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Miranda J, Miller S, Alfieri N, Lalonde A, Ivan-Ortiz E, Hanson C, Steinholt M, Palshetkar N, Suharjono H, Gebhardt S, Dossou JP, Pascali-Bonaro D, Jacobsson B, Okong P. Global health systems strengthening: FIGO's strategic view on reducing maternal and newborn mortality worldwide. Int J Gynaecol Obstet 2024; 165:849-859. [PMID: 38651311 DOI: 10.1002/ijgo.15553] [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] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To demonstrate that successful health systems strengthening (HSS) projects have addressed disparities and inequities in maternal and perinatal care in low-income countries. METHODS A comprehensive literature review covered the period between 1980 and 2022, focusing on successful HSS interventions within health systems' seven core components that improved maternal and perinatal care. RESULTS The findings highlight the importance of integrating quality interventions into robust health systems, as this has been shown to reduce maternal and newborn mortality. However, several challenges, including service delivery gaps, poor data use, and funding deficits, continue to hinder the delivery of quality care. To improve maternal and newborn health outcomes, a comprehensive HSS strategy is essential, which should include infrastructure enhancement, workforce skill development, access to essential medicines, and active community engagement. CONCLUSION Effective health systems, leadership, and community engagement are crucial for a comprehensive HSS approach to catalyze progress toward universal health coverage and global improvements in maternal and newborn health.
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Affiliation(s)
- Jezid Miranda
- Department of Obstetrics and Gynecology, Grupo de Investigación en Cuidado Intensivo y Obstetricia (GRICIO), Universidad de Cartagena, Cartagena de Indias, Colombia
- Centro Hospitalario Serena del Mar y Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Suellen Miller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Nikita Alfieri
- Department of Obstetrics and Gynecology, San Paolo Hospital Medical School, University of Milano, Milano, Italy
| | - Andre Lalonde
- FIGO International Childbirth Initiative and Working Group, Ottawa, Ontario, Canada
| | - Edgar Ivan-Ortiz
- Department of Obstetrics and Gynecology, Universidad del Valle, Cali, Colombia
| | - Claudia Hanson
- Public Health Sciences - Global Health - Health Systems and Policy, Karolinska Institute, Stockholm, Sweden
| | - Margit Steinholt
- Helgeland Hospital Trust, Sandnessjøen, Norway
- Norwegian University of Science and Technology, Trondheim, Norway
| | - Nandita Palshetkar
- Department of Reproductive Medicine, Patil Medical College, Mumbai, India
| | - Harris Suharjono
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Stefan Gebhardt
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Debra Pascali-Bonaro
- International Childbirth Consultant, Trainer, and Speaker, River Vale, New Jersey, USA
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
| | - Pius Okong
- Department of Obstetrics and Gynecology, St Francis Hospital Nsambya, Kampala City, Uganda
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Iroz CB, Ramaswamy R, Bhutta ZA, Barach P. Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review. BMC Health Serv Res 2024; 24:332. [PMID: 38481226 PMCID: PMC10935959 DOI: 10.1186/s12913-024-10802-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs. METHODS We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author. RESULTS We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change. CONCLUSIONS Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.
