Implementing an eHealth tool to improve referral services for obstetric emergencies in Sierra Leone

Background

Maternal health remains a major issue of concern in Sierra Leone. In the main referral maternity institution, Princess Christian Maternity Hospital (PCMH), up to 25% of maternal deaths occur during or shortly after transit from another health facility. There is an urgent need to improve referral systems between peripheral health units (PHUs) and PCMH. Our aim was to pilot and evaluate an eHealth tool facilitating referral of obstetric emergency cases through effective teleconsultation between PHUs and PCMH.

Methods

A web application was designed to capture unclear or complicated delivery cases at PHUs and request respective telemedical counselling from the referral institution PCMH. The eHealth tool was piloted at 10 PHUs in Western area urban and rural in August 2021. Necessary devices were provided and delivery staff was trained to use the app. In December 2021, we conducted focus group discussion with 3-6 delivery staff at five PHUs and at PCMH to evaluate utilization and outcomes of the tool.

Results

All participants perceived the eHealth tool as an improvement of referral procedures. Response time from PCMH after a request for counselling from a PHU was mostly <30 minutes. The main perceived advantage of the tool was the systematic documentation of obstetric complications and procedures. This relieved staff from fear of wrong treatment accusations, and recorded communication with PCMH made processes and responsibilities transparent. Another important benefit was PCMH staff being already prepared to receive a specific emergency case after use of the app, thus reducing the ‘third delay’ within the referral facility. As a major obstacle to smooth referral despite the eHealth tool, a lacking ambulance system was mentioned as a critical gap.

Conclusions

Exceedingly positive user experiences with this simple tool seem to make an expansion to more PHUs worthwhile. Benefits of using the app in more remote districts in Sierra Leone should be further investigated.

Key messages

• Delivery staff in Sierra Leone was capable of using a web app for telemedical counselling in a useful and effective manner.

• The eHealth tool was perceived as very helpful in systematically and transparently documenting emergency delivery cases and treatment procedures.

Psychosocial wellbeing of Berlin school children during the COVID-19 pandemic, June 2020-March 2021

Background

The COVID-19 pandemic and related restrictions have affected the wellbeing of school children worldwide. Specific problems evolving during the pandemic, their extent and duration haveńt been sufficiently explored yet. We aimed at describing school childreńs psychosocial and behavioral parameters and associated factors during the COVID-19 pandemic in Berlin, Germany.

Methods

Our longitudinal study included students from 24 randomly selected Berlin primary and secondary schools, assessing psychosocial wellbeing and behaviors at four time points between June 2020 and March 2021. We analyzed temporal changes in the proportions of anxiety, fear of infection, reduced health-related quality of life (HRQoL), physical activity and social contacts, as well as sociodemographic and economic factors associated with anxiety, fear of infection and HRQoL.

Results

Of initially 384 recruited students, 324 still participated in the fourth study round after nine months. During the observation period, presence of anxiety symptoms increased from 26.2% (96/367) to 34.6% (62/179), and fear of infection from 28.6% (108/377) to 40.6% (73/180). The proportion of children with limited social contacts (<1/week) increased from 16.4% (61/373) to 23.5% (42/179). Low physical activity (<3 times sports/week) was consistent over time. Low HRQoL was observed among 44% (77/174). Factors associated with anxiety were female sex, increasing age, secondary school attendance, lower household income, and presence of adults with anxiety symptoms in the student's household. Fear of infection and low HRQoL were associated with anxiety.

Conclusions

A substantial proportion of school children experienced unfavorable psychosocial conditions during the COVID-19 pandemic in 2020/2021. In particular, students from households with limited social and financial resilience require special attention.

Key messages

Preventing HIV infection in pregnancy: a comprehensive ANC-based intervention in Western Uganda

Introduction

Pregnant women in sub-Saharan Africa represent a high-risk group for HIV infection, but most endemic countries including Uganda do not engage specific HIV prevention measures in pregnancy. This longitudinal study aimed to assess outcomes of a comprehensive, ANC-embedded strategy to prevent seroconversions during pregnancy in Western Uganda.

Methods

HIV-negative ANC clients were administered an HIV risk assessment tool, followed by individual risk counselling. They received a fixed appointment for repeat HIV testing after three months. Those attending ANC without partners obtained formal partner invitation letters. At follow-up after three months, women not attending repeat testing were reminded via text message. Post-intervention risk behavior engagement was captured. We analyzed uptake of the intervention, HIV incidence rate, and associations with risk behavior.

Results

Of 1081 participants, 116 (10.7%) reported risk behavior engagement at first ANC visit, 148/1081 (13.7%) were accompanied by partners. The repeat test visit was attended by 848/1081 (78.5%) women, 42 (5.0%, p < 0.001) reported post-intervention risk behavior engagement, and 248 (29.4%, p < 0.001) were accompanied by partners. Seroconversion occurred in two women. In multivariable logistic regression, rural facility clients compared to urban ones (aOR 3.96; 95%CI 1.53-10.26), and women with positive or unknown partner HIV-status (aOR 2.86; 1.18-6.91) and partner alcohol abuse (aOR 2.68; 1.15-6.26) had increased odds for engagement in risk behavior despite the intervention.

