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Ghosh R, Owa O, Santos N, Butrick E, Piaggio G, Widmer M, Althabe F, Qureshi Z, Lumbiganon P, Katageri G, Walker D. Heat stable carbetocin or oxytocin for prevention of postpartum hemorrhage among women at risk: A secondary analysis of the CHAMPION trial. Int J Gynaecol Obstet 2024; 164:124-130. [PMID: 37357606 DOI: 10.1002/ijgo.14938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To examine whether the observed non-inferiority of heat-stable carbetocin (HSC), compared with oxytocin, was influenced by biologic (macrosomia, parity 3 or more, or history of postpartum hemorrhage [PPH]) and/or pharmacologic (induction or augmentation) risk factors for PPH. METHODS The present study is a secondary analysis of the CHAMPION non-inferiority randomized trial-a two-arm, double-blind, active-controlled study conducted at 23 hospitals in 10 countries, between July 2015 and January 2018. Women with singleton pregnancies, expected to deliver vaginally with cervical dilatation up to 6 cm were eligible. Randomization was stratified by country, with 1:1 assignment. Women in the intervention and control groups received a single intramuscular injection of 100 μg of HSC or 10 IU of oxytocin, respectively. The drugs were administered immediately after birth, and the third stage of labor was managed according to the WHO guidelines. Blood was collected using a plastic drape. For this analysis, we defined a woman as being at risk if she had any one or more of the biologic or pharmacologic risk factor(s). RESULTS The HSC and oxytocin arms contained 14 770 and 14 768 women, respectively. The risk ratios (RR) for PPH were 1.29 (95% confidence interval [CI] 1.08-1.53) or 1.73 (95% CI 1.51-1.98) for those with only biologic (macrosomia, parity 3 or more, and PPH in the previous pregnancy) or only pharmacologic (induced or augmented) risk factors, respectively, compared with those with neither risk factors. CONCLUSIONS Findings reinforce previous evidence that macrosomia, high parity, history of PPH, and induction/augmentation are risk factors for PPH. We did not find a difference in effects between HSC and oxytocin for PPH among women who were neither induced nor augmented or among those who were induced or augmented.
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Affiliation(s)
- Rakesh Ghosh
- Institute for Global Health Sciences, University of California, San Francisco, California, USA
| | - Olorunfemi Owa
- Department of Obstetrics and Gynecology, Mother and Child Hospital, Akure, Nigeria
| | - Nicole Santos
- Institute for Global Health Sciences, University of California, San Francisco, California, USA
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, California, USA
| | | | - Mariana Widmer
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Fernando Althabe
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Zahaida Qureshi
- Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynecology, Khon Kaen University, Bangkok, Thailand
| | | | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, California, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
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Mandu R, Miller L, Namazzi G, Twum-Danso N, Achola KJA, Cooney I, Butrick E, Santos N, Masavah L, Nyakech A, Kirumbi L, Waiswa P, Walker D. Quality improvement collaboratives as part of a quality improvement intervention package for preterm births at sub-national level in East Africa: a multi-method analysis. BMJ Open Qual 2023; 12:e002443. [PMID: 38135302 DOI: 10.1136/bmjoq-2023-002443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives (QIC) are an approach to accelerate the spread and impact of evidence-based interventions across health facilities, which are found to be particularly successful when combined with other interventions such as clinical skills training. We implemented a QIC as part of a quality improvement intervention package designed to improve newborn survival in Kenya and Uganda. We use a multi-method approach to describe how a QIC was used as part of an overall improvement effort and describe specific changes measured and participant perceptions of the QIC. METHODS We examined QIC-aggregated run charts on three shared indicators related to uptake of evidence-based practices over time and conducted key informant interviews to understand participants' perceptions of quality improvement practice. Run charts were evaluated for change from baseline medians. Interviews were analysed using framework analysis. RESULTS Run charts for all indicators reflected an increase in evidence-based practices across both countries. In Uganda, pre-QIC median gestational age (GA) recording of 44% improved to 86%, while Kangaroo Mother Care (KMC) initiation went from 51% to 96% and appropriate antenatal corticosteroid (ACS) use increased from 17% to 74%. In Kenya, these indicators went from 82% to 96%, 4% to 74% and 4% to 57%, respectively. Qualitative results indicate that participants appreciated the experience of working with data, and the friendly competition of the QIC was motivating. The participants reported integration of the QIC with other interventions of the package as a benefit. CONCLUSIONS In a QIC that demonstrated increased evidence-based practices, QIC participants point to data use, friendly competition and package integration as the drivers of success, despite challenges common to these settings such as health worker and resource shortages. TRIAL REGISTRATION NUMBER NCT03112018.
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Affiliation(s)
- Rogers Mandu
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
| | - Lara Miller
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Gertrude Namazzi
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
| | | | | | - Isabella Cooney
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | | | | | - Leah Kirumbi
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
- Karolinska Institutet, Stockholm, Stockholm, Sweden
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
- Department of Obstetrics and Gynecology and Global Health Sciences, University of California San Francisco Medical Center at Parnassus, San Francisco, California, USA
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Miller L, Schmidt CN, Wanduru P, Wanyoro A, Santos N, Butrick E, Lester F, Otieno P, Walker D. Adapting the preterm birth phenotyping framework to a low-resource, rural setting and applying it to births from Migori County in western Kenya. BMC Pregnancy Childbirth 2023; 23:729. [PMID: 37845611 PMCID: PMC10577962 DOI: 10.1186/s12884-023-06012-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 09/19/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Preterm birth is the leading cause of neonatal and under-five mortality worldwide. It is a complex syndrome characterized by numerous etiologic pathways shaped by both maternal and fetal factors. To better understand preterm birth trends, the Global Alliance to Prevent Prematurity and Stillbirth published the preterm birth phenotyping framework in 2012 followed by an application of the model to a global dataset in 2015 by Barros, et al. Our objective was to adapt the preterm birth phenotyping framework to retrospective data from a low-resource, rural setting and then apply the adapted framework to a cohort of women from Migori, Kenya. METHODS This was a single centre, observational, retrospective chart review of eligible births from November 2015 - March 2017 at Migori County Referral Hospital. Adaptations were made to accommodate limited diagnostic capabilities and data accuracy concerns. Prevalence of the phenotyping conditions were calculated as well as odds of adverse outcomes. RESULTS Three hundred eighty-seven eligible births were included in our study. The largest phenotype group was none (no phenotype could be identified; 41.1%), followed by extrauterine infection (25.1%), and antepartum stillbirth (16.7%). Extrauterine infections included HIV (75.3%), urinary tract infections (24.7%), malaria (4.1%), syphilis (3.1%), and general infection (3.1%). Severe maternal condition was ranked fourth (15.6%) and included anaemia (69.5%), chronic respiratory distress (22.0%), chronic hypertension prior to pregnancy (5.1%), diabetes (3.4%), epilepsy (3.4%), and sickle cell disease (1.7%). Fetal anaemia cases were the most likely to transfer to the newborn unit (OR 5.1, 95% CI 0.8, 30.9) and fetal anomaly cases were the most likely to result in a pre-discharge mortality (OR 3.9, 95% CI 0.8, 19.2). CONCLUSIONS Using routine data sources allowed for a retrospective analysis of an existing dataset, requiring less time and fewer resources than a prospective study and demonstrating a feasible approach to preterm phenotyping for use in low-resource settings to inform local prevention strategies.
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Affiliation(s)
- Lara Miller
- University of California San Francisco, Institute for Global Health Sciences, 550 16Th St, San Francisco, CA, 94158, USA.
| | - Christina N Schmidt
- University of California San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Phillip Wanduru
- School of Public Health, Makerere University, New Mulago Gate Rd, Kampala, Uganda
| | - Anthony Wanyoro
- Department of Obstetrics and Gynaecology, Kenyatta University, Main Campus, Kenya Drive, Nairobi, Kenya
| | - Nicole Santos
- University of California San Francisco, Institute for Global Health Sciences, 550 16Th St, San Francisco, CA, 94158, USA
| | - Elizabeth Butrick
- University of California San Francisco, Institute for Global Health Sciences, 550 16Th St, San Francisco, CA, 94158, USA
| | - Felicia Lester
- Department of Obstetrics, University of California San Francisco, Gynaecology & Reproductive Sciences, 1825 Fourth St Third Floor, San Francisco, CA, 94158, USA
| | - Phelgona Otieno
- Kenya Medical Research Institute, 00200 Off Raila Odinga Way, Nairobi, Kenya
| | - Dilys Walker
- University of California San Francisco, Institute for Global Health Sciences, 550 16Th St, San Francisco, CA, 94158, USA
- Department of Obstetrics, University of California San Francisco, Gynaecology & Reproductive Sciences, 1825 Fourth St Third Floor, San Francisco, CA, 94158, USA
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Benitez A, Petersen ML, van der Laan MJ, Santos N, Butrick E, Walker D, Ghosh R, Otieno P, Waiswa P, Balzer LB. Defining and estimating effects in cluster randomized trials: A methods comparison. Stat Med 2023; 42:3443-3466. [PMID: 37308115 PMCID: PMC10898620 DOI: 10.1002/sim.9813] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/27/2023] [Accepted: 05/21/2023] [Indexed: 06/14/2023]
Abstract
Across research disciplines, cluster randomized trials (CRTs) are commonly implemented to evaluate interventions delivered to groups of participants, such as communities and clinics. Despite advances in the design and analysis of CRTs, several challenges remain. First, there are many possible ways to specify the causal effect of interest (eg, at the individual-level or at the cluster-level). Second, the theoretical and practical performance of common methods for CRT analysis remain poorly understood. Here, we present a general framework to formally define an array of causal effects in terms of summary measures of counterfactual outcomes. Next, we provide a comprehensive overview of CRT estimators, including the t-test, generalized estimating equations (GEE), augmented-GEE, and targeted maximum likelihood estimation (TMLE). Using finite sample simulations, we illustrate the practical performance of these estimators for different causal effects and when, as commonly occurs, there are limited numbers of clusters of different sizes. Finally, our application to data from the Preterm Birth Initiative (PTBi) study demonstrates the real-world impact of varying cluster sizes and targeting effects at the cluster-level or at the individual-level. Specifically, the relative effect of the PTBi intervention was 0.81 at the cluster-level, corresponding to a 19% reduction in outcome incidence, and was 0.66 at the individual-level, corresponding to a 34% reduction in outcome risk. Given its flexibility to estimate a variety of user-specified effects and ability to adaptively adjust for covariates for precision gains while maintaining Type-I error control, we conclude TMLE is a promising tool for CRT analysis.
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Affiliation(s)
| | - Maya L. Petersen
- School of Public Health, Biostatistics, University of California Berkeley, Berkeley, California
| | - Mark J. van der Laan
- School of Public Health, Biostatistics, University of California Berkeley, Berkeley, California
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California
| | - Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California
| | - Phelgona Otieno
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Peter Waiswa
- Centre of Excellence for Maternal, Newborn and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Laura B. Balzer
- School of Public Health, Biostatistics, University of California Berkeley, Berkeley, California
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Singh K, Murindahabi N, Butrick E, Sayinzoga F, Nzeyimana D, Musange S, Walker D. Utilizing a mixed-methods approach to assess implementation fidelity of a group antenatal care trial in Rwanda. PLoS One 2023; 18:e0288974. [PMID: 37486950 PMCID: PMC10365308 DOI: 10.1371/journal.pone.0288974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND The Preterm Birth Initiative (PTBi)-Rwanda conducted a cluster randomized controlled trial to assess the impact of group antenatal care (group ANC) on preterm birth, using a group ANC approach adapted for the Rwanda setting, and implemented in 18 health centers. Previous research showed high overall fidelity of implementation, but lacked correlation with provider self-assessment and left unanswered questions. This study utilizes a mixed-methods approach to study the fidelity with which the health centers' implementation followed the model specified for group ANC. METHODS Implementation fidelity was measured using two tools, repeated Model Fidelity Assessments (MFAs) and Activity Reports (ARs) completed by Master Trainers, who visited each health center between 7 and 13 times (9 on average) to provide monitoring and training over 18 months between 2017 and 2019. Each center's MFA item and overall scores were regressed (linear regression) on the time elapsed since the center's start of implementation. The Activity Report (AR) is an open-ended template to record comments on implementation. For the qualitative analysis, the ARs from the times of each center's highest and lowest MFA score were analyzed using thematic analysis. Coding was conducted via Dedoose, with two coders independently reviewing and coding transcripts, followed by joint consensus coding. RESULTS A total of 160 MFA reports were included in the analysis. There was a significant positive association between elapsed time since a health center started implementation and greater implementation fidelity (as measured by MFA scores). In the qualitative AR analysis, Master Trainers identified key areas to improve fidelity of implementation, including: group ANC scheduling, preparing the room for group ANC sessions, provider capacity to co-facilitate group ANC, and facilitator knowledge and skills regarding group ANC content and process. These results reveal that monitoring visits are an important part of acquisition and fidelity of the "soft skills" required to effectively implement group ANC and provide an understanding of the elements that may have impacted fidelity as described by Master Trainers. CONCLUSIONS For interventions like Group ANC, where "soft-skills" like group facilitation are important, we recommend continuous monitoring and mentoring throughout program implementation to strengthen these new skills, provide corrective feedback and guard against skills decay. We suggest the use of quantitative tools to provide direct measures of implementation fidelity over time and qualitative tools to gain a more complete understanding of what factors influence implementation fidelity. Identifying areas of implementation requiring additional support and mentoring may ensure effective translation of evidence-based interventions into real-world settings.