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Affiliation(s)
- Cassandra B Iroz
- Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
| | - Rohit Ramaswamy
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Institute for Global Health & Development, The Aga Khan University, South Central Asia, East Africa, UK
| | - Paul Barach
- Thomas Jefferson University, Philadelphia, PA, USA
- Imperial College, London, UK
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Anguzu R, Walker RJ, Babikako HM, Beyer KMM, Dickson-Gomez J, Zhou Y, Cassidy LD. Intimate partner violence and antenatal care utilization predictors in Uganda: an analysis applying Andersen's behavioral model of healthcare utilization. BMC Public Health 2023; 23:2276. [PMID: 37978467 PMCID: PMC10656909 DOI: 10.1186/s12889-023-16827-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 09/24/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Optimal utilization of antenatal care (ANC) services improves positive pregnancy experiences and birth outcomes. However, paucity of evidence exists on which factors should be targeted to increase ANC utilization among women experiencing intimate partner violence (IPV) in Uganda. OBJECTIVE To determine the independent association between IPV exposure and ANC utilization as well as the predictors of ANC utilization informed by Andersen's Behavioral Model of Healthcare Utilization. METHODS We analyzed 2016 Uganda Demographic and Health Survey data that included a sample of 1,768 women with children aged 12 to 18 months and responded to both ANC utilization and IPV items. Our outcome was ANC utilization, a count variable assessed as the number of ANC visits in the last 12 months preceding the survey. The key independent variable was exposure to any IPV form defined as self-report of having experienced physical, sexual and/or emotional IPV. Covariates were grouped into predisposing (age, formal education, religion, problem paying treatment costs), enabling (women's autonomy, mass media exposure), need (unintended pregnancy, parity, history of pregnancy termination), and healthcare system/environmental factors (rural/urban residence, spatial accessibility to health facility). Poisson regression models tested the independent association between IPV and ANC utilization, and the predictors of ANC utilization after controlling for potential confounders. RESULTS Mean number of ANC visits (ANC utilization) was 3.71 visits with standard deviation (SD) of ± 1.5 respectively. Overall, 60.8% of our sample reported experiencing any form of IPV. Any IPV exposure was associated with lower number of ANC visits (3.64, SD ± 1.41) when compared to women without IPV exposure (3.82, SD ± 1.64) at p = 0.013. In the adjusted models, any IPV exposure was negatively associated with ANC utilization when compared to women with no IPV exposure after controlling for enabling factors (Coef. -0.03; 95%CI -0.06,-0.01), and healthcare system/environmental factors (Coef. -0.06; 95%CI -0.11,-0.04). Predictors of ANC utilization were higher education (Coef. 0.27; 95%CI 0.15,0.39) compared with no education, high autonomy (Coef. 0.12; 95%CI 0.02,0.23) compared to low autonomy, and partial media exposure (Coef. 0.06; 95%CI 0.01,0.12) compared to low media exposure. CONCLUSION Addressing enabling and healthcare system/environmental factors may increase ANC utilization among Ugandan women experiencing IPV. Prevention and response interventions for IPV should include strategies to increase girls' higher education completion rates, improve women's financial autonomy, and mass media exposure to improve ANC utilization in similar populations in Uganda.
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Affiliation(s)
- Ronald Anguzu
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, US.
- Center for Advancing Population Sciences (CAPS), Medical College of Wisconsin, Milwaukee, US.
| | - Rebekah J Walker
- Center for Advancing Population Sciences (CAPS), Medical College of Wisconsin, Milwaukee, US
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, US
| | - Harriet M Babikako
- Department of Child Health and Development Center, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kirsten M M Beyer
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, US
- Center for Advancing Population Sciences (CAPS), Medical College of Wisconsin, Milwaukee, US
| | - Julia Dickson-Gomez
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, US
| | - Yuhong Zhou
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, US
| | - Laura D Cassidy
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, US
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Mianda S, Todowede O, Schneider H. Service delivery interventions to improve maternal and newborn health in low- and middle-income countries: scoping review of quality improvement, implementation research and health system strengthening approaches. BMC Health Serv Res 2023; 23:1223. [PMID: 37940974 PMCID: PMC10634015 DOI: 10.1186/s12913-023-10202-6] [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: 03/15/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
INTRODUCTION This review explores the characteristics of service delivery-related interventions to improve maternal and newborn health (MNH) in low-and middle-income countries (LMICs) over the last two decades, comparing three common framings of these interventions, namely, quality improvement (QI), implementation science/research (IS/IR), and health system strengthening (HSS). METHODS The review followed the staged scoping review methodology proposed by Levac et al. (2010). We developed and piloted a systematic search strategy, limited to English language peer-reviewed articles published on LMICs between 2000 and March 2022. Analysis was conducted in two-quantitative and qualitative-phases. In the quantitative phase, we counted the year of publication, country(-ies) of origin, and the presence of the terms 'quality improvement', 'health system strengthening' or 'implementation science'/ 'implementation research' in titles, abstracts and key words. From this analysis, a subset of papers referred to as 'archetypes' (terms appearing in two or more of titles, abstract and key words) was analysed qualitatively, to draw out key concepts/theories and underlying mechanisms of change associated with each approach. RESULTS The searches from different databases resulted in a total of 3,323 hits. After removal of duplicates and screening, a total of 231 relevant articles remained for data extraction. These were distributed across the globe; more than half (n = 134) were published since 2017. Fifty-five (55) articles representing archetypes of the approach (30 QI, 16 IS/IR, 9 HSS) were analysed qualitatively. As anticipated, we identified distinct patterns in each approach. QI archetypes tended towards defined process interventions (most typically, plan-do-study-act cycles); IS/IR archetypes reported a wide variety of interventions, but had in common evaluation methodologies and explanatory theories; and HSS archetypes adopted systemic perspectives. Despite their distinctiveness, there was also overlap and fluidity between approaches, with papers often referencing more than one approach. Recognising the complexity of improving MNH services, there was an increased orientation towards participatory, context-specific designs in all three approaches. CONCLUSIONS Programmes to improve MNH outcomes will benefit from a better appreciation of the distinctiveness and relatedness of different approaches to service delivery strengthening, how these have evolved and how they can be combined.
