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Pillay Y, Ngonzi J, Nguyen V, Payne BA, Komugisha C, Twinomujuni AH, Vidler M, Lavoie PM, Bebell LM, Christoffersen-Deb A, Kenya-Mugisha N, Kissoon N, Ansermino JM, Wiens MO. The epidemiology and risk factors for postnatal complications among postpartum women and newborns in southwestern Uganda: A prospective cohort study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003458. [PMID: 39110697 PMCID: PMC11305527 DOI: 10.1371/journal.pgph.0003458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 06/13/2024] [Indexed: 08/10/2024]
Abstract
Sub-Saharan Africa accounts for two-thirds of the global burden of maternal and newborn deaths. Adverse outcomes among postpartum women and newborns occurring in the first six weeks of life are often related, though data co-examining patients are limited. This study is an exploratory analysis describing the epidemiology of postnatal complications among postpartum women and newborns following facility birth and discharge in Mbarara, Uganda. This single-site prospective cohort observational study enrolled postpartum women following facility-based delivery. To capture health information about both the postpartum women and newborns, data was collected and categorized according to domains within the continuum of care including (1) social and demographic, (2) pregnancy history and antenatal care, (3) delivery, (4) maternal discharge, and (5) newborn discharge. The primary outcomes were readmission and mortality within the six-week postnatal period as defined by the WHO. Multivariable logistic regression was used to identify risk factors. Among 2930 discharged dyads, 2.8% and 9.0% of women and newborns received three or more postnatal visits respectively. Readmission and deaths occurred among 108(3.6%) and 25(0.8%) newborns and in 80(2.7%) and 0(0%) women, respectively. Readmissions were related to sepsis/infection in 70(88%) women and 68(63%) newborns. Adjusted analysis found that caesarean delivery (OR:2.91; 95%CI:1.5-6.04), longer travel time to the facility (OR:1.54; 95%CI:1.24-1.91) and higher maternal heart rate at discharge (OR:1.02; 95%CI:1.00-1.01) were significantly associated with maternal readmission. Discharge taken on all patients including maternal haemoglobin (per g/dL) (OR:0.90; 95%CI:0.82-0.99), maternal symptoms (OR:1.76; 95%CI:1.02-2.91), newborn temperature (OR:1.66; 95%CI:1.28-2.13) and newborn heart rate at (OR:1.94; 95%CI:1.19-3.09) were risk factors among newborns. Readmission and death following delivery and discharge from healthcare facilities is still a problem in settings with low rates of postnatal care visits for both women and newborns. Strategies to identify vulnerable dyads and provide better access to follow-up care, are urgently required.
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Affiliation(s)
- Yashodani Pillay
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Institute for Global Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology and Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Vuong Nguyen
- Institute for Global Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Beth A. Payne
- Digital Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | | | | | - Marianne Vidler
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pascal M. Lavoie
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa M. Bebell
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Astrid Christoffersen-Deb
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - J. Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Institute for Global Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Institute for Global Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- WALIMU, Kololo, Kampala, Uganda
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Muwema M, Nankabirwa JI, Edwards G, Nalwadda G, Nangendo J, Okiring J, Obeng-Amoako GO, Mwanja W, Ekong EN, Kalyango JN, Kaye DK. Perinatal care and its association with perinatal death among women attending care in three district hospitals of western Uganda. BMC Pregnancy Childbirth 2024; 24:113. [PMID: 38321398 PMCID: PMC10845583 DOI: 10.1186/s12884-024-06305-5] [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: 02/11/2023] [Accepted: 01/29/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Provision of effective care to all women and newborns during the perinatal period is a viable strategy for achieving the Sustainable Development Goal 3 targets on reducing maternal and neonatal mortality. This study examined perinatal care (antenatal, intrapartum, postpartum) and its association with perinatal deaths at three district hospitals in Bunyoro region, Uganda. METHODS A cross-sectional study was conducted in which a questionnaire was administered consecutively to 872 postpartum women before discharge who had attended antenatal care and given birth in the study hospitals. Data on care received during antenatal, labour, delivery, and postpartum period, and perinatal outcome were extracted from medical records of the enrolled postnatal women using a pre-tested structured tool. The care received from antenatal to 24 h postpartum period was assessed against the standard protocol of care established by World Health Organization (WHO). Poisson regression was used to assess the association between care received and perinatal death. RESULTS The mean age of the women was 25 years (standard deviation [SD] 5.95). Few women had their blood tested