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Asefa A, Gebremedhin S, Marthias T, Nababan H, Christou A, Semaan A, Banke-Thomas A, Tabana H, Al-beity FMA, Dossou JP, Gutema K, Delvaux T, Birabwa C, Dennis M, Grovogui FM, McPake B, Beňová L. Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries. Int J Equity Health 2023; 22:203. [PMID: 37784140 PMCID: PMC10544383 DOI: 10.1186/s12939-023-02015-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.
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Affiliation(s)
- Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Tiara Marthias
- School of Population and Global Health, Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Herfina Nababan
- Institut für Public Health und Pflegeforschung, Universität Bremen, Bremen, Germany
| | - Aliki Christou
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aline Semaan
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, London, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Fadhlun M. Alwy Al-beity
- Department of Obstetrcis/Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine Et en Démographie, Cotonou, Bénin
| | - Keneni Gutema
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Fassou Mathias Grovogui
- Centre National de Formation Et de Recherche en Santé Rurale (CNFRSR), Maferinyah, Forécariah Guinea
| | - Barbara McPake
- School of Population and Global Health, Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Njiro BJ, Ngowi JE, Mlunde L, Munishi C, Kapologwe N, Kengia JT, Deng L, Timbrell A, Kitinya WJ, Sunguya BF. Towards sustainable emergence transportation system for maternal and new born: Lessons from the m-mama innovative pilot program in Shinyanga, Tanzania. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002097. [PMID: 37343036 DOI: 10.1371/journal.pgph.0002097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/31/2023] [Indexed: 06/23/2023]
Abstract
Maternal mortality comprises about 10% of all deaths among women of reproductive age (15-49 years). More than 90% of such deaths occur in low- and middle-income countries (LMIC). In this study, we aimed to document lessons learnt and best practices toward sustainability of the m-mama program for reducing maternal and newborn mortality in Tanzania. We conducted a qualitative study from February to March 2022 in Kahama and Kishapu district councils of Shinyanga region. A total of 20 Key Informant Interviews (KII) and four Focused Group Discussions (FGDs) were conducted among key stakeholders. The participants included implementing partners and beneficiaries, Community Care groups (CCGs) facilitators, health facility staff, drivers and dispatchers. We gathered data on their experience with the program, services offered, and recommendations to improve program sustainability. We based the discussion of our findings on the integrated sustainability framework (ISF). Thematic analysis was conducted to summarize the results. To ensure the sustainability of the program, these were recommended. First, active involvement of the government to complement community efforts, through the provision and maintenance of resources including a timely and inclusive budget, dedicated staff, infrastructure development and maintenance. Secondly, support from different stakeholders through a well-coordinated partnership with the government and local facilities. Third, continued capacity building for implementers, health care workers (HCWs) and community health workers (CHWs) and community awareness to increase program trust and services utilization. Dissemination and sharing of evidence and lesson learnt from successful program activities and close monitoring of implemented activities is necessary to ensure smooth, well-coordinated delivery of proposed strategies. Considering the temporality of the external funding, for successful implementation of the program, we propose a package of three key actions; first, strengthening government ownership and engagement at an earlier stage, secondly, promoting community awareness and commitment and lastly, maintaining a well-coordinated multi-stakeholder' involvement during program implementation.
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Affiliation(s)
- Belinda J Njiro
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jackline E Ngowi
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Linda Mlunde
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Castory Munishi
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ntuli Kapologwe
- President's Office Regional Administration and Local Government, Dodoma, Tanzania
| | - James T Kengia
- President's Office Regional Administration and Local Government, Dodoma, Tanzania
| | | | | | | | - Bruno F Sunguya
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Ononge S, Magunda A, Balaba D, Waiswa P, Okello D, Kaula H, Zalwango S, Bua DA, Ayebare A, Kaharuza F, Bennett C, Sulzbach S, Keller B, Mugerwa Y. Strengthening Kampala's Urban Referral System for Maternal and Newborn Care Through Establishment of an Emergency Call and Dispatch Center. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200332. [PMID: 37348939 PMCID: PMC10285736 DOI: 10.9745/ghsp-d-22-00332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/03/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Most pregnant women living in urban slum communities in Uganda deliver at public health centers that are not equipped to provide emergency obstetric and newborn care. When obstetric emergencies occur, pregnant women are referred to a higher-level facility and are responsible for arranging and paying for their own transport. The Kampala Slum Maternal Newborn (MaNe) project developed and tested an emergency call and ambulance dispatch center and a mobile application to request, deploy, and track ambulances. We describe the development of these 2 interventions and findings on the feasibility, acceptability, and sustainability of the interventions. METHODS MaNe conducted a mixed-method feasibility study that included an assessment of the acceptability and demand of the interventions. In-depth interviews (N=26) were conducted with facility proprietors, health providers, ambulance drivers, Kampala Capital City Authority officers, and community members to understand the successes and challenges of establishing the call center and developing the mobile application. Thematic content analysis was done. Quantitative data from the call center dispatch logs were analyzed descriptively to complement the qualitative findings. FINDINGS Between April 2020 and June 2021, 10,183 calls were made to the emergency call and dispatch center. Of these, 25% were related to maternal and newborn health emergencies and 14% were COVID-19 related. An ambulance was dispatched to transfer or evacuate a patient in 35% of the calls. Participants acknowledged that the call center and mobile application allowed for efficient communication, coordination, and information flow between health facilities. Supportive district leadership facilitated the establishment of the call center and has taken over the operating costs of the center. CONCLUSION The call center and referral application improved the coordination of drivers and ambulances and allowed facilities to prepare for and treat cases more efficiently.
