COVID Perceptions among Pregnant Women Living in a Malaria Hyperendemic Rural Region in Uganda: A Cross-Sectional Study

Both SARS-CoV2 and Plasmodium falciparum infection during pregnancy increases the risk for adverse maternal and fetal outcomes, including abortion, severe disease, and death. Indeed, although malaria and COVID-19 show an overlapping clinical presentation, they require a profoundly different approach. The aim of this study was to explore COVID-19 awareness among pregnant women living in a P. falciparum hyperendemic region in rural Uganda. This cross-sectional, prospective study was conducted in one Hospital and two Health Centers (HC) in Lango region, Uganda, from July 14, 2022, to March 14, 2023. Data about demographics, COVID-19 history, and COVID-19 and malaria perceptions were collected using RedCap mobile app platform. Study endpoint was a context-specific COVID-19 awareness score, accounting for the most common disease misconceptions. Association between study variables and good COVID-19 awareness was assessed by χ2 and t test, as appropriate, and variables found to be statistically significant were further explored in multivariate logistic regression analysis. A total of 888 pregnant women were recruited. Median age was 24 (interquartile range: 20-29) years, whereas 79% (n = 704) attained only primary education and 66.6% (n = 591) were used in agriculture. SARS-CoV2 vaccination rate was 92%. In multivariate analysis (Table 3), variables associated with high COVID knowledge were presenting at antenatal care visit in Atipe HC (adjusted odds ratio [aOR]: 8.1, 95% CI: 4.1-16.48) having a previous good knowledge about malaria (aOR: 1.76, 95% CI: 1.21-2.56). Among pregnant women living in rural Uganda, COVID-19 awareness relies on the overall educational level, malaria knowledge and reference HC. Among pregnant women living in P. falciparum endemic areas, community-level malaria awareness might guide educational interventions during future pandemics.

Impact of the COVID-19 pandemic on malaria in pregnancy indicators in Northern Uganda: a joinpoint regression analysis

BACKGROUND

Pregnancy is both a risk factor for P. falciparum infection and development of severe malaria. In low- and middle-income countries, the COVID-19 pandemic severely impacted health systems, including utilization of maternal services. This study aimed to assess trends in delivering malaria in pregnancy-related health-care services before and during COVID-19 in Northern Uganda.

METHODS

An interrupted time-series study comparing pre-COVID-19 (January 2018 to April 2020) and COVID-19 (May to December 2021) periods, based on the date the first COVID case was detected. The study involved 30 health facilities in Northern Uganda with 22,650 estimated pregnancies per year, 14% of which took place in hospital. Monthly data were sourced from District routinely collected indicators. Trends were analyzed by joinpoint regression models.

RESULTS

From the onset of the COVID pandemic in Uganda (May 2020), we found a significant reduction in the number of women accessing a fourth antenatal care visit (from APC + 183.5 to + 4.98; p < 0.001) and taking at least three doses of intermittent preventive treatment in pregnancy (IPTp, from APC + 84.28 to -63.12; p < 0.001). However, we found no significant change in the trend of the total number of pregnant women managed as outpatients or hospitalized for malaria, as well as in the number of women attending their first antenatal visit and in the number of institutional deliveries.

CONCLUSIONS

In our study, the COVID-19 pandemic significantly reduced access to ANC visits and IPTp uptake. However, the healthcare system maintained its capacity for managing malaria cases, first antenatal visits, and institutional deliveries.Trial registration: This study has been registered on the ClinicalTrials.gov public website on 26 April 2022. ClinicalTrials.gov Identifier: NCT05348746.

An integrated care pathway for maternal and childcare: evidence from Ethiopia, Tanzania, and Uganda

 