for hemoglobin levels, HIV, and Syphilis (n = 53, 6.1%); had their urine tested for glucose and proteins (n = 27, 3.1%); undertook an ultrasound scan (n = 262, 30%); and had their maternal status assessed (n = 122, 14%) during antenatal care as well as had their uterus assessed for contraction and bleeding during postpartum care (n = 63, 7.2%). There were 19 perinatal deaths, giving a perinatal mortality rate of 22/1,000 births (95% Confidence interval [CI] 8.1-35.5). Of these 9 (47.4%) were stillbirths while the remaining 10 (52.6%) were early neonatal deaths. In the antenatal phase, only fetal examination was significantly associated with perinatal death (adjusted prevalence ratio [aPR] = 0.22, 95% CI 0.1-0.6). No significant association was found between perinatal deaths and care during labour, delivery, and the early postpartum period. CONCLUSION Women did not receive all the required perinatal care during the perinatal period. Perinatal mortality rate in Bunyoro region remains high, although it's lower than the national average. The study shows a reduction in the proportion of perinatal deaths for pregnancies where the mother received fetal monitoring. Strategies focused on strengthened fetal status monitoring such as fetal movement counting methods and fetal heart rate monitoring devices during pregnancy need to be devised to reduce the incidence of perinatal deaths. Findings from the study provide valuable information that would support the strengthening of perinatal care services for improved perinatal outcomes.
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Affiliation(s)
- Mercy Muwema
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Joaniter I Nankabirwa
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Grace Edwards
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda
| | - Gorrette Nalwadda
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joanita Nangendo
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gloria Odei Obeng-Amoako
- Department of Nutrition and Food Science, School of Biological Sciences, College of Basic and Applied Sciences, University of Ghana, Legon, Ghana
| | | | - Elizabeth N Ekong
- Department of Nursing and Midwifery, Faculty of Public Health, Nursing and Midwifery, Uganda Christian University, Mukono, Uganda
| | - Joan N Kalyango
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Pharmacy, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Dan K Kaye
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Ssegujja E, Andipatin M. National-level key stakeholders' perspectives regarding intervention progression and emerging challenges within the national stillbirth reduction response in Uganda. PLoS One 2023; 18:e0285172. [PMID: 37115790 PMCID: PMC10146451 DOI: 10.1371/journal.pone.0285172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Implementation of evidence-based interventions was adopted to respond to the stillbirth burden from the global campaigns. However, new challenges emerge in the process of rolling out such interventions into routine services more so in the context of resource-limited settings. Since the scale-up of policy recommendations to address stillbirth in Uganda, the health system response has seldom been explored. This study was conducted among national-level key stakeholders to elicit their perspectives regarding intervention progression and challenges emerging from the implementation of the national stillbirth reduction strategies in Uganda. METHODS The study adopted an exploratory qualitative design with interviews conducted among a purposively selected sample of national-level actors drawn from the maternal and Child Health (MCH) policy networks. Respondents were primed with ongoing national-level stillbirth reduction strategies as a case and later asked for their opinions regarding intervention progression and emerging challenges. All interviews were conducted in English and transcribed verbatim. Atlas. ti was used to facilitate the coding processes which used a pre-determined codebook developed a priori based on the applied framework. A thematic analysis technique was used. RESULTS Human resources as reflected in the slow recruitment of essential staff, motivation and attitudes of the available human resource, on and off-drug stockouts, and equipment interruptions posed challenges to the effective implementation of interventions to address the stillbirth burden. The policy translation process was sometimes faced with deviations from the recommended practice. Deviations from guideline implementation, inadequate managerial skills of the health workers and managers in stewarding the implementation processes, inadequate implementation feedback, loops in communication and working with a passive community also posed process-dependent bottlenecks. Outcome expectation challenges stemmed from the inability to deliver stillbirth reduction interventions along the Reproductive Maternal New born Child and Adolescent Health (RMNCAH) continuum of care and the overconcentration of facility-level intervention with less focus on community/demand side interventions. CONCLUSION In this exploratory study, national-level stakeholders perceive the adopted stillbirth reduction strategies as having the potential to address the burden. They, however, highlight potential challenges along the input-process-outcome continuum which ought to be addressed and opportunities to explore potential solutions befitting the national-level context.