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Affiliation(s)
- Solange Mianda
- School of Public Health & SAMRC Health Services to Systems Research Unit, University of the Western Cape, Private Bag X17, Bellville, 7535, Cape Town, South Africa.
| | - Olamide Todowede
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Helen Schneider
- School of Public Health & SAMRC Health Services to Systems Research Unit, University of the Western Cape, Private Bag X17, Bellville, 7535, Cape Town, South Africa
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Ssegujja E, Andipatin M. Examining the variations in the implementation of interventions to address stillbirth from the national to subnational levels: experiences from Uganda. Health Res Policy Syst 2022; 20:123. [PMID: 36333716 PMCID: PMC9636672 DOI: 10.1186/s12961-022-00928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background The current global burden of stillbirth disproportionately affects regions such as sub-Saharan Africa, where Uganda is located. To respond to this burden, policies made at the national level were diffused from the centre and translated into service delivery at the district level, which is charged with implementation under the decentralization of health services arrangement. Variations emerge whenever policy recommendations are moved from national to subnational levels, with some aspects often lost along the way. Tools are available to facilitate knowledge of determinants of policy and innovation implementation within the healthcare system. However, the extent to which these have been applied to explain variations in implementation of interventions to address stillbirth reduction in Uganda remains scant. The aim of this article was to examine the variations in the implementation of interventions to address stillbirth from the national to the subnational levels in Uganda using the Consolidated Framework for Implementation Research (CFIR). Methods The study adopted a qualitative case study design. Data were collected from a purposively selected sample of key informants drawn from both the national and subnational levels. All interviews were conducted in English and transcribed verbatim. ATLAS.ti was used to guide the coding process, which used a codebook developed following the CFIR domains as codes and constructs as sub-codes. Analysis followed a content analysis technique. Results National-level factors that favoured implementation of interventions to address stillbirth included the desire to comply with global norms, incentives to improve performance for stillbirth reduction indicators for better comparison with global peers, and clear policy alternatives as process implementation advanced by champions. Variations at the subnational level revealed aspirations to address service delivery gaps which fell within maternal health routine standard of care and ongoing health systems strengthening initiatives. Coalescing existing networks around maternal and child health was a key mobilization factor for advocacy and programming, with a promise that the set targets would be operationalized at the subnational level. The key champions were defined by their official roles within the district health systems, which enhanced accountability. Feedback and reflection were distinguished from the national to subnational through joint assemblies and formal audit reviews, respectively. Conclusions A heavy influence of the global events directed national-level adaptation of interventions to address stillbirth. Implementation context at the subnational level led to local adaptation and translation of policy provisions from the national level to suit the context, which to a greater extent explains the variations in the final content of policy provisions delivered.
