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Dynes MM, Daniel GA, Mac V, Picho B, Asiimwe A, Nalutaaya A, Opio G, Kamara V, Kaharuza F, Serbanescu F. A qualitative evaluation and conceptual framework on the use of the Birth weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) matrix for perinatal health in Uganda. BMC Pregnancy Childbirth 2023; 23:86. [PMID: 36726073 PMCID: PMC9890791 DOI: 10.1186/s12884-023-05402-1] [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: 10/10/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Perinatal mortality (newborn deaths in the first week of life and stillbirths) continues to be a significant global health threat, particularly in resource-constrained settings. Low-tech, innovative solutions that close the quality-of-care gap may contribute to progress toward the Sustainable Development Goals for health by 2030. From 2012 to 2018, the Saving Mothers, Giving Life Initiative (SMGL) implemented the Birth weight and Age-at-Death Boxes for Intervention and Evaluation System (BABIES) matrix in Western Uganda. The BABIES matrix provides a simple, standardized way to track perinatal health outcomes to inform evidence-based quality improvement strategies. METHODS In November 2017, a facility-based qualitative evaluation was conducted using in-depth interviews with 29 health workers in 16 health facilities implementing BABIES in Uganda. Data were analyzed using directed content analysis across five domains: 1) perceived ease of use, 2) how the matrix was used, 3) changes in behavior or standard operating procedures after introduction, 4) perceived value of the matrix, and 5) program sustainability. RESULTS Values in the matrix were easy to calculate, but training was required to ensure correct data placement and interpretation. Displaying the matrix on a highly visible board in the maternity ward fostered a sense of accountability for health outcomes. BABIES matrix reports were compiled, reviewed, and responded to monthly by interprofessional teams, prompting collaboration across units to fill data gaps and support perinatal death reviews. Respondents reported improved staff communication and performance appraisal, community engagement, and ability to track and link clinical outcomes with actions. Midwives felt empowered to participate in the problem-solving process. Respondents were motivated to continue using BABIES, although sustainability concerns were raised due to funding and staff shortages. CONCLUSIONS District-level health systems can use data compiled from the BABIES matrix to inform policy and guide implementation of community-centered health practices to improve perinatal heath. Future work may consider using the Conceptual Framework on Use of the BABIES Matrix for Perinatal Health as a model to operationalize concepts and test the impact of the tool over time.
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Affiliation(s)
- Michelle M. Dynes
- grid.416738.f0000 0001 2163 0069Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Gaea A. Daniel
- grid.189967.80000 0001 0941 6502Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA USA
| | - Valerie Mac
- grid.189967.80000 0001 0941 6502Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA USA
| | - Brenda Picho
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Alice Asiimwe
- grid.423308.e0000 0004 0397 2008Baylor College of Medicine Children’s Foundation, Kampala, Uganda
| | - Agnes Nalutaaya
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gregory Opio
- grid.423308.e0000 0004 0397 2008Baylor College of Medicine Children’s Foundation, Kampala, Uganda
| | | | - Frank Kaharuza
- grid.440478.b0000 0004 0648 1247Kampala International University, Western Campus, Ishaka Bushenyi, Uganda
| | - Florina Serbanescu
- grid.416738.f0000 0001 2163 0069Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA USA
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Cao WR, Shakya P, Karmacharya B, Xu DR, Hao YT, Lai YS. Equity of geographical access to public health facilities in Nepal. BMJ Glob Health 2021; 6:bmjgh-2021-006786. [PMID: 34706879 PMCID: PMC8552161 DOI: 10.1136/bmjgh-2021-006786] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/03/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Geographical accessibility is important against health equity, particularly for less developed countries as Nepal. It is important to identify the disparities in geographical accessibility to the three levels of public health facilities across Nepal, which has not been available. Methods Based on the up-to-date dataset of Nepal formal public health facilities in 2021, we measured the geographical accessibility by calculating the travel time to the nearest public health facility of three levels (ie, primary, secondary and tertiary) across Nepal at 1×1 km2 resolution under two travel modes: walking and motorised. Gini and Theil L index were used to assess the inequality. Potential locations of new facilities were identified for best improvement of geographical efficiency or equality. Results Both geographical accessibility and its equality were better under the motorised mode compared with the walking mode. If motorised transportation is available to everyone, the population coverage within 5 min to any public health facilities would be improved by 62.13%. The population-weighted average travel time was 17.91 min, 39.88 min and 69.23 min and the Gini coefficients 0.03, 0.18 and 0.42 to the nearest primary, secondary and tertiary facilities, respectively, under motorised mode. For primary facilities, low accessibility was found in the northern mountain belt; for secondary facilities, the accessibility decreased with increased distance from the district centres; and for tertiary facilities, low accessibility was found in most areas except the developed areas like zonal centres. The potential locations of new facilities differed for the three levels of facilities. Besides, the majority of inequalities of geographical accessibility were from within-province. Conclusion The high-resolution geographical accessibility maps and the assessment of inequality provide valuable information for health resource allocation and health-related planning in Nepal.