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Affiliation(s)
- Eric Ssegujja
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Michelle Andipatin
- Department of Psychology, University of the Western Cape, Cape Town, South Africa
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Macharia PM, Joseph NK, Nalwadda GK, Mwilike B, Banke-Thomas A, Benova L, Johnson O. Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens. BMC Pregnancy Childbirth 2022; 22:908. [PMID: 36474193 PMCID: PMC9724345 DOI: 10.1186/s12884-022-05238-1] [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: 06/07/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA. METHODS We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning. RESULTS About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had <ANC4+ visits. The majority of the 366 districts in the three countries had ANC4+ coverage of 50-70%. In Kenya, 13% of districts had < 70% coverage, compared to 10% and 27% of the districts in Uganda and mainland Tanzania, respectively. Only one district in Kenya and ten districts in mainland Tanzania were likely met the target coverage. Six percent, 38%, and 50% of the districts had at most 5000 women with <ANC4+ visits in Kenya, Uganda, and mainland Tanzania, respectively, while districts with > 20,000 women having <ANC4+ visits were 38%, 1% and 1%, respectively. In many districts, ANC4+ coverage and likelihood of attaining the target coverage was lower among the poor, uneducated and those geographically marginalized from healthcare. CONCLUSIONS These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths.
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Affiliation(s)
- Peter M. Macharia
- grid.33058.3d0000 0001 0155 5938Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya ,grid.9835.70000 0000 8190 6402Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Noel K. Joseph
- grid.33058.3d0000 0001 0155 5938Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya ,grid.9835.70000 0000 8190 6402Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
| | | | - Beatrice Mwilike
- grid.25867.3e0000 0001 1481 7466Community Health Nursing Department, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Aduragbemi Banke-Thomas
- grid.36316.310000 0001 0806 5472School of Human Sciences, University of Greenwich, London, UK
| | - Lenka Benova
- grid.11505.300000 0001 2153 5088Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Olatunji Johnson
- grid.5379.80000000121662407Department of Mathematics, The University of Manchester, Manchester, UK
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Kamala SR, Julius Z, Kosia EM, Manzi F. Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns. PLoS One 2022; 17:e0269151. [PMID: 36409741 PMCID: PMC9678323 DOI: 10.1371/journal.pone.0269151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 09/03/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Evidence shows that delivery of prompt and appropriate in-patient newborn care (IPNC) through health facility (HF)-based neonatal care and stabilization units (NCU/NSUs) reduce preventable newborn mortalities (NMs). This study investigated the HFs for availability and performance of NCU/NSUs in providing quality IPNC, and explored factors influencing the observed performance outcomes in Mtwara region, Tanzania. METHODS A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach. HF-based records and characteristics allowing for delivery of quality IPNC were reviewed first to establish the overall HF performance. The review findings were clarified by healthcare staff and managers through in-depth interviews (IDIs) and focus group discussions (FGDs). RESULTS About 70.6% (12/17) of surveyed HFs had at least one NCU/NSU room dedicated for delivery of IPNC but none had a fully established NCUs/NSU, and 74.7% (3,600/4,819) of needy newborns were admitted/transferred in for management. Essential medicines such as tetracycline eye ointment were unavailable in 75% (3/4) of the district hospitals (DHs). A disparity existed between the availability and functioning of equipment including infant radiant warmers (92% vs 73%). Governance, support from implementing patterns (IPs), and access to healthcare commodities were identified from qualitative inquiries as factors influencing the establishment and running of NCUs/NSUs at the HFs in Mtwara region, Tanzania. CONCLUSION Despite the positive progress, the establishment and performance of NCUs/NSUs in providing quality IPNC in HFs in Mtwara region is lagging behind the Tanzania neonatal care guideline requirements, particularly after the IPs of newborn health interventions completed their terms in 2016. This study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower avoidable NMs.