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Affiliation(s)
- Kalee Singh
- University of California Berkeley School of Public Health, Berkeley, California, United States of America
| | | | - Elizabeth Butrick
- Institute of Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division—Institute of HIV/AIDs, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - David Nzeyimana
- University of Rwanda School of Public Health, Kigali, Rwanda
| | - Sabine Musange
- University of Rwanda School of Public Health, Kigali, Rwanda
| | - Dilys Walker
- Institute of Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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Smith Hughes C, Butrick E, Namutundu J, Olwanda E, Otieno P, Waiswa P, Walker D, Kahn JG. Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda. PLoS One 2023; 18:e0287309. [PMID: 37352149 PMCID: PMC10289453 DOI: 10.1371/journal.pone.0287309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/02/2023] [Indexed: 06/25/2023] Open
Abstract
INTRODUCTION Preterm birth is a leading cause of under-5 mortality, with the greatest burden in lower-resource settings. Strategies to improve preterm survival have been tested, but strategy costs are less understood. We estimate costs of a highly effective Preterm Birth Initiative (PTBi) intrapartum intervention package (data strengthening, WHO Safe Childbirth Checklist, simulation and team training, quality improvement collaboratives) and active control (data strengthening, Safe Childbirth Checklist). METHODS In our analysis, we estimated costs incremental to current cost of intrapartum care (in 2020 $US) for the PTBi intervention package and active control in Kenya and Uganda. We costed the intervention package and control in two scenarios: 1) non-research implementation costs as observed in the PTBi study (Scenario 1, mix of public and private inputs), and 2) hypothetical costs for a model of implementation into Ministry of Health programming (Scenario 2, mostly public inputs). Using a healthcare system perspective, we employed micro-costing of personnel, supplies, physical space, and travel, including 3 sequential phases: program planning/adaptation (9 months); high-intensity implementation (15 months); lower-intensity maintenance (annual). One-way sensitivity analyses explored the effects of uncertainty in Scenario 2. RESULTS Scenario 1 PTBi package total costs were $1.11M in Kenya ($48.13/birth) and $0.74M in Uganda ($17.19/birtth). Scenario 2 total costs were $0.86M in Kenya ($23.91/birth) and $0.28M in Uganda ($5.47/birth); annual maintenance phase costs per birth were $16.36 in Kenya and $3.47 in Uganda. In each scenario and country, personnel made up at least 72% of total PTBi package costs. Total Scenario 2 costs in Uganda were consistently one-third those of Kenya, largely driven by differences in facility delivery volume and personnel salaries. CONCLUSIONS If taken up and implemented, the PTBi package has the potential to save preterm lives, with potential steady-state (maintenance) costs that would be roughly 5-15% of total per-birth healthcare costs in Uganda and Kenya.
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Affiliation(s)
- Carolyn Smith Hughes
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | | | | | | | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - James G. Kahn
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
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Miller L, Wanduru P, Wangia J, Calkins K, Spindler H, Butrick E, Santos N, Kirumbi L, Walker D. Simulation and team training to improve preterm birth knowledge, evidence-based practices, and communication skills in midwives in Kenya and Uganda: Findings from a pre- and post-intervention analysis. PLOS Glob Public Health 2023; 3:e0001695. [PMID: 37289721 DOI: 10.1371/journal.pgph.0001695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 05/10/2023] [Indexed: 06/10/2023]
Abstract
Simulation training in basic and emergency obstetric and neonatal care has previously shown success in reducing maternal and neonatal mortality in low-resource settings. Though preterm birth is the leading cause of neonatal deaths, application of this training methodology geared specifically towards reducing preterm birth mortality and morbidity has not yet been implemented and evaluated. The East Africa Preterm Birth Initiative (PTBi-EA) was a multi-country cluster randomized controlled (CRCT) trial that successfully improved outcomes of preterm neonates in Migori County, Kenya and the Busoga region of Uganda through an intrapartum package of interventions. PRONTO simulation and team training (STT) was one component of this package and was introduced to maternity unit providers in 13 facilities. This analysis was nested within the larger CRCT and specifically looked at the impact of the STT portion of the intervention package. The PRONTO STT curriculum was modified to emphasize prematurity-related intrapartum and immediate postnatal care practices, such as assessment of gestational age, identification of preterm labour, and administration of antenatal corticosteroids. Knowledge and communication techniques were assessed at the beginning and end of the intervention through a multiple-choice knowledge test. Clinical skills and communication techniques used in context were assessed through the use of evidence-based practiced (EBPs) as documented in video-recorded simulations through StudioCodeTM video analysis. Pre-and-post scores were compared in both categories using Chi-squared tests. Knowledge assessment scores improved from 51% to 73% with maternal-related questions improving from 61% to 74%, neonatal questions from 55% to 73%, and communication technique questions from 31% to 71%. The portion of indicated preterm birth EBPs performed in simulation increased from 55% to 80% with maternal-related EBPs improving from 48% to 73%, neonatal-related EBPs from 63% to 93%, and communication techniques from 52% to 69%. STT substantially increased preterm birth-specific knowledge and EBPs performed in simulation.
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Affiliation(s)
- Lara Miller
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
| | - Phillip Wanduru
- Makerere University School of Public Health, Kampala, Uganda
| | | | | | - Hilary Spindler
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
| | - Elizabeth Butrick
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
| | - Nicole Santos
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
| | - Leah Kirumbi
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Dilys Walker
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
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Ghosh R, Otieno P, Butrick E, Santos N, Waiswa P, Walker D. Effect of a quality improvement intervention for management of preterm births on outcomes of all births in Kenya and Uganda: A secondary analysis from a facility-based cluster randomized trial. J Glob Health 2022; 12:04073. [PMID: 36580073 PMCID: PMC9799078 DOI: 10.7189/jogh.12.04073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background A large proportion of early neonatal deaths occur at the time or on the first day of birth. The Preterm Birth Initiative East Africa (PTBi EA) set out to decrease mortality among preterm births through improving quality of facility-based intrapartum care. The PTBi EA cluster randomized trial's primary analysis showed the package reduced intrapartum stillbirth and neonatal death among preterm infants. This secondary analysis examines the impact of the PTBi intervention package on stillbirth and predischarge newborn deaths combined, among all births in 20 participating facilities in Kenya and Uganda. Methods Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention or the control group. All facilities received support for data strengthening and a modified World Health Organization (WHO) Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. We abstracted data from maternity registers. Results Of the total 29 442 births that were included, Kenya had 8468 and 6465 births and Uganda had 8719 and 5790 births, in the control and intervention arms, respectively. There were 935 stillbirths and predischarge newborn deaths in the control arm and 439 in the intervention arm. The adjusted odds ratio (aOR) for the effect of the intervention on the combined outcome, among all births, was 0.96 (95% confidence interval (CI) = 0.69-1.32), which was different by country: Kenya - 1.12 (95% CI = 0.72-1.73); Uganda - 0.65 (95% CI = 0.44-0.98); Pinteraction = 0.025. These trends were similar after excluding the PTBi primary cohort. Conclusions The intervention package improved survival among all births in Uganda but not in Kenya. These results suggest the importance of context and facility differences that were observed between the two countries. Registration This trial is registered with ClinicalTrials.gov, NCT03112018.
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Affiliation(s)
- Rakesh Ghosh
- University of California, San Francisco, Institute for Global Health Sciences, USA
| | - Phelgona Otieno
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Butrick
- University of California, San Francisco, Institute for Global Health Sciences, USA
| | - Nicole Santos
- University of California, San Francisco, Institute for Global Health Sciences, USA
| | - Peter Waiswa
- Makerere University, School of Public Health, Uganda,Department of Global Public Health, Karolinska Institutet, Sweden
| | - Dilys Walker
- University of California, San Francisco, Institute for Global Health Sciences, USA,University of California, San Francisco, School of Medicine, Department of OB/GYN and Reproductive Sciences, USA
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Ghosh R, Santos N, Butrick E, Wanyoro A, Waiswa P, Kim E, Walker D. Stillbirth, neonatal and maternal mortality among caesarean births in Kenya and Uganda: a register-based prospective cohort study. BMJ Open 2022; 12:e055904. [PMID: 35387820 PMCID: PMC8987792 DOI: 10.1136/bmjopen-2021-055904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To investigate the interaction of risks for adverse maternal and perinatal outcomes (stillbirth, predischarge neonatal and maternal mortality) among caesarean section (CS) compared with vaginal deliveries (VD). DESIGN Prospective cohort study. SETTING 10 CS-capable facilities in Busoga Region, East-Central Uganda and Migori County, Kenya. PARTICIPANTS Individual birth data were extracted from maternity registers between October 2016 and April 2019. There were a total of 77 242 livebirths and 3734 stillbirths. Overall, 24% of deliveries were by CS with a range of 9%-49% across facilities. PRIMARY OUTCOME MEASURES Stillbirth, predischarge neonatal mortality and maternal mortality. RESULTS The adjusted ORs for stillbirth, predischarge neonatal mortality and maternal mortality after a CS were 1.3 (95% CI 1.1 to 1.6), 1.9 (95% CI 1.6 to 2.2) and 3.3 (95% CI 2.2 to 4.9), respectively, compared with a VD. The association between maternal mortality and CS was 3.9 (95% CI 2.8 to 5.5) when the delivery was a live birth and 1.7 (95% CI 1.0 to 3.0) when it was a stillbirth. Post hoc analyses showed that mothers who received a CS had a lower risk of stillbirth if they were documented as a referral. CONCLUSION In this context, CS births were at higher risk for worse outcomes compared with VD. Better understanding of CS use and associated adverse outcomes within the mother-baby dyad is necessary to identify opportunities to improve quality of intrapartum care. TRIAL REGISTRATION NUMBER NCT03112018.