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Affiliation(s)
- Eric Ssegujja
- grid.11194.3c0000 0004 0620 0548Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda ,grid.8974.20000 0001 2156 8226School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Michelle Andipatin
- grid.8974.20000 0001 2156 8226Department of Psychology, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
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Muwema M, Kaye DK, Edwards G, Nalwadda G, Nangendo J, Okiring J, Mwanja W, Ekong EN, Kalyango JN, Nankabirwa JI. Perinatal care in Western Uganda: Prevalence and factors associated with appropriate care among women attending three district hospitals. PLoS One 2022; 17:e0267015. [PMID: 35639711 PMCID: PMC9154186 DOI: 10.1371/journal.pone.0267015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/31/2022] [Indexed: 11/25/2022] Open
Abstract
Background Perinatal mortality remains high globally and remains an important indicator of the quality of a health care system. To reduce this mortality, it is important to provide the recommended care during the perinatal period. We assessed the prevalence and factors associated with appropriate perinatal care (antenatal, intrapartum, and postpartum) in Bunyoro region, Uganda. Results from this study provide valuable information on the perinatal care services and highlight areas of improvement for better perinatal outcomes. Methods A cross sectional survey was conducted among postpartum mothers attending care at three district hospitals in Bunyoro. Following consent, a questionnaire was administered to capture the participants’ demographics and data on care received was extracted from their antenatal, labour, delivery, and postpartum records using a pre-tested structured tool. The care received by women was assessed against the standard protocol established by World Health Organization (WHO). Poisson regression with robust standard errors was used to assess factors associated with appropriate postpartum care. Results A total of 872 mothers receiving care at the participating hospitals between March and June 2020 were enrolled in the study. The mean age of the mothers was 25 years (SD = 5.95). None of the mothers received appropriate antenatal or intrapartum care, and only 3.8% of the participants received appropriate postpartum care. Factors significantly associated with appropriate postpartum care included mothers being >35 years of age (adjusted prevalence ratio [aPR] = 11.9, 95% confidence interval [CI] 2.8–51.4) and parity, with low parity (2–3) and multiparous (>3) mothers less likely to receive appropriate care than prime gravidas (aPR = 0.3, 95% CI 0.1–0.9 and aPR = 0.3, 95% CI 0.1–0.8 respectively). Conclusions Antenatal, intrapartum, and postpartum care received by mothers in this region remains below the standard recommended by WHO, and innovative strategies across the continuum of perinatal care need to be devised to prevent mortality among the mothers. The quality of care also needs to be balanced for all mothers irrespective of the age and parity.
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Affiliation(s)
- Mercy Muwema
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Dan K. Kaye
- Department of Obstetrics and Gynecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grace Edwards
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda
| | - Gorrette Nalwadda
- Department of Nursing, School of Health Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joanita Nangendo
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Elizabeth N. Ekong
- Department of Nursing, Faculty of Health Sciences, Uganda Christian University, Uganda
| | - Joan N. Kalyango
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Pharmacy, School of Health Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joaniter I. Nankabirwa
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
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Karamagi HC, Ben Charif A, Ngusbrhan Kidane S, Yohanes T, Kariuki D, Titus M, Batungwanayo C, Seydi ABW, Berhane A, Nzinga J, Njuguna D, Kipruto HK, Andrews Annan E, Droti B. Investments for effective functionality of health systems towards Universal Health Coverage in Africa: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001076. [PMID: 36962623 PMCID: PMC10021830 DOI: 10.1371/journal.pgph.0001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/18/2022]
Abstract
The health challenges in Africa underscore the importance of effectively investing in health systems. Unfortunately, there is no information on systems investments adequate for an effective functional health system. We aimed to address this by conducting a scoping review of existing evidence following the Joanna Briggs Institute Manual for Evidence Synthesis and preregistered with the Open Science Framework (https://osf.io/bvg4z). We included any empirical research describing interventions that contributed to the functionality of health systems in Africa or any low-income or lower-middle-income regions. We searched Web of Science, MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL, and ERIC from their inception, and hand-searched other relevant sources. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. We identified 554 unique reports describing 575 interventions, of which 495 reported evidence of effectiveness. Most interventions were undertaken in Africa (80.9%), covered multiple elements of health systems (median: 3), and focused on service delivery (77.4%) and health workforce (65.6%). Effective interventions contributed to improving single (35.6%) or multiple (64.4%) capacities of health systems: access to essential services (75.6%), quality of care (70.5%), demand for essential services (38.6%), or health systems resilience (13.5%). For example, telemedicine models which covered software (technologies) and hardware (health workers) elements were used as a strategy to address issues of access to essential services. We inventoried these effective interventions for improving health systems functionality in Africa. Further analyses could deepen understanding of how such interventions differ in their incorporation of evidence for potential scale across African countries.