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Affiliation(s)
- Serveus Ruyobya Kamala
- Department of Health Systems, Policy, Economic Evaluations, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
- Department of Global Health and Bio-Medical Sciences (GHBM), School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
- Department of Health, Mtwara Regional Secretariat, Mtwara, Tanzania
- * E-mail:
| | - Zamoyoni Julius
- Department of Health Systems, Policy, Economic Evaluations, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
| | - Efraim M. Kosia
- Department of Global Health and Bio-Medical Sciences (GHBM), School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
| | - Fatuma Manzi
- Department of Health Systems, Policy, Economic Evaluations, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
- Department of Global Health and Bio-Medical Sciences (GHBM), School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
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Saweri OP, Batura N, Pulford J, Khan MM, Hou X, Pomat WS, Vallely AJ, Wiseman V. Investigating health service availability and readiness for antenatal testing and treatment for HIV and syphilis in Papua New Guinea. BMC Pregnancy Childbirth 2022; 22:780. [PMID: 36261790 PMCID: PMC9580192 DOI: 10.1186/s12884-022-05097-w] [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: 01/21/2022] [Accepted: 09/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Papua New Guinea (PNG) has one of the highest burdens of HIV and syphilis in pregnancy in the Asia-Pacific region. Timely and effective diagnosis can alleviate the burden of HIV and syphilis and improve maternal and newborn health. Supply-side factors related to implementation and scale up remain problematic, yet few studies have considered their impact on antenatal testing and treatment for HIV and syphilis. This study explores health service availability and readiness for antenatal HIV and/or syphilis testing and treatment in PNG. METHODS Using data from two sources, we demonstrate health service availability and readiness. Service availability is measured at a province level as the average of three indicators: infrastructure, workforce, and antenatal clinic utilization. The readiness score comprises 28 equally weighted indicators across four domains; and is estimated for 73 health facilities. Bivariate and multivariate robust linear regressions explore associations between health facility readiness and the proportion of antenatal clinic attendees tested and treated for HIV and/or syphilis. RESULTS Most provinces had fewer than one health facility per 10 000 population. On average, health worker density was 11 health workers per 10 000 population per province, and approximately 22% of pregnant women attended four or more antenatal clinics. Most health facilities had a composite readiness score between 51% and 75%, with urban health facilities faring better than rural ones. The multivariate regression analysis, when controlling for managing authority, catchment population, the number of clinicians employed, health facility type and residence (urban/rural) indicated a weak positive relationship between health facility readiness and the proportion of antenatal clinic attendees tested and treated for HIV and/or syphilis. CONCLUSION This study adds to the limited evidence base for the Asia-Pacific region. There is a need to improve antenatal testing and treatment coverage for HIV and syphilis and reduce healthcare inequalities faced by rural and urban communities. Shortages of skilled health workers, tests, and medicines impede the provision of quality antenatal care. Improving service availability and health facility readiness are key to ensuring the effective provision of antenatal care interventions.
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Affiliation(s)
- Olga Pm Saweri
- The Kirby Institute, University of New South Wales, Sydney, Australia. .,The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | | | | | | | - William S Pomat
- The Kirby Institute, University of New South Wales, Sydney, Australia.,The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew J Vallely
- The Kirby Institute, University of New South Wales, Sydney, Australia.,The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, Australia.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Mukuru M, Gorry J, Kiwanuka SN, Gibson L, Musoke D, Ssengooba F. Designed to Fail? Revisiting Uganda's Maternal Health Policies to Understand Policy Design Issues Underpinning Missed Targets for Reduction of Maternal Mortality Ratio (MMR): 2000-2015. Int J Health Policy Manag 2022; 11:2124-2134. [PMID: 34664495 PMCID: PMC9808297 DOI: 10.34172/ijhpm.2021.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 09/06/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to '3Cs' (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming. METHODS We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the 'three delay model' combined with a broader literature on 'policy mixing.' RESULTS Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues. CONCLUSION The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the 'three delays' but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.