Performance monitoring and evaluation are key to quality improvement in maternal and child healthcare in Sub-Saharan Africa. This study presents the experience of designing and implementing bottom-up and integrated performance evaluation tools for care pathway to monitor and manage maternity healthcare services. The research project involved four health districts and relative reference hospitals, supported by the NGO Doctors with Africa CUAMM in Ethiopia, Tanzania, and Uganda. The maternal and childcare pathway developed consists of 23 indicators, calculated at hospital and district level, relating to pregnancy, childbirth and first year of life phases. The authors developed staves and performance maps, as graphical representation tools, to display longitudinally integrated health services provision performance along the continuum of care. Substantial variation was observed between the phases of each maternal and childcare pathway and across the care pathways of the different analysed settings. The most impressive results across the four settings are: 1) regarding pregnancy phase, that women tend to attend more than four antenatal classes, still with a quite high drop-out rate, and are largely tested for syphilis, 2) with respect to childbirth, that there are varying percentage levels in terms of C-sections, episiotomies and peri/intra-partum asphyxia cases, and 3) as it regards first year of life, there emerges scope for improvement considering the vaccination coverages attained for pentavalent, measles and polio vaccinations. Thanks to the collaboration with local managers and health professionals, the maternal and childcare pathway allowed to monitor the changes in the quality of maternity services provided within the analysed contexts. The benchmarking approach encouraged local professionals to learn from other settings. The use of such tool allowed the development of targeted quality improvement actions, shared among all involved stakeholders.

Key messages

• In collaboration with local professionals, we designed and implemented an integrated pathway for maternal and childcare, covering the phases of pregnancy, childbirth and first year of life.

• Benchmarking performance results encouraged collaboration among professionals and allowed the identification of actions to improve the provision of maternal and childcare services.

An integrated hospital-district evaluation for communicable diseases in low/middle-income countries

Background

The last two decades saw an extensive effort to design and implement integrated and multidimensional healthcare evaluation systems in high-income countries. However, in low/middle-income countries, few experiences of such systems implementation have been reported in the scientific literature. We developed and piloted an innovative tool to assess the performance of health services provision for communicable diseases in three African countries.

Methods

A total of 42 indicators, 14 per each communicable disease care pathway (Tuberculosis, Gastroenteritis, and HIV/AIDS), were developed. A sub-set of 23 indicators was included in the evaluation process. The indicators assessed four care phases: prevention, diagnosis, treatment, and outcome. All indicators were calculated for the period 2017-2019, while performance evaluation was performed for 2019. The analysis involved four health districts and their relative hospitals in Ethiopia, Tanzania, and Uganda.

Results

Substantial variability was observed over time and across the four different districts. In the TB pathway, the majority of indicators scored below the standards and below-average performance was mainly reported for prevention and diagnosis phases. Along the Gastroenteritis pathway, excellent performance was instead evaluated for most indicators and the highest scores were reported in prevention and treatment phases. The HIV/AIDS pathway indicators related to screening and outcome phases were below the average score, while good or excellent performance was registered within the treatment phase.

Conclusions

The bottom-up approach and stakeholders’ engagement increased local ownership of the process and the likelihood that findings will inform health services performance and quality of care. Despite the intrinsic limitations of data sources, this framework may contribute to promoting good governance, performance evaluation and accountability in settings characterised by multiple healthcare service providers.

Key messages

• A successful experience in developing and implementing a communicable diseases performance evaluation systems in three sub-Saharan African countries using a bottom-up approach.

• The communicable diseases performance evaluation tool helped the data sharing between local healthcare providers and the development of competencies in data collection, analysis and interpretation.

Impact of antimalarial resistance and COVID-19 pandemic on malaria care among pregnant women in Northern Uganda (ERASE): protocol of a prospective observational study

Background

Uganda accounts for 5% of all malaria cases and deaths reported globally and, in endemic countries, pregnancy is a risk factor for both acquisition of P. falciparum infection and development of severe malaria. In recent years, malaria control has been threatened by COVID-19 pandemic and by the emergence, in Northern Uganda, of both resistance to artemisinin derivatives and to sulfadoxine-pyrimethamine.

Methods

In this facility-based, prospective, observational study, pregnant women will be recruited at antenatal-care visits and followed-up until delivery. Collected data will explore the incidence of asymptomatic parasitemia and malaria-related outcomes, as well as the attitudes towards malaria prevention, administration of intermittent preventive treatment, healthcare seeking behavior and use of insecticide-treated nets. A subpopulation of women diagnosed with malaria will be recruited and their blood samples will be analyzed for detection of genetic markers of resistance to artemisinin derivatives and sulfadoxine-pyrimethamine. Also, to investigate the impact of COVID-19 on malaria care among pregnant women, a retrospective, interrupted-time series will be conducted on at the study sites for the period January 2018 to December 2021.