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Affiliation(s)
- Sam Ononge
- Makerere University College of Health Sciences, Kampala, Uganda.
| | - Andrew Magunda
- Population Services International Uganda, Kampala, Uganda
| | - Dorothy Balaba
- Population Services International Uganda, Kampala, Uganda
| | - Peter Waiswa
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Henry Kaula
- Population Services International Uganda, Kampala, Uganda
| | | | | | - Amable Ayebare
- Population Services International Uganda, Kampala, Uganda
| | | | - Cudjoe Bennett
- Office of Maternal and Child Health and Nutrition, Bureau of Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Sara Sulzbach
- Office of Maternal and Child Health and Nutrition, Bureau of Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Brett Keller
- Population Services International Uganda, Kampala, Uganda
| | - Yvonne Mugerwa
- Population Services International Uganda, Kampala, Uganda
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Santos PSPD, Belém JM, Cruz RDSBLC, Calou CGP, Oliveira DRD. Aplicabilidade do Three Delays Model no contexto da mortalidade materna: revisão integrativa. SAÚDE EM DEBATE 2022. [DOI: 10.1590/0103-1104202213517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RESUMO O objetivo desta revisão é sumarizar evidências disponíveis na literatura científica provenientes da aplicabilidade do Three Delays Model no contexto da mortalidade materna quanto aos fatores causais e às medidas interventivas. Trata-se de revisão integrativa da literatura, realizada sem recorte temporal, em sete bases de dados, com os descritores Maternal Mortality, Pregnancy Complications, Maternal Death e a palavra-chave Three Delays Model. 15 estudos foram selecionados para análise. O primeiro atraso destacou-se como determinante para as mortes maternas, sendo a recusa em buscar assistência obstétrica na instituição de saúde uma iniciativa da mulher ou de familiares. No segundo atraso, fatores geográficos e infraestrutura precária das estradas dificultaram o acesso aos serviços de saúde. No terceiro atraso, as condições assistenciais nas instituições de saúde implicaram reduzida qualidade dos cuidados. A aplicabilidade do modelo possibilita demonstrar as barreiras enfrentadas pelas mulheres na busca de cuidados obstétricos e visualizar contextos que necessitam de ações interventivas para enfrentar a problemática.
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Santos PSPD, Belém JM, Cruz RDSBLC, Calou CGP, Oliveira DRD. Applicability of the Three Delays Model in the context of maternal mortality: integrative review. SAÚDE EM DEBATE 2022. [DOI: 10.1590/0103-1104202213517i] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
ABSTRACT The objective of this review is to summarize evidence available in the scientific literature from the applicability of the Three Delays Model in the context of maternal mortality in terms of causal factors and interventional measures. It is an integrative literature review, carried out with no time frame, in seven databases, with the descriptors Maternal Mortality, Pregnancy Complications, Maternal Death and the keyword Three Delays Model. 15 studies were selected for analysis. The first delay stood out as a determinant of maternal deaths, with the refusal to seek obstetric care in the health institution an initiative of the woman or family members. In the second delay, geographic factors and poor road infrastructure made access to health services difficult. In the third delay, the care conditions in the health institutions implied a reduced quality of care. The applicability of the model makes it possible to demonstrate the barriers faced by women in the search for obstetric care and to visualize contexts that need interventional actions to face the problem.
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Mukuru M, Gorry J, Kiwanuka SN, Gibson L, Musoke D, Ssengooba F. Designed to Fail? Revisiting Uganda's Maternal Health Policies to Understand Policy Design Issues Underpinning Missed Targets for Reduction of Maternal Mortality Ratio (MMR): 2000-2015. Int J Health Policy Manag 2022; 11:2124-2134. [PMID: 34664495 PMCID: PMC9808297 DOI: 10.34172/ijhpm.2021.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 09/06/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to '3Cs' (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming. METHODS We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the 'three delay model' combined with a broader literature on 'policy mixing.' RESULTS Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues. CONCLUSION The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the 'three delays' but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.
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Affiliation(s)
- Moses Mukuru
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jonathan Gorry
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Suzanne N. Kiwanuka
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Linda Gibson
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Uwamahoro NS, McRae D, Zibrowski E, Victor-Uadiale I, Gilmore B, Bergen N, Muhajarine N. Understanding maternity waiting home uptake and scale-up within low-income and middle-income countries: a programme theory from a realist review and synthesis. BMJ Glob Health 2022; 7:bmjgh-2022-009605. [PMID: 36180098 PMCID: PMC9528638 DOI: 10.1136/bmjgh-2022-009605] [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: 05/13/2022] [Accepted: 09/01/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Maternity waiting homes (MWHs) link pregnant women to skilled birth attendance at health facilities. Research suggests that some MWH-facility birth interventions are more success at meeting the needs and expectations of their intended users than others. We aimed to develop theory regarding what resources work to support uptake and scale-up of MHW-facility birth interventions, how, for whom, in what contexts and why. Methods A four-step realist review was conducted which included development of an initial programme theory; searches for evidence; selection, appraisal and extraction of data; and analysis and data synthesis. Results A programme theory was developed from 106 secondary sources and 12 primary interviews with MWH implementers. The theory demonstrated that uptake and scale-up of the MWH-facility birth intervention depends on complex interactions between three adopter groups: health system stakeholders, community gatekeepers and pregnant women and their families. It describes relationships between 19 contexts, 11 mechanisms and 31 outcomes accross nine context-mechanism-outcome configurations (CMOCs) which were grouped into 3 themes: (1) Engaging stakeholders to develop, integrate, and sustain MWH-facility birth interventions, (2) Promoting and enabling MWH-facility birth utilisation and (3) Creating positive and memorable MWH-facility birth user experiences. Belief, trust, empowerment, health literacy and perceptions of safety, comfort and dignity were mechanisms that supported diffusion and adoption of the intervention within communities and health systems. Examples of resources provided by implementers to trigger mechanisms associated with each CMOC were identified. Conclusions Implementers of MWHs cannot merely assume that communities will collectively value an MWH-facility birth experience over delivery at home. We posit that MWH-facility birth interventions become vulnerable to under-utilisation when implementers fail to: (1) remove barriers that hinder women’s access to MWH and (2) ensure that conditions and interactions experienced within the MWH and its affiliated health facility support women to feel treated with compassion, dignity and respect. PROSPERO registration number CRD42020173595.