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Affiliation(s)
- Moses Mukuru
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jonathan Gorry
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Suzanne N. Kiwanuka
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Linda Gibson
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Adawiyah RA, Boettiger D, Applegate TL, Probandari A, Marthias T, Guy R, Wiseman V. Supply-side readiness to deliver HIV testing and treatment services in Indonesia: Going the last mile to eliminate mother-to-child transmission of HIV. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000845. [PMID: 36962570 PMCID: PMC10021386 DOI: 10.1371/journal.pgph.0000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Despite national efforts to integrate Prevention of Mother-to-Child Transmission (PMTCT) of HIV services into antenatal care in Indonesia, the rate of mother-to-child transmission of HIV remains the highest in the world. A range of barriers to uptake and long-term engagement in care have been identified, but far less is known about health system preparedness to deliver PMTCT of HIV services. This study explored supply-side barriers to the delivery of PMTCT services in Indonesia and whether these factors are associated with the uptake of antenatal HIV testing. MATERIALS AND METHODS An ecological analysis was undertaken, linking data from the World Bank Quality Service and Delivery Survey (2016) with routine data from Indonesia's HIV and AIDS case surveillance system and district health profile reports (2016). Supply-side readiness scores-generated from a readiness index that measures overall structural capacity and is often used as proxy for quality of care-were adapted from the WHO Service Availability and Readiness Assessment and presented by sector and geographic area. Univariate and multivariate regression analysis was used to explore factors associated with the uptake of antenatal HIV testing in public facilities. RESULTS In general, public facilities scored more highly in most inputs compared to private facilities. Facilities located in urban areas also scored more highly in the majority of inputs compared to ones in rural areas. Readiness scores were lowest for PMTCT services compared to Antenatal Care and HIV Care and Support services, especially for the availability of medicines such as zidovudine and nevirapine. The national composite readiness score for PMTCT was only 0.13 (based on a maximum score of 1) with a composite score of 0.21 for public facilities and 0.06 for private facilities. The multivariate analysis shows that the proportion of pregnant women tested for HIV was more likely to be greater than or equal to 10% in facilities with a higher readiness score and a higher number of trained counsellors available, and less likely in facilities located outside of Java-Bali and in facilities supporting a higher number of village midwives. DISCUSSION Despite targeted efforts by the Indonesian government and multinational agencies, significant gaps exist in the delivery of PMTCT that compromise the standard of care delivered in Indonesia. Future strategies should focus on improving the availability of tests and treatment, especially in the private sector and in rural areas.
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Affiliation(s)
| | - David Boettiger
- The Kirby Institute, University New South Wales, Sydney, Australia
| | | | - Ari Probandari
- The Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Tiara Marthias
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - Rebecca Guy
- The Kirby Institute, University New South Wales, Sydney, Australia
| | - Virginia Wiseman
- The Kirby Institute, University New South Wales, Sydney, Australia
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
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Lee H, Maffioli EM, Veliz PT, Sakala I, Chiboola NM, Lori JR. Direct and opportunity costs related to utilizing maternity waiting homes in rural Zambia. Midwifery 2021; 105:103211. [PMID: 34894428 PMCID: PMC8811481 DOI: 10.1016/j.midw.2021.103211] [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: 05/04/2020] [Revised: 11/13/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022]
Abstract
Lack of financial resources is a critical barrier to utilising Maternity Waiting Homes (MWHs) in low-income countries (LICs). Food and user fees are most frequent expenditures for women utilising MWHs in rural Zambia. Being away from various household chores, the loss of income generating activities (IGAs), may also be a financial constraint in utilising MWHs.
Aim To assess the direct and opportunity costs involved in utilising maternity waiting homes. Method A cross-sectional admission survey administered to women who used ten maternity waiting homes across two rural districts in Zambia. A total of 3,796 women participated in the survey. Descriptive analysis was conducted on three domains of the data: demographic characteristics of women, direct costs, and opportunity costs. Findings Waiting to deliver (86.3%), safe birth (70.8%), and distance (56.0%) were the most frequent reasons women reported for using a maternity waiting home. In terms of direct costs, roughly 65% of the women brought seven days or fewer days' worth of food to the maternity waiting homes, with salt, mealie meals, and vegetables being the most frequently brought items. Only 5.8% of the women spent money on transport. More than half of the women reported paying user fees that ranged from 1 to 5 or more kwacha (US$0.10- 0.52). In terms of opportunity costs, 52% of the women participated in some form of income generating activities (IGAs) when at home. Approximately 35% of the women reported they lost earned income (1 to 50 or more kwacha) by staying at a maternity waiting home. Conclusion A large proportion of women paid for food and user fees to access a maternity waiting home, while a low number of women paid for transport. Even though it is difficult to assign monetary value to women's household chores, being away from these responsibilities and the potential loss of earned income appear to remain a cost to accessing maternity waiting homes. More research is needed to understand how to overcome these financial constraints and assist women in utilising a maternity waiting home.
