health technology to standardise assessments and financial incentives for providers. The primary quality outcome was the rate of neonatal referral to a higher level of care. Results From September 2017 to September 2018, participating midwives attended 869 home deliveries and referred 80 neonates to a higher level of care. A proportion control chart, using the preintervention period from January to September 2017 as the baseline, showed an increase in the referral rate of all births from 1.5% to 9.9%. Special cause was obtained in January 2018 and sustained except for May 2018. The proportion of neonates receiving assessments by midwives in the first week of life increased to >90%. A trend toward an increasing number of days between neonatal deaths did not attain special cause. Conclusions Structured improvement interventions, including mobile health decision support and financial incentives, significantly increased the detection of neonatal complications and referral of neonates to higher levels of care by lay midwives operating in rural home-based settings in Guatemala. The results show the value of improving the integration of lay midwives and other first responders into neonatal systems of care in low-resource settings.
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Affiliation(s)
- Michel Juarez
- Center for Research in Indigenous Health, Wuqu' Kawoq | Maya Health Alliance, Tecpán, Guatemala
| | - Yolanda Juarez
- Center for Research in Indigenous Health, Wuqu' Kawoq | Maya Health Alliance, Tecpán, Guatemala
| | - Enma Coyote
- Center for Research in Indigenous Health, Wuqu' Kawoq | Maya Health Alliance, Tecpán, Guatemala
| | - Tony Nguyen
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Corey Shaw
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Rachel Hall-Clifford
- Department of Sociology, Anthropology and Public Health, Agnes Scott College, Decatur, Georgia, USA
| | - Gari Clifford
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Peter Rohloff
- Center for Research in Indigenous Health, Wuqu' Kawoq | Maya Health Alliance, Tecpán, Guatemala
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Abstract
Antenatal corticosteroids (ACS) are sporadically used in low and middle income countries (LMIC), although their use is considered by the World Health Organization (WHO) as essential for decreasing infant mortality. Presently the WHO recommends the use of ACS only when gestational age is known, delivery is imminent, and the delivery will be in a facility that can provide care for the mother and the infant. We review uncertainties about ACS in high income countries that are underappreciated for anticipating their effectiveness in LMIC. We discuss the implications of a large RCT that evaluated the use of ACS in LMIC and found no benefit for presumed preterm infants and increased mortality in larger infants. The treatment schedules for ACS have not been optimized and more is now known about how to improve treatment strategies to hopefully decrease risks such as neonatal hypoglycemia in LMIC. The benefits from ACS may depend on the patient populations and health care environment in which the therapy is used. Further trials are needed to evaluate the safety and efficacy of ACS in LMIC.
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Affiliation(s)
- Alan H Jobe
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 7029, Cincinnati, OH 45248, USA; University of Western Australia, Perth, Australia.