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Affiliation(s)
- Nadege Sandrine Uwamahoro
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Faculty of Medical Sciences, Newcastle University, Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Daphne McRae
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Chilliwack Division of Family Practice, Chilliwack General Hospital, Chiliwack, British Colombia, Canada
| | - Elaine Zibrowski
- Best Care COPD, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Ify Victor-Uadiale
- Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
| | - Brynne Gilmore
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems, School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Ireland
| | - Nicole Bergen
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nazeem Muhajarine
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Population Health and Evaluation Research Unit, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Smith S, Henrikson H, Thapa R, Tamang S, Rajbhandari R. Maternity Waiting Home Interventions as a Strategy for Improving Birth Outcomes: A Scoping Review and Meta-Analysis. Ann Glob Health 2022; 88:8. [PMID: 35087708 PMCID: PMC8782095 DOI: 10.5334/aogh.3496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Over 300 000 women worldwide die due to pregnancy-related complications annually, with most occurring in developing countries where access to skilled obstetric care is limited. Maternity waiting homes (MWHs) are one intervention designed to increase access to skilled prenatal care in resource-limited settings. MWHs are defined as accommodations at or near a health facility where pregnant women can stay in the final weeks of their pregnancy so they can be easily transferred to the health facility to give birth. While MWHs have existed for decades, evidence regarding their effectiveness in reducing adverse birth outcomes has been mixed. The objective of this study is to comprehensively assess all available MWH research reporting quantitative maternal and childbirth data to determine whether MWHs are an effective maternal health strategy in resource-limited settings. METHODOLOGY We conducted a scoping review and meta-analysis of existing literature on MWHs according to PRISMA guidelines. Descriptive statistics and odds ratios were calculated for the following birth outcomes: maternal mortality, perinatal mortality, and caesarian section. Quantitative analysis was conducted in RStudio and Stata Version 16. RESULTS One hundred seventy-one records were retrieved from our initial database search, of which 66 were identified as relevant. Only 15 of these records reported quantitative data on the health outcomes of interest and therefore met inclusion criteria for our meta-analysis. All studies reporting maternal mortality demonstrated a protective effect of MWHs (aggregate OR: 0.19 [0.10, 0.40]), as did all studies reporting perinatal mortality (aggregate OR: 0.29 [0.16, 0.53]). Studies reporting caesarian section were more varied and indicated less of a protective effect (aggregate OR: 1.80 [1.18, 2.75]). CONCLUSIONS There is some indication that MWHs are an effective strategy for reducing maternal and perinatal mortality in resource-limited settings. However, our analysis was constrained by the observational design of most prior MWH studies. More rigorous MWH evaluations, ideally in the form of randomized-control trials, are needed to better determine MWH effectiveness.
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Affiliation(s)
- Samantha Smith
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
| | - Hannah Henrikson
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
| | - Rita Thapa
- Nick Simons Institute, Sanepa, Lalitpur, Nepal
| | | | - Ruma Rajbhandari
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Mount Auburn Hospital, Department of Medicine, Division of Gastroenterology, Cambridge, Massachusetts, USA
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Lee S, Adam AJ. Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:295. [PMID: 35010561 PMCID: PMC8744962 DOI: 10.3390/ijerph19010295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/25/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.
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Affiliation(s)
- Seohyun Lee
- Department of Global Public Administration, Mirae Campus, Yonsei University, Wonju 26493, Korea
| | - Abdul-jabiru Adam
- Department of Public Administration, Mirae Campus, Yonsei University Graduate School, Wonju 26493, Korea;
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Perera SM, Achakzai H, Giuffrida MM, Kulkarni MJ, Nagle DC, Wali MK, Casey SE. Barriers to seeking post-abortion care in Paktika Province, Afghanistan: a qualitative study of clients and community members. BMC WOMENS HEALTH 2021; 21:390. [PMID: 34742265 PMCID: PMC8571834 DOI: 10.1186/s12905-021-01529-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/28/2021] [Indexed: 11/16/2022]
Abstract
Background Unsafe abortion is a leading cause of maternal mortality. In Afghanistan, which has experienced decades of armed conflict and where abortion is highly restricted, maternal mortality is high at 638 maternal deaths per 100,000 live births. Post-abortion care (PAC) is a lifesaving package of interventions to reduce morbidity and mortality related to induced or spontaneous abortion, but is rarely provided and often of poor quality, particularly in humanitarian settings. In July 2018, we conducted a study to identify the factors that influence access to and use of PAC services at Sharana Provincial Hospital.
Methods In-depth interviews (IDIs) were conducted with ten women who had received PAC services at Sharana Hospital, and eight focus group discussions (FGDs) were conducted with 40 married women and 40 married men aged 18–45 from four villages surrounding Sharana Hospital. Results PAC clients and community participants discussed similar barriers to seeking PAC, including cost, distance to the health facility, the need for male accompaniment to seek care, perceived and actual quality of care, stigma and shame. Despite the mentioned stigma around abortion, community members expressed willingness to help women to receive PAC. Conclusions Our results suggest that while some barriers are not unique to PAC, others, especially those related to stigma around abortion, may be specific to PAC. It is important for the Ministry of Public Health and its partners to prioritize addressing these barriers to ensure that women have access to this critical life-saving care. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01529-5.
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Affiliation(s)
- Shiromi M Perera
- International Medical Corps, 1313 L St. NW, Suite 110, Washington, DC, 20005, USA
| | - Haroon Achakzai
- International Medical Corps Afghanistan, House # 11, Street-6, District -10, Qala-e-Fatullah, Kabul, Afghanistan
| | - Monica M Giuffrida
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY, B210032, USA
| | - Meghana Jayne Kulkarni
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY, B210032, USA
| | - Devin C Nagle
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY, B210032, USA
| | - Mohammad Kameen Wali
- International Medical Corps Afghanistan, House # 11, Street-6, District -10, Qala-e-Fatullah, Kabul, Afghanistan
| | - Sara E Casey
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY, B210032, USA.
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Sserwanja Q, Musaba MW, Mutisya LM, Olal E, Mukunya D. Continuum of maternity care in Zambia: a national representative survey. BMC Pregnancy Childbirth 2021; 21:604. [PMID: 34482830 PMCID: PMC8420052 DOI: 10.1186/s12884-021-04080-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 08/29/2021] [Indexed: 01/20/2023] Open
Abstract
Background Globally, over half of maternal deaths are related to pregnancy-related complications. Provision of a continuum of care during pregnancy, childbirth and the postnatal period results in reduced maternal and neonatal morbidity and mortality. Hence this study determined the prevalence of the continuum of care and its determinants among women in Zambia. Methods We used weighted data from the Zambian Demographic and Health Survey (ZDHS) of 2018 for 7325 women aged 15 to 49 years. Multistage stratified sampling was used to select study participants. Complete continuum of care was considered when a woman had; at least four antenatal care (ANC) contacts, utilized a health facility for childbirth and had at least one postnatal check-up within six weeks. We conducted multivariable logistic regression to explore continuum of care in Zambia. All our analyses were done using SPSS version 25. Results Of the 7,325 women, 38.0% (2787/7325) (95% confidence interval (CI): 36.9-39.1) had complete continuum of maternal healthcare. Women who had attained tertiary level of education (adjusted odds ratio (AOR): 1.93, 95% CI: 1.09-3.42) and whose partners had also attained tertiary level of education (AOR: 2.58, 95% CI: 1.54-4.32) were more likely to utilize the whole continuum of care compared to those who had no education. Women who initiated ANC after the first trimester (AOR: 0.46, 95% CI: 0.39-0.53) were less likely to utilize the whole continuum of care compared to those who initiated in the first semester. Women with exposure to radio (AOR: 1.58, 95% CI: 1.27-1.96) were more likely to utilize the whole continuum of care compared to those who were not exposed to radio. Women residing in the Western province were less likely to utilize the entire continuum of care compared to those in the other nine provinces. Conclusion Level of education of the women and of their partners, early timing of ANC initiation, residing in other provinces other than the Western province, and exposure to information through radio were positively associated with utilization of the entire continuum of care. Improving literacy levels and promoting maternity services through radio may improve the level of utilization of maternity services. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04080-1.