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Affiliation(s)
- Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Butrick
- University of California San Francisco, San Francisco, California, USA
| | | | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Eliana Kim
- University of California San Francisco, San Francisco, California, USA
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
- University of California San Francisco Department of Obstetrics Gynecology and Reproductive Sciences, San Francisco, California, USA
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Whaley B, Butrick E, Sales JM, Wanyoro A, Waiswa P, Walker D, Cranmer JN. Using clinical cascades to measure health facilities' obstetric emergency readiness: testing the cascade model using cross-sectional facility data in East Africa. BMJ Open 2022; 12:e057954. [PMID: 35379635 PMCID: PMC8981352 DOI: 10.1136/bmjopen-2021-057954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Globally, hundreds of women die daily from preventable pregnancy-related causes, with the greatest burden in sub-Saharan Africa. Five key emergencies-bleeding, infections, high blood pressure, delivery complications and unsafe abortions-account for nearly 75% of these obstetric deaths. Skilled clinicians with strategic supplies could prevent most deaths. In this study, we (1) measured facility readiness to manage common obstetric emergencies using the clinical cascades and signal function tracers; (2) compared these readiness estimates by facility characteristics; and (3) measured cascading drop-offs in resources. DESIGN A facility-based cross-sectional analysis of resources for common obstetric emergencies. SETTING Data were collected in 2016 from 23 hospitals (10 designated comprehensive emergency obstetric care (CEmOC) facilities) in Migori County, western Kenya, and Busoga Region, eastern Uganda, in the Preterm Birth Initiative study in East Africa. Baseline data were used to estimate a facility's readiness to manage common obstetric emergencies using signal function tracers and the clinical cascade model. We compared emergency readiness using the proportion of facilities with tracers (signal functions) and the proportion with resources for identifying and treating the emergency (cascade stages 1 and 2). RESULTS The signal functions overestimated practical emergency readiness by 23 percentage points across five emergencies. Only 42% of CEmOC-designated facilities could perform basic emergency obstetric care. Across the three stages of care (identify, treat and monitor-modify) for five emergencies, there was a 28% pooled mean drop-off in readiness. Across emergencies, the largest drop-off occurred in the treatment stage. Patterns of drop-off remained largely consistent across facility characteristics. CONCLUSIONS Accurate measurement of obstetric emergency readiness is a prerequisite for strengthening facilities' capacity to manage common emergencies. The cascades offer stepwise, emergency-specific readiness estimates designed to guide targeted maternal survival policies and programmes. TRIAL REGISTRATION NUMBER NCT03112018.
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Affiliation(s)
- Bridget Whaley
- Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Jessica M Sales
- Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - Anthony Wanyoro
- Department of Obstetrics and Gynecology, Kenyatta University, Nairobi, Kenya
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - John N Cranmer
- Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, USA
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Achola KA, Kajjo D, Santos N, Butrick E, Otare C, Mubiri P, Namazzi G, Merai R, Otieno P, Waiswa P, Walker D. Implementing the WHO Safe Childbirth Checklist modified for preterm birth: lessons learned and experiences from Kenya and Uganda. BMC Health Serv Res 2022; 22:294. [PMID: 35241076 PMCID: PMC8896298 DOI: 10.1186/s12913-022-07650-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background The WHO Safe Childbirth Checklist (SCC) contains 29 evidence-based practices (EBPs) across four pause points spanning admission to discharge. It has been shown to increase EBP uptake and has been tailored to specific contexts. However, little research has been conducted in East Africa on use of the SCC to improve intrapartum care, particularly for preterm birth despite its burden. We describe checklist adaptation, user acceptability, implementation and lessons learned. Methods The East Africa Preterm Birth Initiative (PTBi EA) modified the SCC for use in 23 facilities in Western Kenya and Eastern Uganda as part of a cluster randomized controlled trial evaluating a package of facility-based interventions to improve preterm birth outcomes. The modified SCC (mSCC) for prematurity included: addition of a triage pause point before admission; focus on gestational age assessment, identification and management of preterm labour; and alignment with national guidelines. Following introduction, implementation lasted 24 and 34 months in Uganda and Kenya respectively and was supported through complementary mentoring and data strengthening at all sites. PRONTO® simulation training and quality improvement (QI) activities further supported mSCC use at intervention facilities only. A mixed methods approach, including checklist monitoring, provider surveys and in-depth interviews, was used in this analysis. Results A total of 19,443 and 2229 checklists were assessed in Kenya and Uganda, respectively. In both countries, triage and admission pause points had the highest rates of completion. Kenya’s completion was greater than 70% for all pause points; Uganda ranged from 39 to 75%. Intervention facilities exposed to PRONTO and QI had higher completion rates than control sites. Provider perceptions cited clinical utility of the checklist, particularly when integrated into patient charts. However, some felt it repeated information in other documentation tools. Completion was hindered by workload and staffing issues. Conclusion This study highlights the feasibility and importance of adaptation, iterative modification and complementary activities to reinforce SCC use. There are important opportunities to improve its clinical utility by the addition of prompts specific to the needs of different contexts. The trial assessing the PTBi EA intervention package was registered at ClinicalTrials.gov NCT03112018 Registered December 2016, retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07650-x.
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Affiliation(s)
| | - Darious Kajjo
- Makerere University School of Public Health, Kampala, Uganda
| | - Nicole Santos
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, USA
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, USA.
| | | | - Paul Mubiri
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Rikita Merai
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, USA
| | | | - Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda.,Department of Global Public Health, Karolinska Institutet, Stockolm, Sweden
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, USA.,Dept. of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, USA
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Schmidt CN, Butrick E, Musange S, Mulindahabi N, Walker D. Towards stronger antenatal care: Understanding predictors of late presentation to antenatal services and implications for obstetric risk management in Rwanda. PLoS One 2021; 16:e0256415. [PMID: 34432829 PMCID: PMC8386859 DOI: 10.1371/journal.pone.0256415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/03/2021] [Indexed: 12/03/2022] Open
Abstract
Background Early antenatal care (ANC) reduces maternal and neonatal morbidity and mortality through identification of pregnancy-related complications, yet 44% of Rwandan women present to ANC after 16 weeks gestational age (GA). The objective of this study was to identify factors associated with delayed initiation of ANC and describe differences in the obstetric risks identified at the first ANC visit (ANC-1) between women presenting early and late to care. Methods This secondary data analysis included 10,231 women presenting for ANC-1 across 18 health centers in Rwanda (May 2017-December 2018). Multivariable logistic regression models were constructed using backwards elimination to identify predictors of presentation to ANC at ≥16 and ≥24 weeks GA. Logistic regression was used to examine differences in obstetric risk factors identified at ANC-1 between women presenting before and after 16- and 24-weeks GA. Results Sixty-one percent of women presented to ANC at ≥16 weeks and 24.7% at ≥24 weeks GA, with a mean (SD) GA at presentation of 18.9 (6.9) weeks. Younger age (16 weeks: OR = 1.36, 95% CI: 1.06, 1.75; 24 weeks: OR = 1.33, 95% CI: 0.95, 1.85), higher parity (16 weeks: 1–4 births, OR = 1.55, 95% CI: 1.39, 1.72; five or more births, OR = 2.57, 95% CI: 2.17, 3.04; 24 weeks: 1–4 births, OR = 1.93, 95% CI: 1.78, 2.09; five or more births, OR = 3.20, 95% CI: 2.66, 3.85), lower educational attainment (16 weeks: primary, OR = 0.75, 95% CI: 0.65, 0.86; secondary, OR = 0.60, 95% CI: 0.47,0.76; university, OR = 0.48, 95% CI: 0.33, 0.70; 24 weeks: primary, OR = 0.64, 95% CI: 0.53, 0.77; secondary, OR = 0.43, 95% CI: 0.29, 0.63; university, OR = 0.12, 95% CI: 0.04, 0.32) and contributing to household income (16 weeks: OR = 1.78, 95% CI: 1.40, 2.25; 24 weeks: OR = 1.91, 95% CI: 1.42, 2.55) were associated with delayed ANC-1 (≥16 and ≥24 weeks GA). History of a spontaneous abortion (16 weeks: OR = 0.74, 95% CI: 0.66, 0.84; 24 weeks: OR = 0.70, 95% CI: 0.58, 0.84), pregnancy testing (16 weeks: OR = 0.48, 95% CI: 0.33, 0.71; 24 weeks: OR = 0.41, 95% CI: 0.27, 0.61; 24 weeks) and residing in the same district (16 weeks: OR = 1.55, 95% CI: 1.08, 2.22; 24 weeks: OR = 1.73, 95% CI: 1.04, 2.87) or catchment area (16 weeks: OR = 1.53, 95% CI: 1.05, 2.23; 24 weeks: OR = 1.84, 95% CI: 1.28, 2.66; 24 weeks) as the health facility were protective against delayed ANC-1. Women with a prior preterm (OR, 0.71, 95% CI, 0.53, 0.95) or low birthweight delivery (OR, 0.72, 95% CI, 0.55, 0.95) were less likely to initiate ANC after 16 weeks. Women with no obstetric history were more likely to present after 16 weeks GA (OR, 1.18, 95% CI, 1.06, 1.32). Conclusion This study identified multiple predictors of delayed ANC-1. Focusing existing Community Health Worker outreach efforts on the populations at greatest risk of delaying care and expanding access to home pregnancy testing may improve early care attendance. While women presenting late to care were less likely to present without an identified obstetric risk factor, lower than expected rates were identified in the study population overall. Health centers may benefit from provider training and standardized screening protocols to improve identification of obstetric risk factors at ANC-1.
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Affiliation(s)
- Christina N Schmidt
- School of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Sabine Musange
- School of Public Health, National University of Rwanda, Kigali, Rwanda
| | | | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America.,Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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Santos N, Mulowooza J, Isabirye N, Inhensiko I, Sloan NL, Shah S, Butrick E, Waiswa P, Walker D. Effect of a labor triage checklist and ultrasound on obstetric referral at three primary health centers in Eastern Uganda. Int J Gynaecol Obstet 2021; 153:130-137. [PMID: 33047332 PMCID: PMC7984058 DOI: 10.1002/ijgo.13420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/13/2020] [Accepted: 10/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To test whether introduction of a midwife-performed triage checklist and focused ultrasound improves diagnosis and referral for obstetric conditions, including multiple gestation, placenta previa, oligohydramnios, preterm birth, malpresentation, and abnormal fetal heart rate. METHODS We implemented an intake log (Phase 1), a checklist (Phase 2), and a checklist plus ultrasound scan (Phase 3) at three primary health centers in Eastern Uganda for women presenting in labor. Intake diagnoses, referral status, and delivery outcomes were assessed, as well as sensitivity and positive predictive value (PPV). RESULTS Between February 2018 and July 2019, 1155, 961, and 603 women were enrolled across the three phases (n=2719); 2339 had outcome data. Incidence of any outcome-confirmed condition was 8.8%, 7.9%, and 7.1% (P=0.526) for each phase, respectively. The proportion of referred women with a condition did not change between Phases 1 and 2 (7.8% versus 8.6%, P=0.855), but increased in Phase 3 (48.4%, P<0.001). Sensitivity improved with each intervention; PPV decreased with ultrasound. CONCLUSION Use of ultrasound plus checklist increased referrals and sensitivity for high-risk conditions, with decreased PPV. The checklist alone improved correct diagnosis, but not referral. Further evaluation of these triage interventions to maximize diagnostic accuracy, referral decisions, and outcomes are warranted.
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Affiliation(s)
- Nicole Santos
- Institute for Global Health SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | | | | | - Nancy L. Sloan
- Institute for Global Health SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Sachita Shah
- Department of Emergency MedicineUniversity of WashingtonSeattleWAUSA
| | - Elizabeth Butrick
- Institute for Global Health SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Peter Waiswa
- School of Public HealthMakerere UniversityKampalaUganda
- Global Health Department of Public Health SciencesKarolinska InstitutetStockholmSweden
| | - Dilys Walker
- Institute for Global Health SciencesUniversity of California San FranciscoSan FranciscoCAUSA
- Department of Obstetrics, Gynaecology and Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
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14
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Mulowooza J, Santos N, Isabirye N, Inhensiko I, Sloan NL, Shah S, Butrick E, Waiswa P, Walker D. Midwife-performed checklist and ultrasound to identify obstetric conditions at labour triage in Uganda: A quasi-experimental study. Midwifery 2021; 96:102949. [PMID: 33631411 PMCID: PMC7988503 DOI: 10.1016/j.midw.2021.102949] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/03/2021] [Accepted: 02/10/2021] [Indexed: 11/18/2022]
Abstract
Objective The aim of this study was to evaluate the effect of a midwife-performed checklist and limited obstetric ultrasound on sensitivity and positive predictive value for a composite outcome comprising multiple gestation, placenta praevia, oligohydramnios, preterm birth, malpresentation, abnormal foetal heart rate. Design Quasi-experimental pre-post intervention study. Setting Maternity unit at a district hospital in Eastern Uganda. Interventions Interventions were implemented in a phased approach: standardised labour triage documentation (Phase 1), a triage checklist (Phase 2), and checklist plus limited obstetric ultrasound (Phase 3). Participants Consenting women presenting to labour triage for admission after 28 weeks of gestation between February 2018 and June 2019 were eligible. Women not in labour or those requiring immediate care were excluded. 3,865 women and 3,937 newborns with similar sample sizes per phase were included in the analysis. Measurement and findings Outcome data after birth were used to determine true presence of a complication, while intake and checklist data were used to inform diagnosis before birth. Compared to Phase 1, Phase 2 and 3 interventions improved sensitivity (Phase 1: 47%, Phase 2: 68.8%, Phase 3: 73.5%; p ≤ 0.001) and reduced positive predictive value (65.9%, 55%, 48.7%, p ≤ 0.001) for the composite outcome. No phase differences in adverse maternal or foetal outcomes were observed. Conclusion Both a triage checklist and a checklist plus limited obstetric ultrasound improved accurate identification of cases with some increase in false positive diagnosis. These interventions may be beneficial in a resource-limited maternity triage setting to improve midwives' diagnoses and clinical decision-making.