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Affiliation(s)
- HaEun Lee
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States.
| | - Elisa M Maffioli
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States
| | - Philip T Veliz
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States
| | - Isaac Sakala
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Box 33921 Lusaka, Zambia
| | - Nchimunya M Chiboola
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Box 33921 Lusaka, Zambia
| | - Jody R Lori
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States
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10
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Atuhairwe S, Gemzell-Danielsson K, Byamugisha J, Kaharuza F, Tumwesigye NM, Hanson C. Abortion-related near-miss morbidity and mortality in 43 health facilities with differences in readiness to provide abortion care in Uganda. BMJ Glob Health 2021; 6:bmjgh-2020-003274. [PMID: 33547174 PMCID: PMC7871269 DOI: 10.1136/bmjgh-2020-003274] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction With a view to inform policy for improved postabortion care, we describe abortion-related near-miss and mortality by sociodemographic risk factors and management options by pregnancy trimester in Uganda. Methods This secondary data analysis used an adapted WHO near-miss methodology to collect cross-sectional maternal near-miss and abortion complications data at 43 health facilities in Central and Eastern Uganda in 2016–2017. We computed abortion severe morbidity, near-miss and mortality ratios per 100 000 live births, and described the proportion of cases that worsened to an abortion near-miss or death, stratified by geographical region and trimester. We tested for association between independent variables and abortion near-miss, and obtained prevalence ratios for association between second trimester near-miss and independent demographic and management indicators. We assessed health facility readiness for postabortion care provision in Central and Eastern regions. Results Of 3315 recorded severe abortion morbidity cases, 1507 were near-misses. Severe abortion morbidity, near-miss and mortality ratios were 2063, 938 and 23 per 100 000 live births, respectively. Abortion-related mortality ratios were 11 and 57 per 100 000 in Central and Eastern regions, respectively. Abortion near-miss cases were significantly associated with referral (p<0.001). Second trimester had greater abortion mortality than first trimester. Eastern region had greater abortion-related morbidity and mortality than Central region with facilities in the former characterised by inferior readiness to provide postabortion care. Conclusions Uganda has a major abortion near-miss morbidity and mortality; with mortality higher in the second trimester. Life-saving commodities are lacking especially in Eastern region compromising facility readiness for postabortion care provision.
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Affiliation(s)
- Susan Atuhairwe
- Department of Obstetrics and Gynaecology, Makerere University CHS, Kampala, Uganda .,Reproductive Endocrinology and Infertility, Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | | | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University CHS, Kampala, Uganda
| | - Frank Kaharuza
- Association of Obstetricians and Gynaecologists of Uganda, Kampala, Uganda
| | | | - Claudia Hanson
- Public Health Sciences, Karolinska Institute, Stockholm, Sweden.,Dept of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
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11
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Palo SK, Kripalini P, Sanghamitra P. Situation of labour room documentation at secondary level public health facilities of Cuttack district, Odisha, India - A SWOT analysis. J Family Med Prim Care 2020; 9:3308-3314. [PMID: 33102288 PMCID: PMC7567242 DOI: 10.4103/jfmpc.jfmpc_376_20] [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: 03/13/2020] [Revised: 04/25/2020] [Accepted: 05/11/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Poor documentation practices in labour rooms have been a challenge especially in resource limited countries. This hinders the efforts towards improving quality of maternal healthcare services. Little effort has been made on this regard in many countries including India. SWOT analysis on labour room documentation would be the first step in understanding the situation, barriers and to formulate strategies for improvement. Materials and Methods: Facility based cross-sectional study was carried out in five secondary health facilities of Cuttack district, Odisha, India. A qualitative method using in-depth interviews among 26 healthcare providers was adopted for data collection and inductive content analysis approach for analysis. Strategies like pioneering, positive, conservative and resistive were formulated under each of the three major components identified. Results: Three major components emerged were i) Adherence and completeness of labour room records and reports, ii) Status of the monitoring and supervision and iii) Utilization of labour room data. Improving knowledge and skill through training and supportive supervision, adopting computer-based application for data management, better coordination among supervisors and labour room staff, infrastructural strengthening for documentation and its security, making documentation a priority, more accountability would improve the documentation. Ensuring data analysis and interpretation, discussion in review meetings and regular monitoring and supervision will improve performance. Conclusion: Ensuring documentation of labour room records, regular quality monitoring and supervision, and analysis and interpretation of data are critical to improve labour room performance. Making it a priority and adopting the strategies will achieve the same, thereby better labour outcome.