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Affiliation(s)
- Quraish Sserwanja
- Programs Department, GOAL, Arkaweet Block 65 House No. 227, Khartoum, Sudan.
| | - Milton W Musaba
- Department of Obstetrics and Gynaecology, Busitema University, Mbale, Uganda
| | - Linet M Mutisya
- Maternal and Child Health Project, Swedish Organization for Global Health, Mayuge, Uganda
| | | | - David Mukunya
- Department of Community and Public Health, Busitema University, Mbale, Uganda.,Sanyu Africa Research Institute, Mbale, Uganda
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12
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Mumba JM, Kasonka L, Owiti OB, Andrew J, Lubeya MK, Lukama L, Kasempa C, Msadabwe SC, Kalinda C. Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia. Gynecol Oncol Rep 2021; 37:100784. [PMID: 34095422 PMCID: PMC8165546 DOI: 10.1016/j.gore.2021.100784] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/18/2021] [Accepted: 04/30/2021] [Indexed: 01/07/2023] Open
Abstract
Expedited diagnostic processes for all suspected cervical cancer cases remain essential in the effort to improve clinical outcomes of the disease. However, in some developing countries like Zambia, there is paucity of data that assesses factors influencing diagnostic and treatment turnaround time (TAT) and other metrics vital for quality cancer care. We conducted a retrospective hospital-based study at the Cancer Diseases Hospital (CDH) for cervical cancer cases presenting to the facility between January 2014 and December 2018. Descriptive statistics were used to summarize demographic characteristics while a generalized linear model of the negative binomial was used to assess determinants of overall TAT. Our study included 2121 patient case files. The median age was 49 years (IQR: ±17) and most patients (n = 634, 31%) were aged between 41 and 50 years. The International Federation of Gynaecology and Obstetrics (FIGO) Cancer stage II (n = 941, 48%) was the most prevalent while stage IV (n = 103, 5.2%) was the least. The average diagnostic TAT in public laboratories was 1.48 (95%CI: 1.21-1.81) times longer than in private laboratories. Furthermore, referral delay was 55 days (IQR: 24-152) and the overall TAT (oTAT) was 110 days (IQR: 62-204). The age of the patient, HIV status, stage of cancer and histological subtype did not influence oTAT while marital status influenced oTAT. The observed longer oTAT may increase irreversible adverse health outcomes among cervical cancer patients. There is a need to improve cancer care in Zambia through improved health expenditure especially in public health facilities.
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Affiliation(s)
- Jane Mwamba Mumba
- The University of Zambia, School of Medicine, Department of Obstetrics and Gynaecology, Nationalist Road, P/Box RWX1 50110, Ridgeway, Lusaka, Zambia
- Ndola Teaching Hospital, Department of Obstetrics and Gynaecology, Broadway Road, Postal Agency Ndola, Ndola, Zambia
| | - Lackson Kasonka
- The University of Zambia, School of Medicine, Department of Obstetrics and Gynaecology, Nationalist Road, P/Box RWX1 50110, Ridgeway, Lusaka, Zambia
- Women and Newborn Hospital-University Teaching Hospitals, Nationalist Road, P/Bag RWX1 Ridgeway, Lusaka, Zambia
| | - Okola Basil Owiti
- Hasselt University, Faculty of Science, Campus Diepenbeek, Agoralaan Building D, 3590 Diepenbeek, Belgium
| | - John Andrew
- Hasselt University, Faculty of Science, Campus Diepenbeek, Agoralaan Building D, 3590 Diepenbeek, Belgium
| | - Mwansa Ketty Lubeya
- The University of Zambia, School of Medicine, Department of Obstetrics and Gynaecology, Nationalist Road, P/Box RWX1 50110, Ridgeway, Lusaka, Zambia
- Women and Newborn Hospital-University Teaching Hospitals, Nationalist Road, P/Bag RWX1 Ridgeway, Lusaka, Zambia
| | - Lufunda Lukama
- Ndola Teaching Hospital, Department of Otorhinolaryngology, Head and Neck Surgery, Broadway Road, Postal Agency Ndola, Ndola, Zambia
- University of KwaZulu-Natal, College of Health Sciences., Nelson R Mandela School of Medicine, Durban 4001, South Africa
| | - Charlotte Kasempa
- Cancer Diseases Hospital, Nationalist Road, Nationalist Road, P/Box RWX1 50110 Ridgeway, Lusaka, Zambia
| | - Susan C. Msadabwe
- Cancer Diseases Hospital, Nationalist Road, Nationalist Road, P/Box RWX1 50110 Ridgeway, Lusaka, Zambia
- Zambia College of Medicine and Surgery, Levy Mwanawasa Medical University, Great East Campus, Box 33991, Lusaka, Lusaka
| | - Chester Kalinda
- University of Namibia, Faculty of Agriculture, Engineering and Science, School of Science, Katima Mulilo Campus, Winele Road, Private Bag 1096, Ngweze, Katima Mulilo, Namibia
- University of KwaZulu-Natal, Howard College Campus, College of Health Sciences, School of Public Health and Nursing, Desmond Clarence Building, Durban 4001, South Africa
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13
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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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14
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Relyea B, Wringe A, Afaneh O, Malamas I, Teodoro N, Ghafour M, Scott J. Stakeholders' Perspectives on the Challenges of Emergency Obstetric Referrals and the Feasibility and Acceptability of an mHealth Intervention in Northern Iraq. Front Glob Womens Health 2021; 2:662256. [PMID: 34816217 PMCID: PMC8594019 DOI: 10.3389/fgwh.2021.662256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/06/2021] [Indexed: 11/15/2022] Open
Abstract
The health system in northern Iraq has been weakened by conflict and the internal displacement of over three million people. Mobile phone-based interventions (mHealth) may improve maternal and neonatal health outcomes by enabling emergency referrals, facilitating communication between patients and providers, and improving patient data management; however, they have not been sufficiently studied in conflict-affected settings. We explored stakeholders' perspectives on challenges to obstetric referrals and the feasibility and acceptability of a mobile phone-based application to reduce delays in reaching emergency obstetric care in order to inform its development. We conducted a qualitative study in the Kurdistan region of northern Iraq from May to July, 2018. Using purposive sampling, we carried out 15 semi-structured interviews with coordination actors including healthcare management staff, government health officials, non-government health program managers and ambulance staff. The interviews explored obstetric care delivery, referral processes, mobile phone usage and mHealth implementation strategies. Eleven focus group discussions, which incorporated participatory activities on similar topics, were conducted with ambulance drivers, hospital and primary health center staff. Audio-recorded, transcribed and translated data were coded iteratively to identify emerging concepts, and analyzed thematically. Sixty-eight stakeholders (36 women and 32 men) participated. Challenges regarding the referral system included resource limitations, security concerns, costs and women's reluctance to be transported in male-staffed ambulances. In terms of obstetric care and decision-making, participants noted gaps in communication and coordination of services with the current paper-based system between health care providers, ambulance drivers, and hospital staff. Ambulance drivers reported incurring delays through lack of patient information, poor road conditions, and security issues. A prototype mobile phone application was found to be acceptable based on perceived usefulness to address some of the challenges to safe obstetric care and focused on phone usage, access to information, Global Positioning System (GPS), connectivity, cost, and user-friendliness. However, the feasibility of the innovation was considered in relation to implementation challenges that were identified, including poor connectivity, and digital literacy. Implementation of the app would need to account for the humanitarian context, cultural and gender norms regarding obstetric care, and would require substantial commitment and engagement from policymakers and practitioners.