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Affiliation(s)
- Jude Mulowooza
- Makerere University, School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94158 United States.
| | - Nathan Isabirye
- Makerere University, School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Innocent Inhensiko
- Makerere University, School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Nancy L Sloan
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94158 United States
| | - Sachita Shah
- Department of Emergency Medicine, University of Washington, 325 9th Ave., Seattle, WA 98104 United States
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94158 United States
| | - Peter Waiswa
- Makerere University, School of Public Health, P.O Box 7072, Kampala, Uganda; Global Health Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94158 United States; Department of Obstetrics, Gynaecology and Reproductive Sciences, University of California San Francisco, United States
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15
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Sayinzoga F, Lundeen T, Musange SF, Butrick E, Nzeyimana D, Murindahabi N, Azman-Firdaus H, Sloan NL, Benitez A, Phillips B, Ghosh R, Walker D. Assessing the impact of group antenatal care on gestational length in Rwanda: A cluster-randomized trial. PLoS One 2021; 16:e0246442. [PMID: 33529256 PMCID: PMC7853466 DOI: 10.1371/journal.pone.0246442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 01/16/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Research on group antenatal care in low- and middle-income contexts suggests high acceptability and preliminary implementation success. METHODS We studied the effect of group antenatal care on gestational age at birth among women in Rwanda, hypothesizing that participation would increase mean gestational length. For this unblinded cluster randomized trial, 36 health centers were pair-matched and randomized; half continued individual antenatal care (control), half implemented group antenatal care (intervention). Women who initiated antenatal care between May 2017 and December 2018 were invited to participate, and included in analyses if they presented before 24 weeks gestation, attended at least two visits, and their birth outcome was obtained. We used a generalized estimating equations model for analysis. FINDINGS In total, 4091 women in 18 control clusters and 4752 women in 18 intervention clusters were included in the analysis. On average, women attended three total antenatal care visits. Gestational length was equivalent in the intervention and control groups (39.3 weeks (SD 1.6) and 39.3 weeks (SD 1.5)). There were no significant differences between groups in secondary outcomes except that more women in control sites attended postnatal care visits (40.1% versus 29.7%, p = 0.003) and more women in intervention sites attended at least three total antenatal care visits (80.7% versus 71.7%, p = 0.003). No harms were observed. INTERPRETATION Group antenatal care did not result in a difference in gestational length between groups. This may be due to the low intervention dose. We suggest studies of both the effectiveness and costs of higher doses of group antenatal care among women at higher risk of preterm birth. We observed threats to group care due to facility staff shortages; we recommend studies in which antenatal care providers are exclusively allocated to group antenatal care during visits. TRIAL REGISTRATION ClinicalTrials.gov NCT03154177.
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Affiliation(s)
- Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | | | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - David Nzeyimana
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | | | - Hana Azman-Firdaus
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Nancy L. Sloan
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Alejandra Benitez
- Department of Biostatistics, University of California Berkeley, Berkeley, California, United States of America
| | - Beth Phillips
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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Namazzi G, Achola KA, Jenny A, Santos N, Butrick E, Otieno P, Waiswa P, Walker D. Implementing an intrapartum package of interventions to improve quality of care to reduce the burden of preterm birth in Kenya and Uganda. Implement Sci Commun 2021; 2:10. [PMID: 33509293 PMCID: PMC7841990 DOI: 10.1186/s43058-021-00109-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 01/04/2021] [Indexed: 01/16/2023] Open
Abstract
Background Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication. Methods Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative. Results In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake. Conclusion Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up. The trial is registered at ClinicalTrials.govNCT03112018, registered December 2016, posted April 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00109-w.
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Affiliation(s)
- Gertrude Namazzi
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
| | | | - Alisa Jenny
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | | | - Peter Waiswa
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, USA.,Department of Obstetrics, Gynaecology and Reproductive Sciences, University of California, San Francisco, USA
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Mubiri P, Nambuya H, Kajjo D, Butrick E, Namazzi G, Santos N, Walker D, Waiswa P. Birthweight and gestational age-specific neonatal mortality rate in tertiary care facilities in Eastern Central Uganda. Health Sci Rep 2020; 3:e196. [PMID: 33145442 PMCID: PMC7592235 DOI: 10.1002/hsr2.196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/17/2020] [Accepted: 09/11/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND An estimated 2.8 million neonatal deaths occur each year globally, which accounts for at least 45% of deaths in children aged less than 5 years. Birthweight and gestational age-specific mortality estimates are limited in low-resource countries like Uganda. A deeper analysis of mortality by birthweight and gestational age is critical in identifying the cause and potential solutions to decrease neonatal mortality. OBJECTIVES We studied mortality before discharge in relation to birthweight and gestational age using a large sample size from selected tertiary care facilities in Uganda. METHODS We used secondary data from the East Africa Preterm Birth Initiative study conducted in six tertiary care facilities. Birth records of infants born between October 2016 and March 2019 with a gestational age greater than or equal to 24 weeks and/or birthweight greater than or equal to 500 g were reviewed for inclusion in the analysis. Newborn death before discharge was the outcome variable of interest. Multivariable Poisson regression modeling was used to explore birthweight and gestational age-specific mortality rate. RESULTS We analysed 50 278 birth records. Among these 95.3% (47 913) were live births and 4.8% (2365) were stillbirths. Of the 47 913 live births, 50% (24 147) were males. Overall, pre-discharge mortality was 13.0 per 1000 live births. For each 1 kg increase in birthweight, mortality before discharge decreased by -0.016. As birthweight increases, the mortality before discharge decreased from 336 per 1000 live births among infants born between 500 and 999 g, to 4.7 per 1000 live births among infants born weighing 3500 to 3999 g, and increased again to 11.2 per 1000 live births among infants weighing more than 4500 g. CONCLUSIONS Our study highlights the need for further research to understand newborn survival across different birthweight and gestational categories.
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Affiliation(s)
- Paul Mubiri
- Makerere University School of Public HealthCollege of Health SciencesKampalaUganda
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health SciencesMakerere UniversityKampalaUganda
| | - Harriet Nambuya
- Department of pediatricsJinja Regional Referral HospitalJinjaUganda
| | - Darious Kajjo
- Makerere University School of Public HealthCollege of Health SciencesKampalaUganda
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health SciencesMakerere UniversityKampalaUganda
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San FranciscoSan FranciscoCalifornia
| | - Gertrude Namazzi
- Makerere University School of Public HealthCollege of Health SciencesKampalaUganda
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health SciencesMakerere UniversityKampalaUganda
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San FranciscoSan FranciscoCalifornia
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San FranciscoSan FranciscoCalifornia
- Department of Obstetrics, Gynecology, and Reproductive SciencesUniversity of California San FranciscoSan FranciscoCalifornia
| | - Peter Waiswa
- Makerere University School of Public HealthCollege of Health SciencesKampalaUganda
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health SciencesMakerere UniversityKampalaUganda
- Global Health Department of Public Health SciencesKarolinska InstitutetStockholmSweden
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Walker D, Otieno P, Butrick E, Namazzi G, Achola K, Merai R, Otare C, Mubiri P, Ghosh R, Santos N, Miller L, Sloan NL, Waiswa P. Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-randomised facility-based trial. Lancet Glob Health 2020; 8:e1061-e1070. [PMID: 32710862 PMCID: PMC7388203 DOI: 10.1016/s2214-109x(20)30232-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/28/2022]
Abstract
Background Although gains in newborn survival have been achieved in many low-income and middle-income countries, reductions in stillbirth and neonatal mortality have been slow. Prematurity complications are a major driver of stillbirth and neonatal mortality. We aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised. Methods This unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. The study assessed outcomes of low-birthweight and preterm babies. Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention group or the control group. All facilities received maternity register data strengthening and a modified WHO Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. Liveborn or fresh stillborn babies who weighed between 1000 g and 2500 g, or less than 3000 g with a recorded gestational age of less than 37 weeks, were included in the analysis. We abstracted data from maternity registers for maternal and birth outcomes. Follow-up was done by phone or in person to identify the status of the infant at 28 days. The primary outcome was fresh stillbirth and 28-day neonatal mortality. This trial is registered with ClinicalTrials.gov, NCT03112018. Findings Between Oct 1, 2016, and April 30, 2019, 20 facilities were randomly assigned to either the intervention group (n=10) or the control group (n=10). Among 5343 eligible babies in these facilities, we assessed outcomes of 2938 newborn and fresh stillborn babies (1447 in the intervention and 1491 in the control group). 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group at 28 days (odds ratio 0·66, 95% CI 0·54–0·81). No harm or adverse effects were found. Interpretation Fresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Phelgona Otieno
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Gertrude Namazzi
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kevin Achola
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rikita Merai
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Christopher Otare
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Paul Mubiri
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Lara Miller
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Nancy L Sloan
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Peter Waiswa
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda; Global Health Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Miller L, Wanduru P, Santos N, Butrick E, Waiswa P, Otieno P, Walker D. Working with what you have: How the East Africa Preterm Birth Initiative used gestational age data from facility maternity registers. PLoS One 2020; 15:e0237656. [PMID: 32866167 PMCID: PMC7458293 DOI: 10.1371/journal.pone.0237656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/30/2020] [Indexed: 11/23/2022] Open
Abstract
Objective Preterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the strength of the PTBi-EA eligibility criteria. Methods We conducted a retrospective analysis of maternity register data from March–September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3rd and 97th birth weight percentiles for GA of the INTERGROWTH-21st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA <37 weeks, 2) recorded GA <37 weeks, excluding implausible GAs, 3) birth weight <2500g, and 4) PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks. Results In both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%. Conclusions Maternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks accommodated these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability.
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Affiliation(s)
- Lara Miller
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Phillip Wanduru
- School of Public Health, Makerere University, Kampala, Uganda
| | - Nicole Santos
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California, United States of America
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Waiswa P, Higgins BV, Mubiri P, Kirumbi L, Butrick E, Merai R, Sloan NL, Walker D. Pregnancy outcomes in facility deliveries in Kenya and Uganda: A large cross-sectional analysis of maternity registers illuminating opportunities for mortality prevention. PLoS One 2020; 15:e0233845. [PMID: 32479522 PMCID: PMC7263583 DOI: 10.1371/journal.pone.0233845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 05/13/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction As facility-based deliveries increase globally, maternity registers offer a promising way of documenting pregnancy outcomes and understanding opportunities for perinatal mortality prevention. This study aims to contribute to global quality improvement efforts by characterizing facility-based pregnancy outcomes in Kenya and Uganda including maternal, neonatal, and fetal outcomes at the time of delivery and neonatal discharge outcomes using strengthened maternity registers. Methods Cross sectional data were collected from strengthened maternity registers at 23 facilities over 18 months. Data strengthening efforts included provision of supplies, training on standard indicator definitions, and monthly feedback on completeness. Pregnancy outcomes were classified as live births, early stillbirths, late stillbirths, or spontaneous abortions according to birth weight or gestational age. Discharge outcomes were assessed for all live births. Outcomes were assessed by country and by infant, maternal, and facility characteristics. Maternal mortality was also examined. Results Among 50,981 deliveries, 91.3% were live born and, of those, 1.6% died before discharge. An additional 0.5% of deliveries were early stillbirths, 3.6% late stillbirths, and 4.7% spontaneous abortions. There were 64 documented maternal deaths (0.1%). Preterm and low birthweight infants represented a disproportionate number of stillbirths and pre-discharge deaths, yet very few were born at ≤1500g or <28w. More pre-discharge deaths and stillbirths occurred after maternal referral and with cesarean section. Half of maternal deaths occurred in women who had undergone cesarean section. Conclusion Maternity registers are a valuable data source for understanding pregnancy outcomes including those mothers and infants at highest risk of perinatal mortality. Strengthened register data in Kenya and Uganda highlight the need for renewed focus on improving care of preterm and low birthweight infants and expanding access to emergency obstetric care. Registers also permit enumeration of pregnancy loss <28 weeks. Documenting these earlier losses is an important step towards further mortality reduction for the most vulnerable infants.