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Affiliation(s)
- Subrata Kumar Palo
- Department of Community Medicine, Scientist-D, Regional Medical Research Centre - ICMR, Bhubaneswar, Odisha, India
| | - Patel Kripalini
- Senior Research Fellow, Regional Medical Research Centre - ICMR, Bhubaneswar, Odisha, India
| | - Pati Sanghamitra
- Director, Regional Medical Research Centre - ICMR, Bhubaneswar, Odisha, India
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12
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Kananura RM, Leone T, Nareeba T, Kajungu D, Waiswa P, Gjonca A. Under 10 mortality patterns, risk factors, and mechanisms in low resource settings of Eastern Uganda: An analysis of event history demographic and verbal social autopsy data. PLoS One 2020; 15:e0234573. [PMID: 32525931 PMCID: PMC7289412 DOI: 10.1371/journal.pone.0234573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/28/2020] [Indexed: 11/23/2022] Open
Abstract
Background Globally, the under-10 years of age mortality has not been comprehensively studied. We applied the life-course perspective in the analysis and interpretation of the event history demographic and verbal autopsy data to examine when and why children die before their 10th birthday. Methods We analysed a decade (2005–2015) of event histories data on 22385 and 1815 verbal autopsies data collected by Iganga-Mayuge HDSS in eastern Uganda. We used the lifetable for mortality estimates and patterns, and Royston-Parmar survival analysis approach for mortality risk factors’ assessment. Results The under-10 and 5–9 years of age mortality probabilities were 129 (95% Confidence Interval [CI] = 123–370) per 1000 live births and 11 (95% CI = 7–26) per 1000 children aged 5–9 years, respectively. The top four causes of new-born mortality and stillbirth were antepartum maternal complications (31%), intrapartum-related causes including birth injury, asphyxia and obstructed labour (25%), Low Birth Weight (LBW) and prematurity (20%), and other unidentified perinatal mortality causes (18%). Malaria, protein deficiency including anaemia, diarrhoea or gastrointestinal, and acute respiratory infections were the major causes of mortality among those aged 0–9 years–contributing 88%, 88% and 46% of all causes of mortality for the post-neonatal, child and 5–9 years of age respectively. 33% of all causes of mortality among those aged 5–9 years was a share of Injuries (22%) and gastrointestinal (11%). Regarding the deterministic pattern, nearly 30% of the new-borns and sick children died without access to formal care. Access to the treatment for the top five morbidities was after 4 days of symptoms’ recognition. The childhood mortality risk factors were LBW, multiple births, having no partner, adolescence age, rural residence, low education level and belonging to a poor household, but their association was stronger among infants. Conclusions We have identified the vulnerable groups at risk of mortality as LBW children, multiple births, rural dwellers, those whose mother are of low socio-economic position, adolescents and unmarried. The differences in causes of mortalities between children aged 0–5 and 5–9 years were noted. These findings suggest for a strong life-course approach in the design and implementation of child health interventions that target pregnant women and children of all ages.