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Affiliation(s)
- Bridget Relyea
- Women and Health Alliance International, Erbil, Iraq
- Women and Health Alliance International, Paris, France
| | - Alison Wringe
- Women and Health Alliance International, Paris, France
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Osama Afaneh
- Women and Health Alliance International, Erbil, Iraq
- Women and Health Alliance International, Paris, France
- École des hautes études en santé publique, Rennes, France
| | - Ioannis Malamas
- Women and Health Alliance International, Erbil, Iraq
- Women and Health Alliance International, Paris, France
| | - Nicholas Teodoro
- Beth Israel Deaconess Medical Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | | | - Jennifer Scott
- Women and Health Alliance International, Paris, France
- Beth Israel Deaconess Medical Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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15
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Lori JR, Munro-Kramer ML, Liu H, McGlasson KL, Zhang X, Lee H, Ngoma T, Kaiser JL, Bwalya M, Musonda G, Sakala I, Perosky JE, Fong RM, Boyd CJ, Chastain P, Rockers PC, Hamer DH, Biemba G, Vian T, Bonawitz R, Lockhart N, Scott NA. Increasing facility delivery through maternity waiting homes for women living far from a health facility in rural Zambia: a quasi-experimental study. BJOG 2021; 128:1804-1812. [PMID: 33993600 PMCID: PMC8518771 DOI: 10.1111/1471-0528.16755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility. DESIGN Quasi-experimental design with partial randomisation at the cluster level. SETTING Seven rural districts in Zambia. POPULATION Women delivering at 40 health facilities between June 2016 and August 2018. METHODS Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes. MAIN OUTCOME MEASURES Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher-level health facility between intervention and comparison group. RESULTS We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6-7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3-29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4-16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7-28, P < 0.001). CONCLUSION The core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit. TWEETABLE ABSTRACT A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia.
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Affiliation(s)
- J R Lori
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | | | - H Liu
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - K L McGlasson
- Boston University School of Public Health, Boston, MA, USA
| | - X Zhang
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - H Lee
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - T Ngoma
- Zambia Centre for Applied Health Research and Development, Lusaka, Zambia
| | - J L Kaiser
- Boston University School of Public Health, Boston, MA, USA
| | - M Bwalya
- Zambia Centre for Applied Health Research and Development, Lusaka, Zambia
| | | | | | - J E Perosky
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - R M Fong
- Boston University School of Public Health, Boston, MA, USA
| | - C J Boyd
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - P Chastain
- Boston University School of Public Health, Boston, MA, USA
| | - P C Rockers
- Boston University School of Public Health, Boston, MA, USA
| | - D H Hamer
- Boston University School of Public Health, Boston, MA, USA
| | - G Biemba
- Paediatric Centre of Excellence, National Health Research Authority, Lusaka, Zambia
| | - T Vian
- Boston University School of Public Health, Boston, MA, USA
| | - R Bonawitz
- Boston University School of Public Health, Boston, MA, USA
| | - N Lockhart
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - N A Scott
- Boston University School of Public Health, Boston, MA, USA
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16
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Sacks E, Brizuela V, Perrotta C. It's the Destination and the Journey-A Mapping of the Challenges in Transport and Referral for Maternal and Newborn Health in Pandemics and Beyond. Front Public Health 2021; 9:612409. [PMID: 33937164 PMCID: PMC8085309 DOI: 10.3389/fpubh.2021.612409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/18/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Emma Sacks
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | - Vanessa Brizuela
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | - Carla Perrotta
- School of Public Health, University College Dublin, Dublin, Ireland
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17
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Owen MD, Cassidy AL, Weeks AD. Why are women still dying from obstetric hemorrhage? A narrative review of perspectives from high and low resource settings. Int J Obstet Anesth 2021; 46:102982. [PMID: 33903002 DOI: 10.1016/j.ijoa.2021.102982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 03/02/2021] [Accepted: 03/14/2021] [Indexed: 11/30/2022]
Abstract
The possibility of hemorrhage will always co-exist with pregnancy, whether anticipated or not. It remains the unwelcome guest in the corner of every delivery room, stealing the lives of young women every day across the globe. In 2014, the World Health Organization reported that hemorrhage was the leading contributor to maternal mortality worldwide, with nearly 75% of maternal deaths due to postpartum hemorrhage. In low resource settings, while maternal mortality is decreasing, hemorrhage remains the single most important contributor to maternal death. Hospital-based deliveries with skilled birth attendants have been encouraged to improve outcomes and, as a result, hospital births have dramatically increased. However, access to higher levels of emergency obstetric care as well as blood products and therapeutic resources remain limiting factors. Meanwhile, in high resource settings, maternal mortality from hemorrhage is increasing, particularly among women of color. While very rare, mortality from hemorrhage generally follows medical interventions such as surgical management of placenta accreta or emergency cesarean section. Primary prevention therefore requires careful selection and conduct of medical interventions, as well as the provision of high quality, supportive, and safe maternity care. It is clear that there is not one single solution in preventing obstetric hemorrhage on a global scale. The international community must employ creative solutions to reduce this ever-present problem.