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Affiliation(s)
- Peter Waiswa
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Brennan V. Higgins
- Department of Pediatrics, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Paul Mubiri
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Leah Kirumbi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Butrick
- Institute of Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Rikita Merai
- Institute of Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Nancy L. Sloan
- Institute of Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Dilys Walker
- School of Medicine and Department of Obstetrics-Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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Butrick E, Lundeen T, Phillips BS, Tengera O, Kambogo A, Uwera YDN, Musabyimana A, Sayinzoga F, Nzeyimana D, Murindahabi N, Musange S, Walker D. Model fidelity of group antenatal and postnatal care: a process analysis of the first implementation of this innovative service model by the Preterm Birth Initiative-Rwanda. Gates Open Res 2020; 4:7. [PMID: 32363328 PMCID: PMC7177154 DOI: 10.12688/gatesopenres.13090.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2019] [Indexed: 11/24/2022] Open
Abstract
Background: For a large trial of the effect of group antenatal care on perinatal outcomes in Rwanda, a Technical Working Group customized the group care model for implementation in this context. This process analysis aimed to understand the degree of fidelity with which the group antenatal care model was implemented during the trial period. Methods: We used two discreet questionnaires to collect data from two groups about the fidelity with which the group antenatal care model was implemented during this trial period. Group care facilitators recorded descriptive data about each visit and self-assessed process fidelity with a series of yes/no checkboxes. Master Trainers assessed process fidelity with an 11-item tool using a 5-point scale of 0 (worst) to 4 (best). Results: We analyzed 2763 questionnaires completed by group care facilitators that documented discreet group visits among pregnant and postnatal women and 140 questionnaires completed by Master Trainers during supervision visits. Data recorded by both groups was available for 84 group care visits, and we compared these assessments by visit. Approximately 80% of all group visits were provided as intended, with respect to both objective measures (e.g. group size) and process fidelity. We did not find reliable correlations between conceptually-related items scored by Master Trainers and self-assessment data reported by group visit facilitators. Conclusions: We recommend both the continued participation of expert observers at new and existing group care sites and ongoing self-assessment by group care facilitators. Finally, we present two abbreviated assessment tools developed by a Rwanda-specific Technical Working Group that reviewed these research results.
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Affiliation(s)
- Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Franciso, CA, 94158, USA
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California San Francisco, San Franciso, CA, 94158, USA
| | - Beth S Phillips
- Institute for Global Health Sciences, University of California San Francisco, San Franciso, CA, 94158, USA
| | - Olive Tengera
- School of Nursing and Midwifery, National University of Rwanda, Kigali, Rwanda
| | | | | | | | - Felix Sayinzoga
- Maternal, Child and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - David Nzeyimana
- School of Public Health, National University of Rwanda, Kigali, Rwanda
| | | | - Sabine Musange
- School of Public Health, National University of Rwanda, Kigali, Rwanda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Franciso, CA, 94158, USA
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Musange SF, Butrick E, Lundeen T, Santos N, Azman Firdaus H, Benitez A, Nzeyimana D, Kayiramirwa Murindahabi N, Nyiraneza L, Sayinzoga F, Ndahindwa V, Ngabo F, Condo J, Walker D. Group antenatal care versus standard antenatal care and effect on mean gestational age at birth in Rwanda: protocol for a cluster randomized controlled trial. Gates Open Res 2019; 3:1548. [PMID: 31656954 PMCID: PMC6792348 DOI: 10.12688/gatesopenres.13053.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Group antenatal care has demonstrated promise as a service delivery model that may result in improved outcomes compared to standard antenatal care in socio-demographic populations at disparately high risk for poor perinatal outcomes. Intrigued by results from the United States showing lower preterm birth rates among high-risk women who participate in group antenatal care, partners working together as the Preterm Birth Initiative - Rwanda designed a trial to assess the impact of group antenatal care on gestational age at birth. Methods: This study is a pair-matched cluster randomized controlled trial with four arms. Pairs randomized to group or standard care were further matched with other pairs into quadruples, within which one pair was assigned to implement basic obstetric ultrasound at the health center and early pregnancy testing at the community. At facilities randomized to group care, this will follow the opt-out model of service delivery and individual visits will always be available for those who need or prefer them. The primary outcome of interest is mean gestational age at birth among women who presented for antenatal care before 24 completed weeks of pregnancy and attended more than one antenatal care visit. Secondary outcomes of interest include attendance at antenatal and postnatal care, preterm birth rates, satisfaction of mothers and providers, and feasibility. A convenience sample of women will be recruited to participate in a longitudinal survey in which they will report such indicators as self-reported health-related behaviors and depressive symptoms. Providers will be surveyed about satisfaction and stress. Discussion: This is the largest cluster randomized controlled trial of group antenatal and postnatal care ever conducted, and the first in a low- or middle-income country to examine the effect of this model on gestational age at birth. Trial registration: This study is registered on ClinicalTrials.gov as NCT03154177 May 16, 2017.
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Affiliation(s)
- Sabine Furere Musange
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
| | - Hana Azman Firdaus
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
| | - Alejandra Benitez
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
- University of California, Berkeley, Berkeley, USA
| | - David Nzeyimana
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Lauriane Nyiraneza
- Maternal, Child and Community Health Division - Institute of HIV/AIDs, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division - Institute of HIV/AIDs, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Vedaste Ndahindwa
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Fidele Ngabo
- Maternal, Child and Community Health Division - Institute of HIV/AIDs, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Dylis Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
- Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, USA
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Lundeen T, Musange S, Azman H, Nzeyimana D, Murindahabi N, Butrick E, Walker D. Nurses' and midwives' experiences of providing group antenatal and postnatal care at 18 health centers in Rwanda: A mixed methods study. PLoS One 2019; 14:e0219471. [PMID: 31295335 PMCID: PMC6622527 DOI: 10.1371/journal.pone.0219471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/24/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The East Africa Preterm Birth Initiative-Rwanda began a cluster randomized controlled trial of group antenatal care (ANC) and postnatal care (PNC) in Rwanda in 2017. That trial will report its primary outcome, gestational length at birth, after data collection concludes in 2019. This nested study includes providers of ANC and/or PNC at the 18 health centers randomized to provide the group model of ANC/PNC and the 18 health centers randomized to continue providing ANC/PNC in the traditional, individual visit model. The objective of this study is to understand the experiences of providers of group ANC/PNC and compare their job satisfaction and perceived stress with individual ANC/PNC providers. METHODS We collected both quantitative and qualitative data from providers (nurses and midwives) who were recruited by health center directors to participate as group ANC and PNC facilitators at intervention sites and from a similar number of providers of standard ANC and PNC at control sites. Quantitative data was collected with questionnaires administered at baseline and approximately 9 months later (follow up). Qualitative data was collected in 3 focus groups of group ANC/PNC providers conducted one year after group care began. RESULTS Eighty-six percent of nurses and midwives surveyed who implemented group ANC and PNC reported that they prefer group care to the traditional individual model of ANC and PNC. Perceived stress levels and job satisfaction results were similar between groups. Mixed focus group discussions among both nurses and midwives experienced in group ANC and PNC suggest that the group model of care has advantages for both service beneficiaries and providers. When providers described implementation challenges, their peers in the focus groups offered them suggestions to cope and improve service delivery. DISCUSSION These results are consistent with studies of providers of group ANC and PNC in other LMIC contexts with respect to the perceived benefits of group care. This study adds new insights into the ways peer providers can help one another solve implementation problems. When given the opportunity to meet as a group, these study participants offered one another peer support and shared knowledge about best practices for successful implementation of group ANC/PNC. This trial is registered at clinicaltrials.gov as NCT03154177.
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Affiliation(s)
- Tiffany Lundeen
- University of California San Francisco, Institute of Global Health Sciences, San Francisco, California, United States of America
| | - Sabine Musange
- University of Rwanda School of Public Health, Kigali, Rwanda
| | - Hana Azman
- University of California San Francisco, Institute of Global Health Sciences, San Francisco, California, United States of America
| | - David Nzeyimana
- University of Rwanda School of Public Health, Kigali, Rwanda
| | | | - Elizabeth Butrick
- University of California San Francisco, Institute of Global Health Sciences, San Francisco, California, United States of America
| | - Dilys Walker
- University of California San Francisco, Institute of Global Health Sciences, San Francisco, California, United States of America
- University of California San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California, United States of America
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Musabyimana A, Lundeen T, Butrick E, Sayinzoga F, Rwabufigiri BN, Walker D, Musange SF. Before and after implementation of group antenatal care in Rwanda: a qualitative study of women's experiences. Reprod Health 2019; 16:90. [PMID: 31248425 PMCID: PMC6595554 DOI: 10.1186/s12978-019-0750-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 06/05/2019] [Indexed: 11/17/2022] Open
Abstract
Background The Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women’s experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements. Methods We completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation. Results Before implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout. Discussion These results are consistent with other published reports of women’s perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women’s experiences of care. Conclusion Group antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model. Trial registration This trial is registered at clinicaltrials.gov as NCT03154177. Electronic supplementary material The online version of this article (10.1186/s12978-019-0750-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angele Musabyimana
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA.
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Bernard Ngabo Rwabufigiri
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA
| | - Sabine F Musange
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
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Williams P, Murindahabi NK, Butrick E, Nzeyimana D, Sayinzoga F, Ngabo B, Musabyimana A, Musange SF. Postnatal care in Rwanda: facilitators and barriers to postnatal care attendance and recommendations to improve participation. J Glob Health Rep 2019; 3:JOGHR-03-2019032. [PMID: 33409379 PMCID: PMC7771583 DOI: 10.29392/joghr.3.e2019032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Sub-Saharan Africa has the highest rates of neonatal mortality in the world
with an estimated 1.2 million deaths within the first 28 days of life.
Postnatal care (PNC) can contribute to reductions in morbidity and mortality
in mothers and newborns through vital support that identifies danger signs
and establishes valuable practices and referral processes. Methods This qualitative data was collected as a part the East Africa Preterm Birth
Initiative (PTBi-EA) to guide development of a group antenatal (ANC) and PNC
model in Rwanda. Key-informant in-depth interviews (IDIs) and focus group
discussions (FGDs) were conducted in four districts. Sixteen FGDs with 180
participants and 22 IDIs were completed at the time of thematic
saturation. Results Four themes highlighted facilitators and barriers to PNC attendance and
recommendations to improve participation: 1) There is little awareness in
the community of what the PNC package is; PNC 4 in particular is not well
understood; 2) PNC visits by community health workers (CHWs) are well
accepted and valued; 3) Providers perceive PNC 4 as an added burden to an
already high workload; 4) Community structures exist to better disseminate
key messages about PNC, but have not yet been effectively utilized. Conclusions This qualitative work provides evidence that the PNC package was not
initially well understood. Regardless, PNC service delivery performed by
CHWs in Rwanda is well accepted and appreciated by the population, providing
assurance that the full package has potential to be well utilized and valued
by the population.