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Affiliation(s)
- Humphrey Cyprian Karamagi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | | | - Solyana Ngusbrhan Kidane
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Tewelde Yohanes
- Division of Policy and Planning, Ministry of Health, Asmara, Eritrea
| | | | | | | | - Aminata Binetou-Wahebine Seydi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Araia Berhane
- Conmmunicable Diseases Control Division, Ministry of Health, Asmara, Eritrea
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - David Njuguna
- Health Economist, Ministry of Health, Nairobi, Kenya
| | - Hillary Kipchumba Kipruto
- Essential Drugs and Medicines, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Edith Andrews Annan
- Essential Drugs and Medicines, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Benson Droti
- Health Information Systems, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Congo
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Gitaka J, Mbugua S, Mwaura P, Gatungu D, Githanga D, Ndwiga C, Abuya T, K'Oduol K, Liambila W, Were F. Devolved health system capacity in the provision of care for sick newborns and young infants in four counties serving vulnerable populations in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000183. [PMID: 36962529 PMCID: PMC10022333 DOI: 10.1371/journal.pgph.0000183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/15/2022] [Indexed: 03/26/2023]
Abstract
Possible severe bacterial infections (PSBI) is one of the three leading causes of newborn and young infant mortality globally that can be prevented by timely diagnosis and treatment using suitable antibiotics. High impact interventions such as use of out-patient injectable gentamicin and dispersible Amoxicillin with community-based follow up have been shown to reduce mortality in clinical trials. The objective of this study was to assess the health systems' preparedness and organizational gaps that may impact execution in providing care for newborns and sick young infants. This formative research study was embedded within a three-year implementation research project in 4 Counties in Kenya. The indicators were based on facility audits for existing capacity to care for newborns and young infants as well as County organizational capacity assessment. The organizational capacity assessment domains were derived from the World Health Organization's Health Systems Building blocks for health service delivery. The scores were computed by adding average scores in each domain and calculated against the total possible scores to generate a percentage outcome. Statistical analyses were descriptive with adjustment for clustering of data. Overall, the Counties have inadequate organizational capacity for management of sick young infants with Organizational Capacity Index scores of between 61-64%. Among the domains, the highest score was in Health Management Information System and service delivery. The lowest scores were in monitoring and evaluation (M&E). Counties scored relatively low scores in human resources for health and health products and commodities with one scoring poorly for both areas while the rest scored average performance. The four counties revealed varying levels of organizational capacity deficit to effectively manage sick young infants. The key underlying issues for the below par performance include poor coordination, low funding, inadequate supportive supervision, and M&E to enable data utilisation for quality improvement. It was evident that newborn and young infant health services suffer from inadequate infrastructure, equipment, staffing, and coordination. As Kenya, continuously rolls out the guidelines on management of sick young infants, there is need to focus attention to these challenges to enhance sustainable adoption and reduction of young infant morbidity and mortality.
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Affiliation(s)
- Jesse Gitaka
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | - Samuel Mbugua
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | - Peter Mwaura
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | - Daniel Gatungu
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | | | | | | | | | | | - Fred Were
- Kenya Paediatric Research Consortium, Nairobi, Kenya
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Sequeira Dmello B, Sellah Z, Magembe G, Housseine N, Maaløe N, van den Akker T, Meyrowitsch DW, Mushi T, Masweko M, Jidayi D, van Roosmalen J, Kidanto HL. Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019. BMJ Glob Health 2021; 6:bmjgh-2020-004022. [PMID: 33479018 PMCID: PMC7825259 DOI: 10.1136/bmjgh-2020-004022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/24/2020] [Accepted: 12/26/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction Rapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city’s facility births. Methods Multiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed. Results Significant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%). Conclusions This collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.