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Affiliation(s)
- Wen-Rui Cao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Prabin Shakya
- Departments of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Biraj Karmacharya
- Departments of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Dong Roman Xu
- ACACIA Labs, SMU Institute for Global Health (SIGHT) and Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Center for WHO Studies and Department of Health Management, School of Health Management of Southern Medical University, Guangzhou, Guangdong, China
| | - Yuan-Tao Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Ying-Si Lai
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China .,Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, Guangdong, China
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Curtis A, Monet JP, Brun M, Bindaoudou IAK, Daoudou I, Schaaf M, Agbigbi Y, Ray N. National optimisation of accessibility to emergency obstetrical and neonatal care in Togo: a geospatial analysis. BMJ Open 2021; 11:e045891. [PMID: 34330852 PMCID: PMC8327815 DOI: 10.1136/bmjopen-2020-045891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Improving access to emergency obstetrical and neonatal care (EmONC) is a key strategy for reducing maternal and neonatal mortality. Access is shaped by several factors, including service availability and geographical accessibility. In 2013, the Ministry of Health (MoH) of Togo used service availability and other criteria to designate particular facilities as EmONC facilities, facilitating efficient allocation of limited resources. In 2018, the MoH further revised and rationalised this health facility network by applying an innovative methodology using health facility characteristics and geographical accessibility modelling to optimise timely access to EmONC services. This study compares the geographical accessibility of the network established in 2013 and the smaller network developed in 2018. DESIGN We used data regarding travel modes and speeds, geographical barriers and topographical and urban constraints, to estimate travel times to the nearest EmONC facilities. We compared the EmONC network of 109 facilities established in 2013 with the one composed of 73 facilities established in 2018, using three travel scenarios (walking and motorised, motorcycle-taxi and walking-only). RESULTS When walking and motorised travel is considered, the 2013 EmONC network covers 81% and 96.6% of the population at the 1-hour and 2-hour limit, respectively. These figures are slightly higher when motorcycle-taxis are considered (82.8% and 98%), and decreased to 34.7% and 52.3% for the walking-only scenario. The 2018 prioritised EmONC network covers 78.3% (1-hour) and 95.5% (2-hour) of the population for the walking and motorised scenario. CONCLUSIONS By factoring in geographical accessibility modelling to our iterative EmONC prioritisation process, the MoH was able to decrease the designated number of EmONC facilities in Togo by about 30%, while still ensuring that a high proportion of the population has timely access to these services. However, the physical access to EmONC for women unable to afford motorised transport remains inequitable.
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Affiliation(s)
- Andrew Curtis
- GeoHealth Group, Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | | | - Michel Brun
- Technical Division, UNFPA, New York, New York, USA
| | | | | | | | | | - Nicolas Ray
- GeoHealth Group, Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
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Joiner A, Lee A, Chowa P, Kharel R, Kumar L, Caruzzo NM, Ramirez T, Reynolds L, Sakita F, Van Vleet L, von Isenburg M, Yaffee AQ, Staton C, Vissoci JRN. Access to care solutions in healthcare for obstetric care in Africa: A systematic review. PLoS One 2021; 16:e0252583. [PMID: 34086753 PMCID: PMC8177460 DOI: 10.1371/journal.pone.0252583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/18/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context. METHODS The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach. FINDINGS A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention. INTERPRETATION Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.