| | - Matthew W Kemp
- University of Western Australia, Perth, Australia; Tohoku University Hospital, Sendai, Japan; Murdock University, Perth, Australia
| | - Beena Kamath-Rayne
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 7029, Cincinnati, OH 45248, USA
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10
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Griffin JB, Jobe AH, Rouse D, McClure EM, Goldenberg RL, Kamath-Rayne BD. Evaluating WHO-Recommended Interventions for Preterm Birth: A Mathematical Model of the Potential Reduction of Preterm Mortality in Sub-Saharan Africa. GLOBAL HEALTH, SCIENCE AND PRACTICE 2019; 7:215-227. [PMID: 31249020 PMCID: PMC6641817 DOI: 10.9745/ghsp-d-18-00402] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/13/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Preterm birth, a leading cause of neonatal mortality, has the highest burden in low-income countries. In 2015, the World Health Organization (WHO) published recommendations for interventions to improve preterm outcomes. Our analysis uses the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model to evaluate the potential effects that WHO-recommended interventions could have had on preterm mortality in sub-Saharan Africa in 2015. METHODS We modeled preterm birth subconditions causing mortality (respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, birth asphyxia, and low birth weight). For each subcondition, models were populated with estimates of WHO-recommended intervention prevalence, case fatality, coverage, and efficacy. Various scenarios modeled improved coverage of single and combined interventions compared with baseline. RESULTS In 2015, approximately 500,000 neonatal deaths due to preterm birth occurred in sub-Saharan Africa. Single interventions with the greatest impact on preterm mortality included oxygen/continuous positive airway pressure (44,000 lives saved), cord care (38,500 lives saved), and breastfeeding (30,200 lives saved). Combined with improved diagnosis/transfer to a hospital, the impact of interventions showed greater reductions in mortality (oxygen/continuous positive airway pressure, 134,100 lives saved; antibiotics, 28,600 lives saved). Combined interventions had the greatest impact. Together, hospital delivery with comprehensive care for respiratory distress syndrome saved 190,600 lives, and comprehensive thermal care, breastfeeding, and prevention/treatment for sepsis saved 94,400 lives. CONCLUSION In 2015, WHO-recommended interventions could have saved the lives of nearly 300,000 infants born preterm in sub-Saharan Africa. Combined interventions are necessary to maximize impact. Mathematical models such as MANDATE can estimate effects on health outcomes to allow health officials to prioritize implementation strategies.
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Affiliation(s)
| | - Alan H Jobe
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Beena D Kamath-Rayne
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Global Child Health, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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McClure EM, Goldenberg RL, Jobe AH, Miodovnik M, Koso-Thomas M, Buekens P, Belizan J, Althabe F. Reducing neonatal mortality associated with preterm birth: gaps in knowledge of the impact of antenatal corticosteroids on preterm birth outcomes in low-middle income countries. Reprod Health 2016; 13:61. [PMID: 27221397 PMCID: PMC4877818 DOI: 10.1186/s12978-016-0180-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 05/04/2016] [Indexed: 12/29/2022] Open
Abstract
The Global Network's Antenatal Corticosteroids Trial (ACT), was a multi-country, cluster-randomized trial to improve appropriate use of antenatal corticosteroids (ACS) in low-resource settings in low-middle income countries (LMIC). ACT substantially increased ACS use in the intervention clusters, but the intervention failed to show benefit in the targeted < 5th percentile birth weight infants and was associated with increased neonatal mortality and stillbirth in the overall population. In this issue are six papers which are secondary analyses related to ACT that explore potential reasons for the increase in adverse outcomes overall, as well as site differences in outcomes. The African sites appeared to have increased neonatal mortality in the intervention clusters while the Guatemalan site had a significant reduction in neonatal mortality, perhaps related to a combination of ACS and improving obstetric care in the intervention clusters. Maternal and neonatal infections were increased in the intervention clusters across all sites and increased infections are a possible partial explanation for the increase in neonatal mortality and stillbirth in the intervention clusters, especially in the African sites. The analyses presented here provide guidance for future ACS trials in LMIC. These include having accurate gestational age dating of study subjects and having care givers who can diagnose conditions leading to preterm birth and predict which women likely will deliver in the next 7 days. All study subjects should be followed through delivery and the neonatal period, regardless of when they deliver. Clearly defined measures of maternal and neonatal infection should be utilized. Trials in low income country facilities including clinics and those without newborn intensive care seem to be of the highest priority.
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Affiliation(s)
- Elizabeth M McClure
- Social, Statistical and Environmental Health Sciences, RTI International, 3040 Cornwallis Road, Durham, NC, USA.
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Alan H Jobe
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Menachem Miodovnik
- Eunice Kennedy Shriver National Institute of Child and Human Development, Bethesda, MD, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child and Human Development, Bethesda, MD, USA
| | - Pierre Buekens
- Tulane University School of Tropical Medicine and Hygiene, New Orleans, LA, USA
| | - Jose Belizan
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Fernando Althabe
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
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