Discussion

The present study will explore the impact of COVID-19 pandemic on incidence of malaria and malaria-related adverse outcomes, along with the prevalence of resistance to artemisinin derivatives and to sulfadoxine-pyrimethamine. To our knowledge, this is the first study aiming to explore the combined effect of these factors on a cohort of pregnant women.

Trial registration: This study has been registered on the ClinicalTrials.gov public website on 26th April, 2022. ClinicalTrials.gov Identifier: NCT05348746.

Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey

Background

Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation’s lowest scores on key development and health indicators and presents a substantial challenge to Uganda’s stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided.

Methods

A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated.

Results

There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section.

Conclusions

To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.

A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming

BACKGROUND

Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda.

METHODS

Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified.

RESULTS

The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery.

CONCLUSION

A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.

A new rheometer with special features designed for bronchial mucus analysis in clinical practice

Changes in production and in physico-chemical properties of bronchial mucus is a common denominator of many pulmonary diseases. A rheometer with innovative features aimed at bronchial mucus routine investigation in clinical practice at the bedside of the patient has been designed. Searle-type configuration with a coaxial cylinder sensor system and the Mooney-Ewart geometry has been adopted. Another new feature is that bob and cup are disposable. Dynamic viscoelasticity is calculated through a microprocessor with specific software and by means of a magnetic torque--motor electronically driven by the microprocessor. The self-zeroing procedure and the autorange greatly simplify the measuring-cycle which is driven by only one switch. Data (eta and G') are automatically printed on paper. The whole measuring-cycle at the bedside of the patient takes 3-5 min, so that in 1h about 12 samples can be investigated.

Simple and precise method for counting ciliary beats directly from the TV monitor screen

The modern optical microscopic technique together with the use of the small perfusion chamber allows the maintenance and observation of isolated ciliated epithelia for many hours in vitro. Counting ciliary beats is a good means for evaluating the behavior of these cells immediately under different environmental conditions and also for evaluating the pharmacologic or toxic action of drugs. Using a TV camera joined to a microscope equipped with the Nomarsky differential interference contrast set, it is possible to see on a TV monitor an image of the cilia at a very high magnification (over 1000 X), with a good resolution. This paper describes a method and an instrument, with a digital readout purposely designed to receive and count signals from a phototransistor placed directly on the protective screen of the TV monitor to correspond exactly with the point of passage of the coming and going movement of the selected cilia. In this way, it is possible to obtain (in real time and in a simple way through visual observation of the beat) the final count, which consists of the number of passages, in a prefixed time, in front of the phototransistors of the dark area which represents the ciliary body on the light background.

Dermorphin, a new peptide from amphibian skin, inhibits the nociceptive thalamic neurons firing rate evoked by noxious stimuli

Dermorphin is the representative of a new class of potent opioid peptides occurring in amphibian skin and possesses the unique feature of having a D-Ala residue incorporated in the peptide molecule. The effect of dermorphin on the spontaneous and evoked neuronal activity by a nociceptive stimulus was studied in the nucleus lateralis anterior and ventrobasal complex of the rat thalamus. The high firing frequency induced by nociceptive stimuli was blocked when dermorphin was injected intraperitoneally at the dose of 1.5 mg/kg. The action starts about 10 min after injection and lasts on average for 120 min. Naloxone, a specific opioid antagonist, injected i.p. at a dose of 1 mg/kg antagonized the effect of dermorphin. The dermorphin time-course is about twice that of morphine (1.5 mg/kg i.p.) under the same experimental conditions.

Inhibitory effect of eseroline, an opiate like drug, on the rat nociceptive thalamic neurons activated by peripheral noxious stimuli

Eseroline is a new agent, derived from physostigmine but lacking in pseudocholinesterase activity, that possesses opioid properties in vivo and in vitro in cats and rodents. The electrophysiological effect of this drug has been investigated. Our findings show that Eseroline (5 mg/kg i.p.), suppresses the nociceptive responses evoked by noxious (mechanical and thermal) stimuli, without affecting the spontaneous firing of neurons in the thalamus of anesthetized rat. This effect starts about 5 min after the administration and lasts on average for about 60 min. Naloxone (1 mg/kg i.p.), injected 10 min before Eseroline, antagonized the antinociceptive action of this drug.