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Affiliation(s)
- Anjni Joiner
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Austin Lee
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Phindile Chowa
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ramu Kharel
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Lekshmi Kumar
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Nayara Malheiros Caruzzo
- Physical Education Department, State University of Maringá, Maringá, PR, United States of America
| | - Thais Ramirez
- Duke Global Health Institute, Durham, NC, United States of America
| | - Lindy Reynolds
- University of Alabama School of Public Health, Birmingham, AL, United States of America
| | - Francis Sakita
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Lee Van Vleet
- Durham County Emergency Services, Durham, NC, United States of America
| | - Megan von Isenburg
- Medical Center Library, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Anna Quay Yaffee
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Catherine Staton
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
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Verma VR, Dash U. Geographical accessibility and spatial coverage modelling of public health care network in rural and remote India. PLoS One 2020; 15:e0239326. [PMID: 33085682 PMCID: PMC7577445 DOI: 10.1371/journal.pone.0239326] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 09/04/2020] [Indexed: 11/23/2022] Open
Abstract
Background Long distances to facilities, topographical constraints, inadequate service capacity of institutions and insufficient/ rudimentary road & transportation network culminate into unprecedented barriers to access. These barriers gets exacerbated in presence of external factors like conflict and political disruptions. Thus, this study was conducted in rural, remote and fragile region in India measuring geographical accessibility and modelling spatial coverage of public healthcare network. Methods Vector and raster based approaches were used to discern accessibility for various packages of service delivery. Alternative scenarios derived from local experiences were modelled using health facility, population and ancillary data. Based on that, a raster surface of travel time between facilities and population was developed by incorporating terrain, physical barriers, topography and travelling modes and speeds through various land-cover classes. Concomitantly, spatial coverage was modelled to delineate catchment areas. Further, underserved population and zonal statistics were assessed in an interactive modelling approach to ascertain spatial relationship between population, travel time and zonal boundaries. Finally, raster surface of travel time was re-modelled for the conflict situation in villages vulnerable to obstruction of access due to disturbed security scenario. Results Euclidean buffers revealed 11% villages without ambulatory & immunization care within 2 km radius. Similarly, for 5 km radius, 11% and 12% villages were bereft of delivery and inpatient care. Travel time accessibility analysis divulged walking scenario exhibiting lowest level of accessibility. Enabling motorized travel improved accessibility measures, with highest degree of accessibility for privately owned vehicle (motorcycle and cars). Differential results were found between packages of services where ambulatory & immunization care was relatively accessible by walking; whereas, delivery and inpatient care had a staggering average of three hours walking time. Even with best scenario, around 2/3rd population remained unserved for all package of services. Moreover, 90% villages in conflict zone grapples with inaccessibility when the scenario of heightened border tensions was considered. Conclusions Our study demonstrated the application of GIS technique to facilitate evidence backed planning at granular level. Regardless of the scenario, the analysis divulged inaccessibility to delivery and inpatient care to be most pronounced and majority of population to be unserved. It was suggested to have concerted efforts to bolster already existing facilities and adapt systems approach to exploit synergies of inter-sectoral development.
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Affiliation(s)
- Veenapani Rajeev Verma
- Department of Humanities and Social Sciences, Indian Institute of Technology Madras (IIT M), Tamil Nadu, Chennai, India
- * E-mail:
| | - Umakant Dash
- Department of Humanities and Social Sciences, Indian Institute of Technology Madras (IIT M), Tamil Nadu, Chennai, India
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Kim C, Tappis H, McDaniel P, Soroush MS, Fried B, Weinberger M, Trogdon JG, Kristen Hassmiller Lich, Delamater PL. National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility. Health Place 2020; 66:102452. [PMID: 33011490 DOI: 10.1016/j.healthplace.2020.102452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/30/2022]
Abstract
In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015 at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2 h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2 h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2 h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Hannah Tappis
- Technical Leadership and Innovations Department, Jhpiego, Baltimore, MD, USA.
| | - Philip McDaniel
- Davis Library, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Bruce Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul L Delamater
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Joseph NK, Macharia PM, Ouma PO, Mumo J, Jalang'o R, Wagacha PW, Achieng VO, Ndung'u E, Okoth P, Muñiz M, Guigoz Y, Panciera R, Ray N, Okiro EA. Spatial access inequities and childhood immunisation uptake in Kenya. BMC Public Health 2020; 20:1407. [PMID: 32933501 PMCID: PMC7493983 DOI: 10.1186/s12889-020-09486-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Poor access to immunisation services remains a major barrier to achieving equity and expanding vaccination coverage in many sub-Saharan African countries. In Kenya, the extent to which spatial access affects immunisation coverage is not well understood. The aim of this study was to quantify spatial accessibility to immunising health facilities and determine its influence on immunisation uptake in Kenya while controlling for potential confounders. METHODS Spatial databases of immunising facilities, road network, land use and elevation were used within a cost friction algorithim to estimate the travel time to immunising health facilities. Two travel scenarios were evaluated; (1) Walking only and (2) Optimistic scenario combining walking and motorized transport. Mean travel time to health facilities and proportions of the total population living within 1-h to the nearest immunising health facility were computed. Data from a nationally representative cross-sectional survey (KDHS 2014), was used to estimate the effect of mean travel time at survey cluster units for both fully immunised status and third dose of diphtheria-tetanus-pertussis (DPT3) vaccine using multi-level logistic regression models. RESULTS Nationally, the mean travel time to immunising health facilities was 63 and 40 min using the walking and the optimistic travel scenarios respectively. Seventy five percent of the total population were within one-hour of walking to an immunising health facility while 93% were within one-hour considering the optimistic scenario. There were substantial variations across the country with 62%(29/47) and 34%(16/47) of the counties with < 90% of the population within one-hour from an immunising health facility using scenarios 1 and 2 respectively. Travel times > 1-h were significantly associated with low immunisation coverage in the univariate analysis for both fully immunised status and DPT3 vaccine. Children living more than 2-h were significantly less likely to be fully immunised [AOR:0.56(0.33-0.94) and receive DPT3 [AOR:0.51(0.21-0.92) after controlling for household wealth, mother's highest education level, parity and urban/rural residence. CONCLUSION Travel time to immunising health facilities is a barrier to uptake of childhood vaccines in regions with suboptimal accessibility (> 2-h). Strategies that address access barriers in the hardest to reach communities are needed to enhance equitable access to immunisation services in Kenya.