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Affiliation(s)
- Brenda Sequeira Dmello
- Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania .,Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark.,Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania
| | - Ziada Sellah
- Director, Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dodoma, United Republic of Tanzania
| | - Grace Magembe
- Director, Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dodoma, United Republic of Tanzania
| | - Natasha Housseine
- Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania
| | - Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark.,Department of Obstetrics and Gynaecology, Hvidovre Hospital, Hvidovre, Denmark
| | - Thomas van den Akker
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Dan W Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark
| | - Timothy Mushi
- Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Mangalu Masweko
- Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Dorcas Jidayi
- Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Jos van Roosmalen
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Hussein L Kidanto
- Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania
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10
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Bonney E, Villalobos M, Elison J, Sung S, Wosu A, SSemugabo C, Pariyo G, Kajungu D, Rutebemberwa E, Hyder AA, Gibson D. Caregivers' estimate of early childhood developmental status in rural Uganda: a cross-sectional study. BMJ Open 2021; 11:e044708. [PMID: 34158295 PMCID: PMC8220531 DOI: 10.1136/bmjopen-2020-044708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To characterise developmental milestones among young children living in rural communities in Uganda. DESIGN Cross-sectional study. SETTING Iganga-Mayuge Health and Demographic Surveillance Site in rural eastern Uganda. PARTICIPANTS A total of 720 caregivers of children aged 3-4 years old from a health and demographic surveillance site in rural eastern Uganda were recruited into this study. Caregivers reported on their child's developmental skills and behaviours using the 10-item Early Childhood Development Index (ECDI) developed by UNICEF. Childhood development was characterised based on the ECDI's four domains: literacy-numeracy, learning/cognition, physical and socioemotional development. As an exploratory analysis, we implemented a hierarchical agglomerative cluster analysis to identify homogenous subgroups of children based on the features assessed. The cluster analysis was performed to identify potential subgroups of children who may be at risk of developmental problems. RESULTS Between November 2017 and June 2018, 720 caregivers of children aged 3-4 years completed the ECDI. The proportions of children at risk of delay in each domain were as follows: literacy-numeracy: 75% (n=538); socioemotional development: 22% (n=157); physical: 3% (n=22); and cognitive: 4% (n=32). The cluster analysis revealed a three-cluster solution that included 93% of children assigned to a low-risk group, 4% assigned to a moderate-risk group and 3% assigned to a high-risk group characterised by low scores in almost all domains. CONCLUSION The findings suggest that a high proportion of children in rural eastern Uganda demonstrate poor literacy-numeracy skills. These results underscore the need to improve population-based screening and intervention efforts to improve early childhood developmental outcomes, particularly in literacy and socioemotional domains, in low-income and middle-income countries such as Uganda.
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Affiliation(s)
- Emmanuel Bonney
- The Elison Lab for Developmental Brain and Behaviour Research, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
- Department of Psychiatry, Makerere University, CHS, Kampala, Uganda
- Institute of Child Development, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Michele Villalobos
- Department of Paediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Jed Elison
- The Elison Lab for Developmental Brain and Behaviour Research, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
- Institute of Child Development, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Sooyeon Sung
- The Elison Lab for Developmental Brain and Behaviour Research, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
- Institute of Child Development, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Adaeze Wosu
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Charles SSemugabo
- Department of Disease Control and Environmental Health, Makerere University CHS, Kampala, Uganda
| | - George Pariyo
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dan Kajungu
- Centre for Health and Population Research (MUCHAP), Makerere University, Kampala, Uganda
| | - Elizeus Rutebemberwa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
- Centre for Tobacco Control in Africa, Makerere University, Kampala, Uganda
| | - Adnan A Hyder
- Milken Institute of Public Health, George Washington University, Washington, District of Columbia, USA
| | - Dustin Gibson
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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11