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Affiliation(s)
- Pamela Williams
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | | | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - David Nzeyimana
- University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division, Rwanda Ministry of Health, Rwanda Biomedical Center, Kigali, Rwanda
| | - Bernard Ngabo
- University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda
| | - Angèle Musabyimana
- University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda
| | - Sabine F Musange
- University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda
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Otieno P, Waiswa P, Butrick E, Namazzi G, Achola K, Santos N, Keating R, Lester F, Walker D. Strengthening intrapartum and immediate newborn care to reduce morbidity and mortality of preterm infants born in health facilities in Migori County, Kenya and Busoga Region, Uganda: a study protocol for a randomized controlled trial. Trials 2018; 19:313. [PMID: 29871696 PMCID: PMC5989441 DOI: 10.1186/s13063-018-2696-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preterm birth (birth before 37 weeks of gestation) and its complications are the leading contributors to neonatal and under-5 mortality. The majority of neonatal deaths in Kenya and Uganda occur during the intrapartum and immediate postnatal period. This paper describes our study protocol for implementing and evaluating a package of facility-based interventions to improve care during this critical window. METHODS/DESIGN This is a pair-matched, cluster randomized controlled trial across 20 facilities in Eastern Uganda and Western Kenya. The intervention facilities receive four components: (1) strengthening of routine data collection and data use activities; (2) implementation of the WHO Safe Childbirth Checklist modified for preterm birth; (3) PRONTO simulation training and mentoring to strengthen intrapartum and immediate newborn care; and (4) support of quality improvement teams. The control facilities receive both data strengthening and introduction of the modified checklist. The primary outcome for this study is 28-day mortality rate among preterm infants. The denominator will include all live births and fresh stillbirths weighing greater than 1000 g and less than 2500 g; all live births and fresh stillbirths weighing between 2501 and 3000 g with a documented gestational age less than 37 weeks. DISCUSSION The results of this study will inform interventions to improve personnel and facility capacity to respond to preterm labor and delivery, as well as care for the preterm infant. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03112018 . Registered on 13 April 2017.
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Affiliation(s)
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Center of Excellence for Maternal, Newborn and Child Health, Makerere University, Kampala, Uganda
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, CA USA
| | - Gertrude Namazzi
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Kevin Achola
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Nicole Santos
- Institute for Global Health Sciences, University of California, San Francisco, CA USA
| | - Ryan Keating
- Institute for Global Health Sciences, University of California, San Francisco, CA USA
| | - Felicia Lester
- Institute for Global Health Sciences, University of California, San Francisco, CA USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA USA
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, CA USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA USA
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Jordan K, Butrick E, Yamey G, Miller S. Barriers and Facilitators to Scaling Up the Non-Pneumatic Anti-Shock Garment for Treating Obstetric Hemorrhage: A Qualitative Study. PLoS One 2016; 11:e0150739. [PMID: 26938211 PMCID: PMC4777561 DOI: 10.1371/journal.pone.0150739] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/18/2016] [Indexed: 11/19/2022] Open
Abstract
Background Obstetric hemorrhage (OH), which includes hemorrhage from multiple etiologies during pregnancy, childbirth, or postpartum, is the leading cause of maternal mortality and accounts for one-quarter of global maternal deaths. The Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device for obstetric hemorrhage that can be applied for post-partum/post miscarriage and for ectopic pregnancies to buy time for a woman to reach a health care facility for definitive treatment. Despite successful field trials, and endorsement by safe motherhood organizations and the World Health Organization (WHO), scale-up has been slow in some countries. This qualitative study explores contextual factors affecting uptake. Methods From March 2013 to April 2013, we conducted 13 key informant interviews across four countries with a large burden of maternal mortality that had achieved varying success in scaling up the NASG: Ethiopia, India, Nigeria, and Zimbabwe. These key informants were health providers or program specialists working with the NASG. We applied a health policy analysis framework to organize the results. The framework has five domains: attributes of the intervention, attributes of the implementers, delivery strategy, attributes of the adopting community, the socio-political context, and the research context. Results The interviews from our study found that relevant facilitators for scale-up are the simplicity of the device, local and international champions, well-developed training sessions, recommendations by WHO and the International Federation of Gynecology and Obstetrics, and dissemination of NASG clinical trial results. Barriers to scaling up the NASG included limited health infrastructure, relatively high upfront cost of the NASG, initial resistance by providers and policy makers, lack of in-country champions or policy makers advocating for NASG implementation, inadequate return and exchange programs, and lack of political will. Conclusions There was a continuum of uptake ranging in both speed and scale. Ethiopia while not the first country to use the NASG has the most rapid scale-up, followed by Nigeria, then India, and finally Zimbabwe. Increasing the coverage of the NASG will require collaboration with local NASG champions, greater NASG awareness among clinicians and policymakers, as well as stronger political will and advocacy.
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Affiliation(s)
- Keely Jordan
- College of Global Public Health, New York University, New York, New York, United States of America
- * E-mail:
| | - Elizabeth Butrick
- Private Sector Healthcare Initiative, Global Health Group, University of California, San Francisco, United States of America
| | - Gavin Yamey
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Suellen Miller
- Safe Motherhood Program, Bixby Center for Global Reproductive Health, University of California, San Francisco, United States of America
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Byamugisha J, El Ayadi A, Obore S, Mwanje H, Kakaire O, Barageine J, Lester F, Butrick E, Korn A, Nalubwama H, Knight S, Miller S. Beyond repair - family and community reintegration after obstetric fistula surgery: study protocol. Reprod Health 2015; 12:115. [PMID: 26683687 PMCID: PMC4683951 DOI: 10.1186/s12978-015-0100-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/16/2015] [Indexed: 12/04/2022] Open
Abstract
Background Obstetric fistula is a debilitating birth injury that affects an estimated 2–3 million women globally, most in sub-Saharan Africa and Asia. The urinary and/or fecal incontinence associated with fistula affects women physically, psychologically and socioeconomically. Surgical management of fistula is available with clinical success rates ranging from 65–95 %. Previous research on fistula repair outcomes has focused primarily on clinical outcomes without considering the broader goal of successful reintegration into family and community. The objectives for this study are to understand the process of family and community reintegration post fistula surgery and develop a measurement tool to assess long-term success of post-surgical family and community reintegration. Methods This study is an exploratory sequential mixed-methods design including a preliminary qualitative component comprising in-depth interviews and focus group discussions to explore reintegration to family and community after fistula surgery. These results will be used to develop a reintegration tool, and the tool will be validated within a small longitudinal cohort (n = 60) that will follow women for 12 months after obstetric fistula surgery. Medical record abstraction will be conducted for patients managed within the fistula unit. Ethical approval for the study has been granted. Discussion This study will provide information regarding the success of family and community reintegration among women returning home after obstetric fistula surgery. The clinical and research community can utilize the standardized measurement tool in future studies of this patient population.
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Affiliation(s)
- Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda. .,Mulago National Referral and Teaching Hospital, Kampala, Uganda.
| | - Alison El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, California, USA
| | - Susan Obore
- Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Haruna Mwanje
- Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Othman Kakaire
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Felicia Lester
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, California, USA
| | - Elizabeth Butrick
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, California, USA
| | - Abner Korn
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, California, USA
| | - Hadija Nalubwama
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Sharon Knight
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, California, USA
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, California, USA
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Manandhar S, El Ayadi AM, Butrick E, Hosang R, Miller S. The Role of the Nonpneumatic Antishock Garment in Reducing Blood Loss and Mortality Associated with Post-Abortion Hemorrhage. Stud Fam Plann 2015; 46:281-96. [PMID: 26347091 DOI: 10.1111/j.1728-4465.2015.00030.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Maternal mortality attributable to post-abortion hemorrhage is often associated with delays in reaching or receiving definitive care. The nonpneumatic antishock garment (NASG), a low-technology first-aid device, has been shown to decrease blood loss and mortality among women experiencing hypovolemic shock secondary to obstetric hemorrhage etiologies. Women experiencing post-abortion hemorrhage face longer delays in receiving definitive treatment as a result of abortion-related stigma and lack of access to quality abortion care; thus the NASG has the potential to make an even greater impact within this population. We conducted a secondary analysis of data collected in Egypt, Nigeria, Zambia, and Zimbabwe in NASG trials, limiting our analytic sample to women who experienced post-abortion hemorrhage (n = 953). Blood loss significantly decreased when the NASG was added to standard hemorrhage management during the intervention phase, and there was a large, although not statistically significant, 52 percent decrease in mortality during the NASG phase. The results indicate that adding the NASG to post-abortion care among women experiencing severe hemorrhage and hypovolemic shock would decrease blood loss and mortality.
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Affiliation(s)
- Shila Manandhar
- Resident Physician at Kaiser Permanente Los Angeles Medical Center, California
| | - Alison M El Ayadi
- Assistant Research Scientist, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158.
| | - Elizabeth Butrick
- Project Coordinator, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158
| | - Robert Hosang
- Professor, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158
| | - Suellen Miller
- Lecturer, School of Public Health, University of California, Berkeley
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Magwali TL, Butrick E, Ayadi AE, Bergel E, Gibbons L, Huong NT, Merialdi M, Mambo V, Miller S. A cluster randomized controlled trial of the non-pneumatic anti-shock garment for obstetric haemorrhage: sub-analysis of the Zimbabwean Arm. Cent Afr J Med 2015; 61:27-32. [PMID: 29144074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives To determine whether earlier application of the Non-pneumatic Anti-Shock Garment (NASG) at clinic level compared to the referral hospital level reduces maternal morbidity and mortality and recovery time from shock due to severe Obstetric Haemorrhage (OH) and to determine the safety of the NASG when applied at clinic level. Design A cluster Randomized Controlled Trial (RCT) Setting Harare and Parirenyatwa Referral Hospitals (RH) in Harare and the twelve Harare City Council clinics that offer maternity care. Subjects Women who had suffered severe OH at clinic level and were being transferred to a Referral Hospital (RH). Iterventions The clinics were randomized into two groups. In the early NASG group eligible women were given the standard management for OH and had the NASG applied at the clinic level before transport to RH. In the control group, eligible women were given the standard management for OH at the clinic level, transferred to the RH, and received the NASG at the RH. All women received equivalent OH/hypovolemic shock management at the RH. Main Outcome Measures The main outcome measures were maternal mortality and morbidity, blood loss, recovery from shock and the occurrence of side effects whilst in the NASG. Results There were few maternal deaths and morbidities, and no statistically significant differences between the two groups were noted. Women in the early NASG group spent a statistically significant shorter time in the NASG at referral hospital level (OR 0.64, 95% CI 0.52 - 0.79, p < 0.001) and had a non-significant 40% faster recovery from shock (HR 1.39; 95% CI 0.98-1.97, p=0.07). There were no differences in reported side effects. Conclusion Earlier NASG application at the clinic level was associated with faster recovery from shock in women who had suffered severe OH and appears safe to use.
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Downing J, El Ayadi A, Miller S, Butrick E, Mkumba G, Magwali T, Kaseba-Sata C, Kahn JG. Cost-effectiveness of the non-pneumatic anti-shock garment (NASG): evidence from a cluster randomized controlled trial in Zambia and Zimbabwe. BMC Health Serv Res 2015; 15:37. [PMID: 25627322 PMCID: PMC4322462 DOI: 10.1186/s12913-015-0694-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 01/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstetric hemorrhage is the leading cause of maternal mortality, particularly in low resource settings where delays in obtaining definitive care contribute to high rates of death. The non-pneumatic anti-shock garment (NASG) first-aid device has been demonstrated to be highly cost-effective when applied at the referral hospital (RH) level. In this analysis we evaluate the incremental cost-effectiveness of early NASG application at the Primary Health Center (PHC) compared to later application at the RH in Zambia and Zimbabwe. METHODS We obtained data on health outcomes and costs from a cluster-randomized clinical trial (CRCT) and participating study hospitals. We translated health outcomes into disability-adjusted life years (DALYs) using standard methods. Econometric regressions estimated the contribution of earlier PHC NASG application to DALYs and costs, varying geographic covariates (country, referral hospital) to yield regression models best fit to the data. We calculated cost-effectiveness as the ratio of added costs to averted DALYs for earlier PHC NASG application compared to later RH NASG application. RESULTS Overall, the cost-effectiveness of early application of the NASG at the primary health care level compared to waiting until arrival at the referral hospital was $21.78 per DALY averted ($15.51 in added costs divided by 0.712 DALYs averted per woman, both statistically significant). By country, the results were very similar in Zambia, though not statistically significant in Zimbabwe. Sensitivity analysis suggests that results are robust to a per-protocol outcome analysis and are sensitive to the cost of blood transfusions. CONCLUSIONS Early NASG application at the PHC for women in hypovolemic shock has the potential to be cost-effective across many clinical settings. The NASG is designed to reverse shock and decrease further bleeding for women with obstetric hemorrhage; therefore, women who have received the NASG earlier may be better able to survive delays in reaching definitive care at the RH and recover more quickly from shock, all at a cost that is highly acceptable.