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Affiliation(s)
- M D Owen
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - A L Cassidy
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - A D Weeks
- Department of Women's and Children's Health, University of Liverpool (for Liverpool Health Partners), Liverpool, UK
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18
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Beck D, Veliz PT, Munro-Kramer M, Ngoma T, Scott N, Kaiser JL, Musonda G, Lori JR. Home Birth in Rural Zambia: The Role of Intimate Partner Violence and Autonomous Decision-Making. J Midwifery Womens Health 2021; 66:256-264. [PMID: 33710761 DOI: 10.1111/jmwh.13208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/26/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Skilled care is indicated as a measure to prevent the deaths of pregnant women across sub-Saharan Africa. Despite this, many women continue to give birth at home. There has been little attention as to how the experience of intimate partner violence (IPV) or autonomous decision-making about place of birth influences home births in rural Zambia. This study explores how markers of sociocultural gender inequities (prevalence of IPV and autonomous decision-making) correlate with home birth in rural Zambia. METHODS This secondary analysis uses quantitative data from a baseline household survey with women who had given birth within the past 13 months in rural Zambia. Control variables shown to be significant in the literature were included in the model, and binary logistic regression was used to assess the influence of IPV and autonomous decision-making on home birth. RESULTS This sample included 2381 women from rural Zambia, of whom 384 reported a home birth within the past 13 months. Women who were autonomously making the decision about where to give birth were more likely to have a home birth (adjusted odds ratio [AOR], 1.729; SE, 0.210; 95% CI, 1.362-2.194; P < .001). Self-report of experiencing physical IPV in the past 2 weeks was not significant in predicting home birth (AOR, 0.783; SE, 0.181; 95% CI, 0.496-1.234; P = .293). Women who self-identified as Tumbuka or other, were able to afford school fees, had completed secondary education or higher, were married, and had 4 or more antenatal care visits were significantly less likely to report a home birth. DISCUSSION This quantitative analysis did not corroborate findings from other research that implicates IPV as a predictor of home birth. Additionally, autonomous decision-making was not associated with a decrease in home births. Future work should incorporate qualitative or mixed methods strategies to comprehensively explore household- and facility-level interventions to promote facility birth.
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Affiliation(s)
- Dana Beck
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Philip T Veliz
- Department of Populations, Systems, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Michelle Munro-Kramer
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan.,Office of Global Affairs, University of Michigan School of Nursing, Ann Arbor, Michigan
| | | | - Nancy Scott
- Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts
| | | | - Gertrude Musonda
- Office of Global Affairs, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Jody R Lori
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan.,Office of Global Affairs, University of Michigan School of Nursing, Ann Arbor, Michigan
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Kinney RG, Zakumumpa H, Rujumba J, Gibbons K, Heard A, Galárraga O. Community-funded integrated care outreach clinics as a capacity building strategy to expand access to health care in remote areas of Uganda. Glob Health Action 2021; 14:1988280. [PMID: 34720066 PMCID: PMC8567937 DOI: 10.1080/16549716.2021.1988280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Most Ugandans live in rural, medically underserved communities where geography and poverty lead to reduced access to healthcare. We present a novel low-cost approach for supplemental primary care financing through 1) pooling community wealth to cover overhead costs for outreach clinic activities and 2) issuing microfinance loans to motorcycle taxi entrepreneurs to overcome gaps in access to transportation. The intervention described here, which leverages community participation as a means to extend the reach of government health service delivery, was developed and implemented by Health Access Connect (HAC), a non-governmental organization based in Uganda. HAC began its work in August 2015 in the Lake Victoria region and now serves over 40 sites in Uganda across 5 districts, helping government health-care workers to provide over 1,300 patient services per month (and over 35,000 since the program's inception) with an average administrative cost of $6.24 per patient service in 2020. In this article, we demonstrate how integrated and appropriately resourced monthly outreach clinics, based on a microfinance-linked model of wealth pooling and government cooperation, can expand the capacity of government-provided healthcare to reach more patients living in remote communities. This scalable, sustainable, and flexible model is responsive to shifting needs of patients and health systems and presents an alternative approach to healthcare financing in low-resource settings. More rigorous evaluation of health outcomes stemming from such community-based models of service delivery is warranted.
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Affiliation(s)
| | - Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Joseph Rujumba
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Kampala, Uganda
| | | | - Anna Heard
- Independent Consultant, Washington, DC, USA
| | - Omar Galárraga
- School of Public Health, Brown University, Providence, RI, USA
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20
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Emergency Transportation Interventions for Reducing Adverse Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review. Ann Glob Health 2020; 86:147. [PMID: 33262936 PMCID: PMC7678559 DOI: 10.5334/aogh.2934] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective: To assess the effect of emergency transportation interventions on the outcome of labor and delivery in low- and middle-income countries (LMICs). Methods: Eleven databases were searched through December 2019: Medline/PubMed, EMBASE, Web of Science, EBSCO (PsycINFO and CINAHL), SCIELO, LILACS, JSTOR, POPLINE, Google Scholar, the Cochrane Pregnancy and Childbirth Group’s Specialized Register, and the Cochrane Central Register of Controlled Trials. Methodological quality of included studies was assessed using the ROBINS-I tool. Results: Nine studies (three in Asia and six in Africa) were included: one cluster randomized controlled trial, three controlled before-and-after (CBA) studies, four uncontrolled before and after studies, and one case-control study. The means of emergency obstetric transportation evaluated by the studies included bicycle (n = 1) or motorcycle ambulances (n = 3), 4-wheel drive vehicles (n = 3), and formal motor-vehicle ambulances (n = 2). Transportation support was offered within multi-component interventions including financial incentives (n = 1), improved communication (n = 7), and community mobilization (n = 2). Two controlled before-and-after studies that implemented interventions including financial support, three-wheeled motorcycles, and use of mobile phones reported reduction of maternal mortality. One cluster-randomized study which involved community mobilization and strengthening of referral, and transportation, and one controlled before-and-after that implemented free-of-charge, 24-hour, 4 × 4 wheel ambulance and a mobile phone showed reductions in stillbirth, perinatal, and neonatal mortality. Six studies reported increases in facility delivery ranging from 12–50%, and one study showed a 19% reduction in home delivery. There was a significant increase of caesarian sections in two studies; use of motorcycle ambulances compared to car ambulance resulted in reduction in referral delay by 2 to 4.5 hours. Only three included studies had low risk of bias on all domains. Conclusion: Integrating emergency obstetric transportation with complimentary maternal health interventions may reduce adverse pregnancy outcomes and increase access to skilled obstetric services for women in LMICs. The strength of evidence is limited by the paucity of high-quality studies.