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Affiliation(s)
- Rornald Muhumuza Kananura
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
- Department of Health Policy Planning and Management, Makerere University School of Public Health, New Mulago Complex, Kampala, Uganda
- * E-mail: ,
| | - Tiziana Leone
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Tryphena Nareeba
- Makerere University Centre for Health and Population Research (MUCHAP) and Iganga-Mayuge Health and Demographic Surveillance Site, Iganga, Kampala, Uganda
| | - Dan Kajungu
- Makerere University Centre for Health and Population Research (MUCHAP) and Iganga-Mayuge Health and Demographic Surveillance Site, Iganga, Kampala, Uganda
| | - Peter Waiswa
- Department of Health Policy Planning and Management, Makerere University School of Public Health, New Mulago Complex, Kampala, Uganda
- Global Health Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Arjan Gjonca
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
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13
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Awor P, Nabiryo M, Manderson L. Innovations in maternal and child health: case studies from Uganda. Infect Dis Poverty 2020; 9:36. [PMID: 32295648 PMCID: PMC7161188 DOI: 10.1186/s40249-020-00651-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 03/23/2020] [Indexed: 12/01/2022] Open
Abstract
Background Nearly 300 children and 20 mothers die from preventable causes daily, in Uganda. Communities often identify and introduce pragmatic and lasting solutions to such challenging health problems. However, little is known of these solutions beyond their immediate surroundings. If local and pragmatic innovations were scaled-up, they could contribute to better health outcomes for larger populations. In 2017 an open call was made for local examples of community-based solutions that contribute to improving maternal and child health in Uganda. In this article, we describe three top innovative community-based solutions and their contributions to maternal health. Main text In this study, all innovations were implemented by non-government entities. Two case studies highlight the importance of bringing reproductive health and maternal delivery services closer to populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service, through task-shifting certain sonography services to midwives. Various health system and policy relevant lessons are highlighted. Conclusions The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Emphasis should be put on identification, capacity building and research to support the scale up of these community-based health solutions.
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Affiliation(s)
- Phyllis Awor
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
| | - Maxencia Nabiryo
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Lenore Manderson
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,School of Social Sciences, Monash University, Melbourne, Australia.,Institute at Brown for Environment and Society, Brown University, Providence, RI, USA
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14
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Chiu C, Scott NA, Kaiser JL, Ngoma T, Lori JR, Boyd CJ, Rockers PC. Household saving during pregnancy and facility delivery in Zambia: a cross-sectional study. Health Policy Plan 2019; 34:102-109. [PMID: 30768183 PMCID: PMC6481286 DOI: 10.1093/heapol/czz005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 11/25/2022] Open
Abstract
Financial barriers cause many women in low- and middle-income countries to deliver outside of a health facility, contributing to maternal and neonatal mortality. Savings accrued during pregnancy can increase access to safe delivery services. We investigated the relationship between household saving during pregnancy and facility delivery. A cross-section of 2381 women who delivered a child in the previous 12 months was sampled from 40 health facility catchment areas across eight districts in three provinces in Zambia in April and May of 2016. During a household survey, women reported on their perceptions of the adequacy of their household savings during their recent pregnancy. Households were categorized based on women’s responses as: did not save; saved but not enough; and saved enough. We estimated crude and adjusted associations between perceived adequacy of savings and facility delivery. We also explored associations between savings and expenditures on delivery. Overall, 51% of women surveyed reported that their household saved enough for delivery; 32% reported saving but not enough; and 17% did not save. Household wealth was positively associated with both categories of saving, while earlier attendance at antenatal care was positively associated with saving enough. Compared with women in households that did not save, those in households that saved but not enough (aOR 1.63; 95% CI: 1.17, 2.25) and saved enough (aOR 2.86; 95% CI: 2.05, 3.99) had significantly higher odds of facility delivery. Both categories of saving were significantly associated with higher overall expenditure on delivery, driven in large part by higher expenditures on baby clothes and transportation. Our findings suggest that interventions that encourage saving early in pregnancy may improve access to facility delivery services.
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Affiliation(s)
- Calvin Chiu
- Innovations for Poverty Action Zambia, Plot 26, Mwambula Street, Jesmondine, Lusaka, Zambia.,School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA, USA
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA
| | - Thandiwe Ngoma
- Right to Care - Zambia, 11059 Off Brentwood Road, Longacres, Lusaka, Zambia
| | - Jody R Lori
- University of Michigan School of Nursing, Center for Global Affairs & PAHO/WHO Collaborating Center, 426 N Ingalls St, Ann Arbor, MI, USA
| | - Carol J Boyd
- Alcohol, Smoking and Health, University of Michigan School of Nursing, Center for the Study of Drugs, 426 N Ingalls St, Ann Arbor, MI, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA
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15
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Harahap NC, Handayani PW, Hidayanto AN. Barriers and technologies of maternal and neonatal referral system in developing countries: A narrative review. INFORMATICS IN MEDICINE UNLOCKED 2019. [DOI: 10.1016/j.imu.2019.100184] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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