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Affiliation(s)
- Janelle Downing
- Health Services and Policy Analysis, University of California, Berkeley, CA, USA.
| | - Alison El Ayadi
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California, San Francisco, CA, USA.
| | - Suellen Miller
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California, San Francisco, CA, USA.
| | - Elizabeth Butrick
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California, San Francisco, CA, USA.
| | - Gricelia Mkumba
- Department of Obstetrics and Gynecology, University Teaching Hospital and University of Zambia, Lusaka, Zambia.
| | - Thulani Magwali
- Department of Obstetrics and Gynecology, University of Zimbabwe, Harare, Zimbabwe.
| | - Christine Kaseba-Sata
- Department of Obstetrics and Gynecology, University Teaching Hospital and University of Zambia, Lusaka, Zambia.
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies and Global Health Sciences, University of California, San Francisco, CA, USA.
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Nathan HL, El Ayadi A, Hezelgrave NL, Seed P, Butrick E, Miller S, Briley A, Bewley S, Shennan AH. Shock index: an effective predictor of outcome in postpartum haemorrhage? BJOG 2014; 122:268-75. [DOI: 10.1111/1471-0528.13206] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2014] [Indexed: 11/29/2022]
Affiliation(s)
- HL Nathan
- Women's Health Academic Centre; King's College London; London UK
| | - A El Ayadi
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - NL Hezelgrave
- Women's Health Academic Centre; King's College London; London UK
| | - P Seed
- Women's Health Academic Centre; King's College London; London UK
| | - E Butrick
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - S Miller
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - A Briley
- Women's Health Academic Centre; King's College London; London UK
| | - S Bewley
- Women's Health Academic Centre; King's College London; London UK
| | - AH Shennan
- Women's Health Academic Centre; King's College London; London UK
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Butrick E, Penn A, Itakura K, Mkumba G, Winter K, Amafumba R, Miller S. Access to transport for women with hypovolemic shock differs according to weeks of pregnancy. Int J Gynaecol Obstet 2014; 127:171-4. [PMID: 25022343 DOI: 10.1016/j.ijgo.2014.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/12/2014] [Accepted: 06/19/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To examine whether women with hypovolemic shock secondary to obstetric hemorrhage are transported to referral hospitals differently depending on weeks of pregnancy in Zambia. METHODS In a retrospective study, transport type, wait time, and transit time were assessed for women with obstetric hemorrhage and hypovolemic shock transported from 26 primary health centers to three referral hospitals during 2007-2012. A mean arterial pressure of less than 60 mm Hg was used to indicate severe shock. Women were split into two categories on the basis of the number of weeks of pregnancy (<24 weeks vs ≥24 weeks). RESULTS Overall, 616 women were included. Mode of transport differed significantly by group (P<0.001). 414 (93.0%) of 445 women at 24 weeks of pregnancy or more were transported by ambulance versus 114 (66.7%) of 171 women at less than 24 weeks. Among those in severe shock, 106 (93.0%) of 114 women at 24 weeks of pregnancy or more were transported in ambulances versus 26 (52.0%) of 50 women at less than 24 weeks (P<0.001). CONCLUSION Women at 24 weeks of pregnancy or more were given preference for ambulance transport even when signs of shock were equivalent. Policy-makers aiming to lower maternal mortality need to address transport issues regardless of the etiology of hemorrhage or week of pregnancy.
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Affiliation(s)
- Elizabeth Butrick
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Amy Penn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Kaoru Itakura
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gricelia Mkumba
- Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Kelly Winter
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Rhoda Amafumba
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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El Ayadi A, Gibbons L, Bergel E, Butrick E, Huong NTMY, Mkumba G, Kaseba C, Magwali T, Merialdi M, Miller S. Per-protocol effect of earlier non-pneumatic anti-shock garment application for obstetric hemorrhage. Int J Gynaecol Obstet 2014; 126:95-6. [PMID: 24721615 DOI: 10.1016/j.ijgo.2014.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/31/2014] [Accepted: 03/12/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Alison El Ayadi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Luz Gibbons
- Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
| | - Eduardo Bergel
- Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
| | - Elizabeth Butrick
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - N T M Y Huong
- UN Development Programme, UN Population Fund, WHO, and World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Gricelia Mkumba
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Christine Kaseba
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Thulani Magwali
- Department of Obstetrics and Gynecology, University of Zimbabwe, Harare, Zimbabwe
| | - Mario Merialdi
- UN Development Programme, UN Population Fund, WHO, and World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Suellen Miller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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Curtis M, El Ayadi A, Mkumba G, Butrick E, Leech A, Geissler J, Miller S. Association between severe obstetric hemorrhage and HIV status. Int J Gynaecol Obstet 2014; 125:79-80. [PMID: 24507890 DOI: 10.1016/j.ijgo.2013.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 10/08/2013] [Accepted: 01/08/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Megan Curtis
- Department of Medicine, Tulane University School of Medicine, New Orleans, USA.
| | - Alison El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Safe Motherhood Program, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, USA
| | - Gricelia Mkumba
- Department of Obstetrics and Gynecology, University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Elizabeth Butrick
- Department of Obstetrics, Gynecology and Reproductive Sciences, Safe Motherhood Program, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, USA
| | - Ashley Leech
- Department of Health Policy and Management, Boston University, Boston, USA
| | - Jillian Geissler
- Department of Obstetrics, Gynecology and Reproductive Sciences, Safe Motherhood Program, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, USA
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, Safe Motherhood Program, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, USA
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El Ayadi AM, Butrick E, Geissler J, Miller S. Combined analysis of the non-pneumatic anti-shock garment on mortality from hypovolemic shock secondary to obstetric hemorrhage. BMC Pregnancy Childbirth 2013; 13:208. [PMID: 24237656 PMCID: PMC3834872 DOI: 10.1186/1471-2393-13-208] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 10/25/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obstetric hemorrhage is the leading cause of maternal mortality, particularly in low-resource settings where women face significant delays in accessing definitive treatment. The Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device to stabilize women in hypovolemic shock secondary to obstetric hemorrhage. Prior studies on the effectiveness of the NASG have suffered from small sample sizes and insufficient statistical power. We sought to generate a summary effect estimate of this intervention by combining data from all previous quasi-experimental studies. METHODS Five quasi-experimental studies that tested the NASG as treatment for hypovolemic shock secondary to obstetric hemorrhage at the tertiary care facility level were included in the analysis. We evaluated heterogeneity of effect across studies and calculated pooled odds ratios. We also conducted a subgroup analysis among women in the most severe condition. RESULTS Participant characteristics were similar across studies with some variation in hemorrhage etiology. Median blood loss was at least 50% lower in the intervention group than the control group. The pooled odds ratio suggested that NASG intervention was associated with a 38% significantly reduced odds of mortality among the overall sample, and a 59% significantly reduced odds of mortality among the most severe women. CONCLUSIONS The results from this combined analysis suggest that NASG intervention is associated with a reduced odds of death for women with hypovolemic shock secondary to obstetric hemorrhage. Further research should focus on application of the NASG at the community or primary health care level, and utilize a more robust methodology.
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Affiliation(s)
- Alison M El Ayadi
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA
| | - Elizabeth Butrick
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA
| | - Jillian Geissler
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA
| | - Suellen Miller
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA
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El Ayadi A, Raifman S, Jega F, Butrick E, Ojo Y, Geller S, Miller S. Comorbidities and lack of blood transfusion may negatively affect maternal outcomes of women with obstetric hemorrhage treated with NASG. PLoS One 2013; 8:e70446. [PMID: 23950937 PMCID: PMC3738589 DOI: 10.1371/journal.pone.0070446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 06/18/2013] [Indexed: 11/18/2022] Open
Abstract
The Non-Pneumatic Anti-Shock Garment (NASG) is a first-aid device to reduce mortality from severe obstetric hemorrhage, the leading cause of maternal mortality globally. We sought to evaluate patient characteristics associated with mortality among a cohort of women treated with the NASG in Nigeria. Data on 1,149 women were collected from 50 facilities participating in the Pathfinder International Continuum of Care: Addressing Postpartum Hemorrhage project in Nigeria from 2007-2012. Characteristics were compared using the appropriate distributional tests, and we estimated multivariable logistic regression models to control for treatment received. There were 201 deaths (17.5%). Women who died were significantly more likely to have any co-morbidity (AOR 3.63, 95% CI: 2.41-5.48), ruptured uterus (AOR 2.79, 95% CI: 1.48-5.28), macerated stillbirth (AOR 2.96, 95% CI 1.60-5.48) and to have had 6 or more previous births, (AOR 1.53, 95% CI 1.11-2.12), after adjusting for treatment received. These results suggest certain maternal conditions, particularly the presence of another life-threatening co-morbidity or macerated stillbirth, conferred a higher risk of mortality from PPH. This underscores the need for multi-system assessment and a comprehensive approach to the treatment of women with pregnancy complications.
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Affiliation(s)
- Alison El Ayadi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America.
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Sutherland T, Downing J, Miller S, Bishai DM, Butrick E, Fathalla MMF, Mourad-Youssif M, Ojengbede O, Nsima D, Kahn JG. Use of the non-pneumatic anti-shock garment (NASG) for life-threatening obstetric hemorrhage: a cost-effectiveness analysis in Egypt and Nigeria. PLoS One 2013; 8:e62282. [PMID: 23646124 PMCID: PMC3640005 DOI: 10.1371/journal.pone.0062282] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 03/19/2013] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the cost-effectiveness of a non-pneumatic anti-shock garment (NASG) for obstetric hemorrhage in tertiary hospitals in Egypt and Nigeria. Methods We combined published data from pre-intervention/NASG-intervention clinical trials with costs from study sites. For each country, we used observed proportions of initial shock level (mild: mean arterial pressure [MAP] >60 mmHg; severe: MAP ≤60 mmHg) to define a standard population of 1,000 women presenting in shock. We examined three intervention scenarios: no women in shock receive the NASG, only women in severe shock receive the NASG, and all women in shock receive the NASG. Clinical data included frequencies of adverse health outcomes (mortality, severe morbidity, severe anemia), and interventions to manage bleeding (uterotonics, blood transfusions, hysterectomies). Costs (in 2010 international dollars) included the NASG, training, and clinical interventions. We compared costs and disability-adjusted life years (DALYs) across the intervention scenarios. Results For 1000 women presenting in shock, providing the NASG to those in severe shock results in decreased mortality and morbidity, which averts 357 DALYs in Egypt and 2,063 DALYs in Nigeria. Differences in use of interventions result in net savings of $9,489 in Egypt (primarily due to reduced transfusions) and net costs of $6,460 in Nigeria, with a cost per DALY averted of $3.13. Results of providing the NASG for women in mild shock has smaller and uncertain effects due to few clinical events in this data set. Conclusion Using the NASG for women in severe shock resulted in markedly improved health outcomes (2–2.9 DALYs averted per woman, primarily due to reduced mortality), with net savings or extremely low cost per DALY averted. This suggests that in resource-limited settings, the NASG is a very cost-effective intervention for women in severe hypovolemic shock. The effects of the NASG for mild shock are less certain.