Conclusions

After our intervention, risk behavior in pregnancy was reduced by half, and partner attendance had doubled compared to baseline. Our cohort showed a 0.76/100 women-years HIV incidence rate compared to 2.85 in pre-intervention data from the same setting. Clients from rural settings and women experiencing precarious partner situations require special attention to reduce risk behavior engagement during pregnancy.

Key messages

• HIV incidence in pregnancy in Western Uganda can be significantly reduced through a comprehensive, ANC-based counselling intervention.

• Pregnant women from rural settings and those experiencing precarious partner situations require special attention regarding sexual risk behavior.

Risk factors for preeclampsia and eclampsia at a main referral maternity hospital in Freetown, Sierra Leone: a case-control study

BACKGROUND

In the African region, 5.6% of pregnancies are estimated to be complicated by preeclampsia and 2.9% by eclampsia, with almost one in ten maternal deaths being associated with hypertensive disorders. In Sierra Leone, representing one of the countries with the highest maternal mortality rates in the world, 16% of maternal deaths were caused by pregnancy-induced hypertension in 2016. In the light of the high burden of preeclampsia and eclampsia (PrE/E) in Sierra Leone, we aimed at assessing population-based risk factors for PrE/E to offer improved management for women at risk.

METHODS

A facility-based, unmatched observational case-control study was conducted in Princess Christian Maternity Hospital (PCMH). PCMH is situated in Freetown and is the only health care facility providing 'Comprehensive Emergency Obstetric and Neonatal Care services' throughout the entire country. Cases were defined as pregnant or postpartum women diagnosed with PrE/E, and controls as normotensive postpartum women. Data collection was performed with a questionnaire assessing a wide spectrum of factors influencing pregnant women's health. Statistical analysis was performed by estimating a binary logistic regression model.

RESULTS

We analyzed data of 672 women, 214 cases and 458 controls. The analysis yielded several independent predictors for PrE/E, including family predisposition for PrE/E (AOR = 2.72, 95% CI: 1.46-5.07), preexisting hypertension (AOR = 3.64, 95% CI: 1.32-10.06), a high mid-upper arm circumflex (AOR = 3.09, 95% CI: 1.83-5.22), presence of urinary tract infection during pregnancy (AOR = 2.02, 95% CI: 1.28-3.19), presence of prolonged diarrhoea during pregnancy (AOR = 2.81, 95% CI: 1.63-4.86), low maternal assets (AOR = 2.56, 95% CI: 1.63-4.02), inadequate fruit intake (AOR = 2.58, 95% CI: 1.64-4.06), well or borehole water as the main source of drinking water (AOR = 2.05, 95% CI: 1.31-3.23) and living close to a waste deposit (AOR = 1.94, 95% CI: 1.15-3.25).

CONCLUSION

Our findings suggest that systematic assessment of identified PrE/E risk factors, including a family predisposition for PrE/E, preexisting hypertension, or obesity, should be performed early on in ANC, followed by continued close monitoring of first signs and symptoms of PrE/E. Additionally, counseling on nutrition, exercise, and water safety is needed throughout pregnancy as well as education on improved hygiene behavior. Further research on sources of environmental pollution in Freetown is urgently required.

Animal experiments for the determination of an optimal wavelength for retinal coagulations

The retina of rabbits was coagulated with different wave-lengths (570-630 nm) using a tunable dye laser with Rhodamin 6G. To achieve comparable ophthalmoscopic appearance the intensity of the laser beam was varied with neutral filters of varying absorption. Histologic examination of fresh coagulation effects and 3-week-old coagulation scars showed no difference in relation to the wave-length used. Theoretically, 577 nm seems to be a particularly useful wavelength for the treatment of a wide variety of retinal lesions because it is not absorbed in xanthophyll and penetrates opacities of the optic media better than argon blue green. Furthermore, it is absorbed maximally in hemoglobin, making it particularly suitable for the coagulation of blood vessels.

The effect of topical cyclosporin A on the rabbit cornea. A clinical and electron microscopic study

To investigate the effect of topical cyclosporin A (CSA) on the rabbit cornea, both eyes of 80 animals were treated with CSA 2% eye drops over a 3-week period under various conditions. CSA was dissolved in castor oil or ethanol 13.8 vol. %. Slit-lamp, scanning and transmission electron microscopic examinations were performed. CSA 2% in castor oil given 5 times daily showed no damage to either the corneal epithelium or endothelium. In contrast the solutions containing ethanol revealed considerable epithelial cell damage.

Ciclosporin concentration in the rabbit aqueous humor and cornea following subconjunctival administration. Importance of anatomical site of injection

The model compound lidocaine was used in the rabbit to investigate different sites of subconjunctival injection for the achievement of reproducible drug concentrations in the aqueous humor. Only epibulbar injections were satisfactory, but not parabulbar or injections under the lower fornix. After epibulbar administration of 0.8 ml 5% ciclosporin, median concentrations in the aqueous humor were 360, 700 and 200 ng/ml after 2, 8, and 24 h, respectively. Corresponding levels in the cornea were 32, 27, and 12 ng/ml. It appears that drug concentrations resulting from epibulbar injections may be therapeutically useful.