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Affiliation(s)
- Noel K Joseph
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Peter M Macharia
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul O Ouma
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jeremiah Mumo
- Health Information System Unit, Ministry of Health, Nairobi, Kenya
| | - Rose Jalang'o
- National Vaccines and Immunization Programme, Ministry of Health, Nairobi, Kenya
| | - Peter W Wagacha
- School of Computing and Informatics, University of Nairobi, Nairobi, Kenya
| | - Victor O Achieng
- Kenya Country Office, The United Nations Children's Fund, Nairobi, Kenya
| | - Eunice Ndung'u
- Kenya Country Office, The United Nations Children's Fund, Nairobi, Kenya
| | - Peter Okoth
- Kenya Country Office, The United Nations Children's Fund, Nairobi, Kenya
| | - Maria Muñiz
- Regional Office for Eastern and Southern Africa, The United Nations Children's Fund, Nairobi, Kenya
| | - Yaniss Guigoz
- GeoHealth group, Institute of Global Health & Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Rocco Panciera
- Health section, The United Nations Children's Fund, New York, USA
| | - Nicolas Ray
- GeoHealth group, Institute of Global Health & Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Emelda A Okiro
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ, UK
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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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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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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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Ngoma T, Asiimwe AR, Mukasa J, Binzen S, Serbanescu F, Henry EG, Hamer DH, Lori JR, Schmitz MM, Marum L, Picho B, Naggayi A, Musonda G, Conlon CM, Komakech P, Kamara V, Scott NA. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S68-S84. [PMID: 30867210 PMCID: PMC6519669 DOI: 10.9745/ghsp-d-18-00367] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/13/2018] [Indexed: 12/22/2022]
Abstract
The Saving Mothers, Giving Life initiative employed 2 key strategies to improve the ability of pregnant women to reach maternal care: (1) increase the number of emergency obstetric and newborn care facilities, including upgrading existing health facilities, and (2) improve accessibility to such facilities by renovating and constructing maternity waiting homes, improving communication and transportation systems, and supporting community-based savings groups. These interventions can be adapted in low-resource settings to improve access to maternity care services. Background: Between June 2011 and December 2016, the Saving Mothers, Giving Life (SMGL) initiative in Uganda and Zambia implemented a comprehensive approach targeting the persistent barriers that impact a woman's decision to seek care (first delay), ability to reach care (second delay), and ability to receive adequate care (third delay). This article addresses how SMGL partners implemented strategies specifically targeting the second delay, including decreasing the distance to facilities capable of managing emergency obstetric and newborn complications, ensuring sufficient numbers of skilled birth attendants, and addressing transportation challenges. Methods: Both quantitative and qualitative data collected by SMGL implementing partners for the purpose of monitoring and evaluation were used to document the intervention strategies and to describe the change in outputs and outcomes related to the second delay. Quantitative data sources included pregnancy outcome monitoring data in facilities, health facility assessments, and population-based surveys. Qualitative data were derived from population-level verbal autopsy narratives, programmatic reports and SMGL-related publications, and partner-specific evaluations that include focus group discussions and in-depth interviews. Results: The proportion of deliveries in any health facility or hospital increased from 46% to 67% in Uganda and from 63% to 90% in Zambia between baseline and endline. Distance to health facilities was reduced by increasing the number of health facilities capable of providing basic emergency obstetric and newborn care services in both Uganda and Zambia—a 200% and 167% increase, respectively. Access to facilities improved through integrated transportation and communication services efforts. In Uganda there was a 6% increase in the number of health facilities with communication equipment and a 258% increase in facility deliveries supported by transportation vouchers. In Zambia, there was a 31% increase in health facilities with available transportation, and the renovation and construction of maternity waiting homes resulted in a 69% increase in the number of health facilities with associated maternity waiting homes. Conclusion: The collective SMGL strategies addressing the second delay resulted in increased access to delivery services as seen by the increase in the proportion of facility deliveries in SMGL districts, improved communication and transportation services, and an increase in the number of facilities with associated maternity waiting homes. Sustaining and improving on these efforts will need to be ongoing to continue to address the second delay in Uganda and Zambia.
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Affiliation(s)
| | - Alice R Asiimwe
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Joseph Mukasa
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Susanna Binzen
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jody R Lori
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Michelle M Schmitz
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence Marum
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired
| | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | | | - Patrick Komakech
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Vincent Kamara
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
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