Audit of Childbirth Emergency Referrals by Trained Traditional Birth Attendants in Enugu, Southeast, Nigeria

Types, reporting and acceptability of community-based interventions for stillbirth prevention in sub-Saharan Africa (SSA): a systematic review

Background

Community-based interventions are increasingly being implemented in Sub-Saharan Africa (SSA) for stillbirth prevention, but the nature of these interventions, their reporting and acceptability are poorly assessed. In addition to understanding their effectiveness, complete reporting of the methods, results and intervention acceptability is essential as it could potentially reduce research waste from replication of inadequately implemented and unacceptable interventions. We conducted a systematic review to investigate these aspects of community-based interventions for preventing stillbirths in SSA.

Methods

In this systematic review, eight databases (MEDLINE(OvidSP), Embase (OvidSP), Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index (Web of Science Core Collection), CINAHL (EBSCOhost) and Global Index Medicus) and four grey literature sources were searched from January 1, 2000 to July 7, 2023 for relevant quantitative and qualitative studies from SSA (PROSPERO-CRD42021296623). Following deduplication, abstract screening and full-text review, studies were included if the interventions were community-based with or without a health facility component. The main outcomes were types of community-based interventions, completeness of intervention reporting using the TIDier (Template for Intervention Description and replication) checklist, and themes related to intervention acceptability identified using a theoretical framework. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools.

Findings

Thirty-nine reports from thirty-four studies conducted in 18 SSA countries were eligible for inclusion. Four types of interventions were identified: nutritional, infection prevention, access to skilled childbirth attendants and health knowledge/behaviour of women. These interventions were implemented using nine strategies: mHealth (defined as the use of mobile and wireless technologies to support the achievement of health objectives), women's groups, community midwifery, home visits, mass media sensitisation, traditional birth attendant and community volunteer training, community mobilisation and transport vouchers. The completeness of reporting using the TIDier checklist varied across studies with a very low proportion of the included studies reporting the intervention intensity, dosing, tailoring and modification. The quality of the included studies were graded as poor (n = 6), fair (n = 14) and good (n = 18). Though interventions were acceptable, only 4 (out of 7) studies explored women's perceptions, mostly focusing on perceived intervention effects and how they felt, omitting key constructs like ethicality, opportunity cost and burden of participation.

Interpretation

Different community-based interventions have been tried and evaluated for stillbirth prevention in SSA. The reproducibility and implementation scale-up of these interventions may be limited by incomplete intervention descriptions in the published literature. To strengthen impact, it is crucial to holistically explore the acceptability of these interventions among women and their families.

Funding

Clarendon/Balliol/NDPH DPhil scholarship for UGA. MN is funded by a Medical Research Council Transition Support Award (MR/W029294/1).

Screening methods for congenital anomalies in low and lower-middle income countries: A systematic review

INTRODUCTION

Surgically correctable congenital anomalies are responsible for a significant burden of morbidity and mortality in children from low-and lower-middle-income countries (LMICs). Early identification through fetal and neonatal screening is critical to reducing death and disability. This study aims to identify feasible screening methods for surgically correctable congenital anomalies in LMICs.

METHODS

A systematic search looking at screening for congenital anomalies in LMIC was conducted in seven databases from 2000 until May 25, 2020, with no language restriction. All articles discussing screening methods for surgically correctable congenital anomalies in LMICs were included. Articles were screened by two independent contributors using Rayyan software, with a third contributor resolving conflicts. Feasibility of the screening method and its risk of bias were assessed using the MINORS scale.

RESULTS

Of 3473 articles, 24 were included in the full-text review. Nine screening methods (three prenatal and six postnatal) were identified - the most frequently utilized being physician clinical examination (45.8%), pulse oximetry (33.3%) and fetal ultrasound (20.8%). The use of a birth defect picture toolkit was the most feasible screening method. The risk of bias scale yielded an average of 11.9 points, which corresponds to a moderate level of bias.

CONCLUSION

Despite clear benefits, prenatal and neonatal screening methods are infrequently used in LMICs to identify surgically correctable congenital anomalies in neonates, likely due to financial, material, and human resource constraints. Further research into the development of low-cost feasible methods is needed within these settings.

PROSPERO REGISTRATION NUMBER

CRD42020192051.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

IV.

Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria's most urbanised state

The criticality of referral makes it imperative to study its patterns and factors influencing it at a health systems level. This study of referral in Lagos, Nigeria is based on health records of 4181 pregnant women who presented with obstetric emergencies at one of the 24 comprehensive emergency obstetric care (EmOC) facilities in the state between November 2018 and October 2019 complemented with distance and time data extracted from Google Maps. Univariate, bivariate, and multivariate analyses were conducted. About a quarter of pregnant women who presented with obstetric emergencies were referred. Most referrals were from primary health centres (41.9 %), private (23.5 %) and public (16.2 %) hospitals. Apart from the expected low-level to high-level referral pattern, there were other patterns observed including non-formal, multiple, and post-delivery referrals. Travel time and distance to facilities that could provide needed care increased two-fold on account of referrals compared to scenarios of going directly to the final facility, mostly travelling to these facilities by private cars/taxis (72.8 %). Prolonged/obstructed labour was the commonest obstetric indication for referral, with majority of referred pregnant women delivered via caesarean section (52.9 %). After adjustment, being married, not being registered for antenatal care at facility of care, presenting at night or with a foetus in distress increased the odds of referral. However, parity, presentation in the months following the commissioning of a new comprehensive EmOC facility or with abortion reduced the likelihood of being referred. Our findings underscore the need for health systems strengthening interventions that support women during referral and the importance of antenatal care and early booking to aid identification of potential pregnancy complications whilst establishing robust birth preparedness plans that can minimise the need for referral in the event of emergencies. Indeed, there are context-specific influences that need to be addressed if effective referral systems are to be designed.

Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review

Background

sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women.

Methods

Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility.

Results

Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral.

Conclusions

Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals.

Trial registration

Systematic review registration: PROSPERO registration CRD42018114261.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.