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Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review. BMC Pregnancy Childbirth 2020; 20:682. [PMID: 33176732 PMCID: PMC7656726 DOI: 10.1186/s12884-020-03339-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/15/2020] [Indexed: 01/23/2023] Open
Abstract
Background sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women. Methods Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility. Results Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral. Conclusions Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals. Trial registration Systematic review registration: PROSPERO registration CRD42018114261. Supplementary information Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.
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Cavallaro FL, Benova L, Dioukhane EH, Wong K, Sheppard P, Faye A, Radovich E, Dumont A, Mbengue AS, Ronsmans C, Martinez-Alvarez M. What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal. BMJ Glob Health 2020; 5:e001915. [PMID: 32201621 PMCID: PMC7059423 DOI: 10.1136/bmjgh-2019-001915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Increases in facility deliveries in sub-Saharan Africa have not yielded expected declines in maternal mortality, raising concerns about the quality of care provided in facilities. The readiness of facilities at different health system levels to provide both emergency obstetric and newborn care (EmONC) as well as referral is unknown. We describe this combined readiness by facility level and region in Senegal. Methods For this cross-sectional study, we used data from nine Demographic and Health Surveys between 1992 and 2017 in Senegal to describe trends in location of births over time. We used data from the 2017 Service Provision Assessment to describe EmONC and emergency referral readiness across facility levels in the public system, where 94% of facility births occur. A national global positioning system facility census was used to map access from lower-level facilities to the nearest facility performing caesareans. Results Births in facilities increased from 47% in 1992 to 80% in 2016, driven by births in lower-level health posts, where half of facility births now occur. Caesarean rates in rural areas more than doubled but only to 3.7%, indicating minor improvements in EmONC access. Only 9% of health posts had full readiness for basic EmONC, and 62% had adequate referral readiness (vehicle on-site or telephone and vehicle access elsewhere). Although public facilities accounted for three-quarters of all births in 2016, only 16% of such births occurred in facilities able to provide adequate combined readiness for EmONC and referral. Conclusions Our findings imply that many lower-level public facilities—the most common place of birth in Senegal—are unable to treat or refer women with obstetric complications, especially in rural areas. In light of rising lower-level facility births in Senegal and elsewhere, improvements in EmONC and referral readiness are urgently needed to accelerate reductions in maternal and perinatal mortality.
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Affiliation(s)
- Francesca L Cavallaro
- CEPED, Institut de Recherche Pour le Développement, Paris, France.,Institute of Child Health, University College London, London, UK
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kerry Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Paula Sheppard
- Institute of Social and Cultural Anthropology, Oxford University, Oxford, UK
| | - Adama Faye
- Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
| | - Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alexandre Dumont
- CEPED, Institut de Recherche Pour le Développement, Paris, France
| | - Abdou Salam Mbengue
- IRESSEF: Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | - Carine Ronsmans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Melisa Martinez-Alvarez
- Medical Research Council Unit in The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, The Gambia
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Kaiser JL, Fong RM, Ngoma T, McGlasson KL, Biemba G, Hamer DH, Bwalya M, Chasaya M, Scott NA. The effects of maternity waiting homes on the health workforce and maternal health service delivery in rural Zambia: a qualitative analysis. HUMAN RESOURCES FOR HEALTH 2019; 17:93. [PMID: 31801578 PMCID: PMC6894259 DOI: 10.1186/s12960-019-0436-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/04/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Maternity waiting homes (MWHs) are a potential strategy to address low facility delivery rates resulting from access-associated barriers in resource-limited settings. Within a cluster-randomized controlled trial testing a community-generated MWH model in rural Zambia, we qualitatively assessed how MWHs affect the health workforce and maternal health service delivery at their associated rural health centers. METHODS Four rounds of in-depth interviews with district health staff (n = 21) and health center staff (n = 73) were conducted at intervention and control sites over 24 months. We conducted a content analysis using a mixed inductive-deductive approach. Data were interpreted through the lens of the World Health Organzation Health Systems Framework. RESULTS Nearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman's final stage of pregnancy and labor onset, detect complications earlier, and either more confidently manage those complications at the health center or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. When understaffing and overwork were frequently discussed, this satisfaction in providing better care was a meaningful departure. CONCLUSIONS MWHs may benefit staff at rural health centers and the health system more broadly, allowing for the provision of more timely and comprehensive obstetric care. We recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities. Considering the limited numbers of skilled birth attendants available in rural Zambia, it is important to strategically select locations for new MWHs. TRIAL REGISTRATION Clinicaltrials.gov, NCT02620436. Registered December 3, 2015, https://clinicaltrials.gov/ct2/show/NCT02620436.