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Kabugo D, Nakamura H, Magnusson B, Vaughan M, Niyonshaba B, Nakiganda C, Otai C, Haddix-McKay K, Seela M, Nankabala J, Nakakande J, Ssekidde M, Tann CJ, Al-Haddad BJS, Nyonyintono J, Mubiri P, Waiswa P, Paudel M. Mixed-method study to assess the feasibility, acceptability and early effectiveness of the Hospital to Home programme for follow-up of high-risk newborns in a rural district of Central Uganda: a study protocol. BMJ Open 2021; 11:e043773. [PMID: 33653756 PMCID: PMC7929893 DOI: 10.1136/bmjopen-2020-043773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/07/2021] [Accepted: 02/10/2021] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION A follow-up programme designed for high-risk newborns discharged from inpatient newborn units in low-resource settings is imperative to ensure these newborns receive the healthiest possible start to life. We aim to assess the feasibility, acceptability and early outcomes of a discharge and follow-up programme, called Hospital to Home (H2H), in a neonatal unit in central Uganda. METHODS AND ANALYSIS We will use a mixed-methods study design comparing a historical cohort and an intervention cohort of newborns and their caregivers admitted to a neonatal unit in Uganda. The study design includes two main components. The first component includes qualitative interviews (n=60 or until reaching saturation) with caregivers, community health workers called Village Health Team (VHT) members and neonatal unit staff. The second component assesses and compares outcomes between a prospective intervention cohort (n=100, born between July 2019 and September 2019) and a historical cohort (n=100, born between July 2018 and September 2018) of infants. The historical cohort will receive standard care while the intervention cohort will receive standard care plus the H2H intervention. The H2H intervention comprises training for healthcare workers on lactation, breast feeding and neurodevelopmentally supportive care, including cue-based feeding, and training to caregivers on recognition of danger signs and care of their high-risk infants. Infants and their families receive home visits until 6 months of age, or longer if necessary, by specially trained VHTs. Quantitative data will be analysed using descriptive statistics and regression analysis. All results will be stratified by cohort group. Qualitative data will be analysed guided by Braun and Clarke's thematic analysis technique. ETHICS AND DISSEMINATION This study protocol was approved by the relevant Ugandan ethics committees. All participants will provide written informed consent. We will disseminate through peer-reviewed publications and key stakeholders and public engagement. TRIAL REGISTRATION NUMBER ISRCTN51636372; Pre-result.
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Affiliation(s)
- Daniel Kabugo
- Adara Development (Uganda), Adara Group, Nakaseke, Uganda
| | - Heidi Nakamura
- Adara Development (USA), Adara Group, Edmonds, Washington, USA
| | | | - Madeline Vaughan
- Adara Development (Australia), Adara Group, Sydney, New South Wales, Australia
| | | | | | - Christine Otai
- Adara Development (Uganda), Adara Group, Nakaseke, Uganda
| | - Kimber Haddix-McKay
- Adara Development (USA), Adara Group, Edmonds, Washington, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | | | | | | | | | - Cally J Tann
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Neonatal Medicine, University College London Hospitals NHS Trust, London, UK
| | - Benjamin J S Al-Haddad
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | | | - Paul Mubiri
- School of Public Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Peter Waiswa
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Makerere University Centre of Excellence for Maternal Newborn and Child Health, Makerere University School of Public Health, Kampala, Uganda
| | - Mohan Paudel
- Adara Development (Australia), Adara Group, Sydney, New South Wales, Australia
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12
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Uldbjerg CS, Schramm S, Kaducu FO, Ovuga E, Sodemann M. Perceived barriers to utilization of antenatal care services in northern Uganda: A qualitative study. SEXUAL & REPRODUCTIVE HEALTHCARE 2019; 23:100464. [PMID: 31710878 DOI: 10.1016/j.srhc.2019.100464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/10/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Antenatal care (ANC) utilization remains a challenge in efforts to reduce maternal mortality and improve maternal health in Uganda. This study aimed to identify perceived barriers to utilization of ANC services in a rural post-conflict area in northern Uganda. METHODS A qualitative study using in-depth interviews and focus group discussions of seventeen participants (pregnant women, health workers and a traditional birth attendant). The study was informed through a phenomenological approach to capture perceived barriers to utilization of ANC. The study was carried out in post-conflict Awach sub-county, Gulu District, northern Uganda. Data was analyzed using inductive conventional content analysis. RESULTS The main perceived barriers to ANC utilization were identified as: poor quality of care, including poor attitude of health workers; socio-cultural practices not being successfully aligned to ANC; and lack of support from the husband, including difficulties in encouraging him to attend ANC. Additionally, institutional structures and procedures at the health centers in terms of compulsory HIV testing and material requirements and transportation were perceived to prevent some pregnant women from attending ANC. CONCLUSIONS Identifying local barriers to ANC utilization are important and should be considered when planning ANC programs. We propose that future efforts should focus on how to ensure a good patient-provider relationship and perceived quality of care, and further how to improve inter-spousal communication and sensitization of husbands for increased involvement in ANC. We recommend more research on how socio-cultural context can meaningfully be aligned to ANC to improve maternal health and reduce maternal mortality.