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Affiliation(s)
- Tori Sutherland
- University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Janelle Downing
- Philip R Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California San Francisco, San Francisco, California, United States of America
| | - David M. Bishai
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elizabeth Butrick
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California San Francisco, San Francisco, California, United States of America
| | - Mohamed M. F. Fathalla
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Women's Health Center, Assiut, Egypt
| | | | - Oladosu Ojengbede
- Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria
| | - David Nsima
- Department of Obstetrics and Gynecology, Katsina General Hospital, Katsina, Nigeria
| | - James G. Kahn
- Philip R Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
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Magwali T, Butrick E, Mambo V, El Ayadi A, Lippman S, Bergel E, Gibbons L, Merialdi M, Miller S. O421 NON-PNEUMATIC ANTI-SHOCK GARMENT (NASG) FOR OBSTETRIC HEMORRHAGE: HARARE, ZIMBABWE. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)60851-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Sutherland T, Downing J, Kahn J, Bishai D, Butrick E, Fathalla M, Youssif M, Ojengbede O, Miller S. O666 COST EFFECTIVENESS OF NON-PNEUMATIC ANTI-SHOCK GARMENT (NASG) FOR OBSTETRIC HEMORRHAGE. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)61096-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kaseba C, Anderson A, Mkumba G, Butrick E, Amafumba R, Miller S. O449 A randomized cluster trial of the NASG for the treatment of obstetric hemorrhage and hypovolemic shock in Zambia: Challenges, lessons learned and proposed solutions. Int J Gynaecol Obstet 2011. [DOI: 10.1016/s0020-7292(09)60822-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fathalla MMF, Youssif MM, Meyer C, Camlin C, Turan J, Morris J, Butrick E, Miller S. Nonatonic obstetric haemorrhage: effectiveness of the nonpneumatic antishock garment in egypt. ISRN Obstet Gynecol 2011; 2011:179349. [PMID: 21845226 PMCID: PMC3154575 DOI: 10.5402/2011/179349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 06/22/2011] [Indexed: 11/25/2022]
Abstract
The study aims to determine if the nonpneumatic antishock garment (NASG), a first aid compression device, decreases severe adverse outcomes from nonatonic obstetric haemorrhage. Women with nonatonic aetiologies (434), blood loss > 1000 mL, and signs of shock were eligible. Women received standard care during the preintervention phase (226) and standard care plus application of the garment in the NASG phase (208). Blood loss and extreme adverse outcomes (EAO-mortality and severe morbidity) were measured. Women who used the NASG had more estimated blood loss on admission. Mean measured blood loss was 370 mL in the preintervention phase and 258 mL in the NASG phase (P < 0.0001). EAO decreased with use of the garment (2.9% versus 4.4%, (OR 0.65, 95% CI 0.24–1.76)). In conclusion, using the NASG improved maternal outcomes despite the worse condition on study entry. These findings should be tested in larger studies.
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Affiliation(s)
- Mohamed M F Fathalla
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University Women's Health Center, P.O. Box 30, Assiut, Egypt
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Turan J, Ojengbede O, Fathalla M, Mourad-Youssif M, Morhason-Bello IO, Nsima D, Morris J, Butrick E, Martin H, Camlin C, Miller S. Positive effects of the non-pneumatic anti-shock garment on delays in accessing care for postpartum and postabortion hemorrhage in Egypt and Nigeria. J Womens Health (Larchmt) 2010; 20:91-8. [PMID: 21190486 DOI: 10.1089/jwh.2010.2081] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We examined whether the non-pneumatic anti-shock garment (NASG) ameliorates the effects of delays in transport to and treatment at hospitals for women with postpartum hemorrhage (PPH) and postabortion hemorrhage (PAH) and investigated the effects of NASG use on timing of delivery of interventions in-hospital. METHODS Pre/post studies of the NASG were conducted at hospitals in Cairo (n = 349 women), Assuit (n = 274), Southern Nigeria (n = 57), and Northern Nigeria (n = 124). In post-hoc analyses, comparisons of delays were conducted using analysis of variance (ANOVA), and associations of delays with extreme adverse outcomes (EAO, mortality or severe morbidity) were examined using chi-square tests, odds ratios (ORs), and multivariate logistic regression. RESULTS Median minutes from hemorrhage start to study admission differed by site, ranging from 15 minutes in Cairo to 225 minutes in Northern Nigeria (p < 0.001). Median minutes from study admission to blood transfusion ranged from 30 minutes in Cairo to 209 minutes in Southern Nigeria (p < 0.001). Twenty percent of women with ≥60 minutes between hemorrhage start and study admission experienced an EAO without the NASG compared with only 6% with the NASG (χ(2) = 13.71, p < 0.001). In-hospital delays in receiving intravenous (IV) fluids and blood were more common in the NASG phase. CONCLUSIONS Women with PPH or PAH in Egypt and Nigeria often face delays in reaching emergency obstetrical care facilities and delays in receiving definitive therapies after arrival. Our results indicate that the NASG can reduce the impact of these delays. Stabilization does not replace treatment, however, and delays in fluid/blood administration with NASG use must be avoided.
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Affiliation(s)
- Janet Turan
- University of California San Francisco, San Francisco, CA 94105, USA.
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Ojengbede OA, Morhason-Bello IO, Galadanci H, Meyer C, Nsima D, Camlin C, Butrick E, Miller S. Assessing the role of the non-pneumatic anti-shock garment in reducing mortality from postpartum hemorrhage in Nigeria. Gynecol Obstet Invest 2010; 71:66-72. [PMID: 21160197 DOI: 10.1159/000316053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 05/31/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Postpartum hemorrhage (PPH) is the leading cause of maternal mortality. The non-pneumatic anti-shock garment (NASG), a first-aid lower-body pressure device, may decrease mortality. METHODS This pre-intervention/NASG study of 288 women was conducted in four referral facilities in Nigeria, 2004-2008. Entry criteria: women with PPH due to uterine atony, retained placenta, ruptured uterus, vaginal or cervical lacerations or placenta accreta with estimated blood loss of ≥750 ml and one clinical sign of shock. Differences in demographics, conditions on study entry, treatment and outcomes were examined. t tests and relative risks with 95% confidence intervals were calculated for primary outcomes - measured blood loss and mortality. Multiple logistic regression analysis was performed to examine independent association of the NASG with mortality. RESULTS Mean measured blood loss decreased by 80% between phases. Women experienced 350 ml of median blood loss after study entry in the pre-intervention and 50 ml in the NASG phase (p < 0.0001). Mortality decreased from 18% pre-intervention to 6% in the NASG phase (RR = 0.31, 95% CI 0.15-0.64, p = 0.0007). In a multiple logistic regression model, the NASG was associated with reduced mortality (odds ratio 0.30; 95% CI 0.13-0.68, p = 0.004). CONCLUSION The NASG shows promise for reducing mortality from PPH in referral facilities in Nigeria.
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Affiliation(s)
- Oladosu A Ojengbede
- Center for Population and Reproductive Health, College of Medicine/University College Hospital, University of Ibadan, Ibadan, Nigeria
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Butrick E, Peabody JW, Solon O, DeSalvo KB, Quimbo SA. A comparison of objective biomarkers with a subjective health status measure among children in the Philippines. Asia Pac J Public Health 2010; 24:565-76. [PMID: 21159692 DOI: 10.1177/1010539510390204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
UNLABELLED Large health surveys use subjective (self-reported) and objective (biomarkers) measures to assess heath status. However, the linkage or disparity of these measures has not been systematically studied in developing countries. METHOD Using data from the Philippine Quality Improvement Demonstration Study, QIDS, this study evaluated the associations between General Self-Reported Health Status (GSRH) and height, weight, hemoglobin, red blood cell folate, C-reactive protein, and blood lead levels. The authors modeled each biomarker as a function of GSRH controlling for socioeconomic status and selection effects. Changes in biomarkers and GSRH in children who had previously been hospitalized were also examined. RESULTS GSRH independently predicted hemoglobin, C-reactive protein, stunting, and wasting. GSRH did not vary significantly with folate deficiency and blood lead levels. CONCLUSIONS In addition to being a measure of overall child health status, GSRH may be a useful and inexpensive screening tool for identifying children that need further health testing.
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Miller S, Fathalla MMF, Ojengbede OA, Camlin C, Mourad-Youssif M, Morhason-Bello IO, Galadanci H, Nsima D, Butrick E, Al Hussaini T, Turan J, Meyer C, Martin H, Mohammed AI. Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities. BMC Pregnancy Childbirth 2010; 10:64. [PMID: 20955600 PMCID: PMC2966449 DOI: 10.1186/1471-2393-10-64] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 10/18/2010] [Indexed: 11/10/2022] Open
Abstract
Background Obstetric hemorrhage is the leading cause of maternal mortality globally. The Non-pneumatic Anti-Shock Garment (NASG) is a low-technology, first-aid compression device which, when added to standard hypovolemic shock protocols, may improve outcomes for women with hypovolemic shock secondary to obstetric hemorrhage in tertiary facilities in low-resource settings. Methods This study employed a pre-intervention/intervention design in four facilities in Nigeria and two in Egypt. Primary outcomes were measured mean and median blood loss, severe end-organ failure morbidity (renal failure, pulmonary failure, cardiac failure, or CNS dysfunctions), mortality, and emergency hysterectomy for 1442 women with ≥750 mL blood loss and at least one sign of hemodynamic instability. Comparisons of outcomes by study phase were assessed with rank sum tests, relative risks (RR), number needed to treat for benefit (NNTb), and multiple logistic regression. Results Women in the NASG phase (n = 835) were in worse condition on study entry, 38.5% with mean arterial pressure <60 mmHg vs. 29.9% in the pre-intervention phase (p = 0.001). Despite this, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p < 0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35-0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08-0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23-0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27-0.77). The NNTb to prevent either mortality or severe morbidity was 18 (12-36). Conclusion Adding the NASG to standard shock and hemorrhage management may significantly improve maternal outcomes from hypovolemic shock secondary to obstetric hemorrhage at tertiary care facilities in low-resource settings.
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Affiliation(s)
- Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, USA.
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Glasnapp J, Butrick E, Jamerson S, Espinoza M. Assessment of clients health needs of two urban Native American health centers in the San Francisco Bay Area. J Health Care Poor Underserved 2010; 20:1060-7. [PMID: 20168018 DOI: 10.1353/hpu.0.0196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A needs assessment was compiled from self-administered questionnaires completed by 796 clients at the Urban Indian Health Service clinics in San Francisco and Oakland, California. Data on the health disparities between Native Americans and Alaskan Natives and the rest of the U.S. population are limited. The data that exist, however, indicate that Native Americans continue to fare worse than the general population. This needs assessment reveals the same trend among a sample of clients of two Native American Health Centers in the San Francisco Bay Area and provides further information about the health needs and interests of the population currently attending these centers.
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Affiliation(s)
- James Glasnapp
- Computing Science Laboratory, Palo Alto Research Center, 3333 Coyote Hill Rd., Palo Alto, CA 94304, USA.
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Miller S, Fathalla MMF, Youssif MM, Turan J, Camlin C, Al-Hussaini TK, Butrick E, Meyer C. A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt. Int J Gynaecol Obstet 2010; 109:20-4. [PMID: 20096836 DOI: 10.1016/j.ijgo.2009.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 11/04/2009] [Accepted: 12/10/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome following severe obstetric hemorrhage. METHODS A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss >or=1000 mL and/or >or=1 sign of shock [systolic blood pressure <100 mm Hg or pulse >100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the NASG with EAO. RESULTS Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (P<0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17-0.85). CONCLUSION The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.
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Affiliation(s)
- Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94105, USA.
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Mkumba G, Anderson A, Kaseba C, Butrick E, Miller S. O622 A randomized cluster trial of the NASG for the treatment of obstetric hemorrhage and hypovolemic shock: interim analysis of patient outcomes in a referral hospital, Lusaka, Zambia. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)60995-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Miller S, Mourad-Youssif M, Fathalla M, Al-Hussaini T, Meyer C, Camlin C, Butrick E, Ismail S. O614 Non-pneumatic anti-shock garment (NASG) reduces extreme adverse outcomes from obstetric hemorrhage and shock in Egyptian hospitals. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)60987-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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