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Affiliation(s)
- Jeanette L. Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - Rachel M. Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | | | - Godfrey Biemba
- National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA USA
| | - Misheck Bwalya
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | | | - Nancy A. Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA 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 (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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25
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Healey J, Conlon CM, Malama K, Hobson R, Kaharuza F, Kekitiinwa A, Levitt M, Zulu DW, Marum L. Sustainability and Scale of the Saving Mothers, Giving Life Approach in Uganda and Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S188-S206. [PMID: 30867217 PMCID: PMC6519672 DOI: 10.9745/ghsp-d-18-00265] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 11/08/2018] [Indexed: 11/23/2022]
Abstract
The Saving Mothers, Giving Life district health systems strengthening approach provides a sustainable model for reducing maternal mortality at scale. Lessons from the learning districts demonstrated increased efficiency in allocation of resources for maternal and newborn health, better use of strategic information, improved management capacities, and increased community engagement. Background: Saving Mothers, Giving Life (SMGL) significantly reduced maternal and perinatal mortality in Uganda and Zambia by using a district health systems strengthening approach to address the key delays women and newborns face in receiving quality, timely, and appropriate medical care. This article documents the transition of SMGL from pilot to scale in Uganda and Zambia and analyzes the sustainability of the approach, examining the likelihood of maintaining positive trends in maternal and newborn health in both countries. Methods: We analyzed the potential sustainment of SMGL achievements using a tool adapted from the HIV-focused domains and elements of the U.S. President's Emergency Plan for AIDS Relief Sustainability Index and Dashboard for maternal and neonatal health pro-gramming adding a domain on community normative change. Information for each of the 5 resulting domains was drawn from SMGL and non-SMGL reports, individual stakeholder interviews, and group discussions. Findings: In both Uganda and Zambia, the SMGL proof-of-concept phase catalyzed commitment to saving mothers and newborns and a renewed belief that significant change is possible. Increased leadership and accountability for maternal and newborn health, particularly at the district and facility levels, was bolstered by routine maternal death surveillance reviews that engaged a wide range of local leadership. The SMGL district-strengthening model was found to be cost-effective with cost of death averted estimated at US$177-206 per year of life gained. When further considering the ripple effect that saving a mother has on child survival and the household economy, the value of SMGL increases. Ministries of health and donor agencies have already demonstrated a willingness to pay this amount per year of life for other programs, such as HIV and AIDS. Conclusion: As SMGL scaled up in both Uganda and Zambia, the intentional integration of SMGL interventions into host country systems, alignment with other large-scale programs, and planned reductions in annual SMGL funding all contributed to increasing host government ownership of the interventions and set the SMGL approach on a path more likely to be sustained following the close of the initiative. Lessons from the learning districts resulted in increased efficiency in allocation of resources for maternal and newborn health, better use of strategic information, improved management capacities, and increased community engagement.
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Affiliation(s)
- Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia.
| | | | - Kennedy Malama
- Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | | | - Frank Kaharuza
- HIV Health Office, U.S. Agency for International Development, Kampala, Uganda
| | | | - Marta Levitt
- Bureau for Global Health, U.S. Agency for International Development and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria
| | - Davy Wadula Zulu
- Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | - Lawrence Marum
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired
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Serbanescu F, Clark TA, Goodwin MM, Nelson LJ, Boyd MA, Kekitiinwa AR, Kaharuza F, Picho B, Morof D, Blanton C, Mumba M, Komakech P, Carlosama F, Schmitz MM, Conlon CM. Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S27-S47. [PMID: 30867208 PMCID: PMC6519676 DOI: 10.9745/ghsp-d-18-00428] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/28/2019] [Indexed: 01/09/2023]
Abstract
Through district system strengthening, integrated services, and community engagement interventions, the Saving Mothers, Giving Life initiative increased emergency obstetric care coverage and access to, and demand for, improved quality of care that led to rapid declines in district maternal and perinatal mortality. Significant reductions in intrapartum stillbirth rate and maternal mortality ratios around the time of birth attest to the success of the initiative. Background: Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions. Methods: SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities. Results: Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country. Conclusions: MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths.
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Affiliation(s)
- Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Thomas A Clark
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mary M Goodwin
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lisa J Nelson
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Mary Adetinuke Boyd
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Frank Kaharuza
- HIV Health Office, U.S. Agency for International Development, Kampala, Uganda
| | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Diane Morof
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.,U.S. Public Health Service Commissioned Corps, Rockville, MD, USA
| | - Curtis Blanton
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Maybin Mumba
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Patrick Komakech
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Fernando Carlosama
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michelle M Schmitz
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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27
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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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28
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Schmitz MM, Serbanescu F, Kamara V, Kraft JM, Cunningham M, Opio G, Komakech P, Conlon CM, Goodwin MM. Did Saving Mothers, Giving Life Expand Timely Access to Lifesaving Care in Uganda? A Spatial District-Level Analysis of Travel Time to Emergency Obstetric and Newborn Care. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S151-S167. [PMID: 30867215 PMCID: PMC6519675 DOI: 10.9745/ghsp-d-18-00366] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 11/13/2018] [Indexed: 12/31/2022]
Abstract
A spatial analysis of facility accessibility, taking into account road networks and environmental constraints on travel, suggests that the Saving Mothers, Giving Life (SMGL) initiative increased access to emergency obstetric and neonatal care in SMGL-supported districts in Uganda. Spatial travel-time analyses can inform policy and program efforts targeting underserved populations in conjunction with the geographic distribution of maternity services. Introduction: Interventions for the Saving Mothers, Giving Life (SMGL) initiative aimed to ensure all pregnant women in SMGL-supported districts have timely access to emergency obstetric and newborn care (EmONC). Spatial travel-time analyses provide a visualization of changes in timely access. Methods: We compared travel-time estimates to EmONC health facilities in SMGL-supported districts in western Uganda in 2012, 2013, and 2016. To examine EmONC access, we analyzed a categorical variable of travel-time duration in 30-minute increments. Data sources included health facility assessments, geographic coordinates of EmONC facilities, geolocated population estimates of women of reproductive age (WRA), and other road network and geographic sources. Results: The number of EmONC facilities almost tripled between 2012 and 2016, increasing geographic access to EmONC. Estimated travel time to EmONC facilities declined significantly during the 5-year period. The proportion of WRA able to access any EmONC and comprehensive EmONC (CEmONC) facility within 2 hours by motorcycle increased by 18% (from 61.3% to 72.1%, P < .01) and 37% (from 51.1% to 69.8%, P < .01), respectively from baseline to 2016. Similar increases occurred among WRA accessing EmONC and CEmONC respectively if 4-wheeled vehicles (14% and 31% increase, P < .01) could be used. Increases in timely access were also substantial for nonmotorized transportation such as walking and/or bicycling. Conclusions: Largely due to the SMGL-supported expansion of EmONC capability, timely access to EmONC significantly improved. Our analysis developed a geographic outline of facility accessibility using multiple types of transportation. Spatial travel-time analyses, along with other EmONC indicators, can be used by planners and policy makers to estimate need and target underserved populations to achieve further gains in EmONC accessibility. In addition to increasing the number and geographic distribution of EmONC facilities, complementary efforts to make motorized transportation available are necessary to achieve meaningful increases in EmONC access.
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Affiliation(s)
- Michelle M Schmitz
- 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.
| | - Vincent Kamara
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Joan Marie Kraft
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Marc Cunningham
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Gregory Opio
- Infectious Diseases Institute, Makerere University, Kibaale, Uganda
| | - Patrick Komakech
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | | | - Mary M Goodwin
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 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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