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Affiliation(s)
- Cecilie Skaarup Uldbjerg
- Centre for Global Health, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Stine Schramm
- Centre for Global Health, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Felix Ocaka Kaducu
- Department of Public Health, Faculty of Medicine, Gulu University, Uganda.
| | - Emilio Ovuga
- Department of Mental Health, Faculty of Medicine, Gulu University, Uganda.
| | - Morten Sodemann
- Centre for Global Health, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
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13
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Conlon CM, Serbanescu F, Marum L, Healey J, LaBrecque J, Hobson R, Levitt M, Kekitiinwa A, Picho B, Soud F, Spigel L, Steffen M, Velasco J, Cohen R, Weiss W. Saving Mothers, Giving Life: It Takes a System to Save a Mother (Republication). GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:20-40. [PMID: 30926736 PMCID: PMC6538123 DOI: 10.9745/ghsp-d-19-00092] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/11/2018] [Indexed: 11/21/2022]
Abstract
A multi-partner effort in Uganda and Zambia employed a districtwide health systems strengthening approach, with supply- and demand-side interventions, to address timely use of appropriate, quality maternity care. Between 2012 and 2016, maternal mortality declined by approximately 40% in both partnership-supported facilities and districts in each country. This experience has useful lessons for other low-resource settings. Background: Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public–private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. Implementation: The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. Results: Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (−13% in Uganda and −36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. Conclusion: A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.
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Affiliation(s)
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence Marum
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired
| | - Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia
| | - Jonathan LaBrecque
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Reeti Hobson
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
| | - Marta Levitt
- Bureau for Global Health, U.S. Agency for International Development and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria
| | | | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fatma Soud
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now an independent consultant, Gainesville, FL, USA
| | - Lauren Spigel
- ICF, Fairfax, VA, USA. Now with Ariadne Labs, Boston, MA, USA
| | - Mona Steffen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
| | - Jorge Velasco
- U.S. Agency for International Development, Papua, New Guinea
| | - Robert Cohen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - William Weiss
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
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14
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Quam L, Achrekar A, Clay R. Saving Mothers, Giving Life: A Systems Approach to Reducing Maternal and Perinatal Deaths in Uganda and Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S1-S5. [PMID: 30867206 PMCID: PMC6519674 DOI: 10.9745/ghsp-d-19-00037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 01/21/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Lois Quam
- Director, Global Health Initiative, U.S. Department of State. Now with Pathfinder International, Boston, MA, USA
| | - Angeli Achrekar
- Principal Deputy Coordinator (acting), U.S. Department of State. Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA.
| | - Robert Clay
- Deputy Assistant Administrator, Bureau for Global Health, U.S. Agency for International Development. Now with Save the Children USA, Washington, DC, USA
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15
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Conlon CM, Serbanescu F, Marum L, Healey J, LaBrecque J, Hobson R, Levitt M, Kekitiinwa A, Picho B, Soud F, Spigel L, Steffen M, Velasco J, Cohen R, Weiss W. Saving Mothers, Giving Life: It Takes a System to Save a Mother. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S6-S26. [PMID: 30867207 PMCID: PMC6519673 DOI: 10.9745/ghsp-d-18-00427] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/11/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public-private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. IMPLEMENTATION The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. RESULTS Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (-13% in Uganda and -36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. CONCLUSION A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.
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Affiliation(s)
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence Marum
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired
| | - Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia
| | - Jonathan LaBrecque
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Reeti Hobson
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
| | - Marta Levitt
- Bureau for Global Health, U.S. Agency for International Development and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria
| | | | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fatma Soud
- Centers for Disease Control and Prevention, Lusaka, Zambia. Now an independent consultant, Gainesville, FL, USA
| | - Lauren Spigel
- ICF, Fairfax, VA, USA. Now with Ariadne Labs, Boston, MA, USA
| | - Mona Steffen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC. Now with ICF, Rockville, MD, USA
| | - Jorge Velasco
- U.S. Agency for International Development, Papua, New Guinea
| | - Robert Cohen
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - William Weiss
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
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