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Straneo M, Hanson C, van den Akker T, Afolabi BB, Asefa A, Delamou A, Dennis M, Gadama L, Mahachi N, Mlilo W, Pembe AB, Tsuala Fouogue J, Beňová L. Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data. BMJ Glob Health 2024; 9:e013029. [PMID: 38262683 PMCID: PMC10806834 DOI: 10.1136/bmjgh-2023-013029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/21/2023] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity. METHODS Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators. RESULTS This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda. DISCUSSION Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.
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Affiliation(s)
- Manuela Straneo
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Thomas van den Akker
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics & Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bosede B Afolabi
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
| | - Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Alexandre Delamou
- Africa Center for Excellence (CEA-PMCT), Universite Gamal Abdel Nasser de Conakry, Conakry, Guinea
- Maferinyah Training and Research Center, Forécariah, Guinea
| | | | - Luis Gadama
- Kamuzu University of Health Sciences, Blantyre, Southern Region, Malawi
| | - Nyika Mahachi
- Zimbabwe College of Public Health Physicians, Harare, Zimbabwe
| | - Welcome Mlilo
- Matabeleland North Provincial Medical Directorate, Zimbabwe Ministry of Health and Child Care, Bulawayo, Zimbabwe
| | - Andrea B Pembe
- Department of Obstetric and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jovanny Tsuala Fouogue
- Department of Obstetrics and Gynecology and Maternal Health, Faculty of Medicine and Pharmaceutical Sciences, Université de Dschang, Dschang, Cameroon
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Epidemiology and Population Health, LSHTM, London, UK
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Steege R, Mwaniki H, Ogueji IA, Baraka J, Salimu S, Kumar MB, Kawaza K, Odedere O, Shamba D, Bokea H, Chiume M, Adudans S, Ezeaka C, Paul C, Banyira L, Lungu G, Salim N, Zimba E, Ngwala S, Tarus A, Bohne C, Gathara D, Lawn JE. Protecting small and sick newborn care in the COVID-19 pandemic: multi-stakeholder qualitative data from four African countries with NEST360. BMC Pediatr 2023; 23:572. [PMID: 37974092 PMCID: PMC10655439 DOI: 10.1186/s12887-023-04358-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 10/10/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Health system shocks are increasing. The COVID-19 pandemic resulted in global disruptions to health systems, including maternal and newborn healthcare seeking and provision. Yet evidence on mitigation strategies to protect newborn service delivery is limited. We sought to understand what mitigation strategies were employed to protect small and sick newborn care (SSNC) across 65 facilities Kenya, Malawi, Nigeria and Tanzania, implementing with the NEST360 Alliance, and if any could be maintained post-pandemic. METHODS We used qualitative methods (in-depth interviews n=132, focus group discussions n=15) with purposively sampled neonatal health systems actors in Kenya, Malawi, Nigeria and Tanzania. Data were collected from September 2021 - August 2022. Topic guides were co-developed with key stakeholders and used to gain a detailed understanding of approaches to protect SSNC during the COVID-19 pandemic. Questions explored policy development, collaboration and investments, organisation of care, human resources, and technology and device innovations. Interviews were conducted by experienced qualitative researchers and data were collected until saturation was reached. Interviews were digitally recorded and transcribed verbatim. A common coding framework was developed, and data were coded via NVivo and analysed using a thematic framework approach. FINDINGS We identified two pathways via which SSNC was strengthened. The first pathway, COVID-19 specific responses with secondary benefit to SSNC included: rapid policy development and adaptation, new and collaborative funding partnerships, improved oxygen systems, strengthened infection prevention and control practices. The second pathway, health system mitigation strategies during the pandemic, included: enhanced information systems, human resource adaptations, service delivery innovations, e.g., telemedicine, community engagement and more emphasis on planned preventive maintenance of devices. Chronic system weaknesses were also identified that limited the sustainability and institutionalisation of actions to protect SSNC. CONCLUSION Innovations to protect SSNC in response to the COVID-19 pandemic should be maintained to support resilience and high-quality routine SSNC delivery. In particular, allocation of resources to sustain high quality and resilient care practices and address remaining gaps for SSNC is critical.
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Affiliation(s)
- Rosie Steege
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK.
- Liverpool School of Tropical Medicine, Liverpool, UK.
| | | | | | - Jitihada Baraka
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Sangwani Salimu
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Meghan Bruce Kumar
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
- Kenya Medical Research Institute, Wellcome Trust Research Program, Nairobi, Kenya
| | - Kondwani Kawaza
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Opeyemi Odedere
- Rice360 Institute for Global Health Technologies, Houston, Texas, USA
| | - Donat Shamba
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Helen Bokea
- Rice360 Institute for Global Health Technologies, Houston, Texas, USA
| | - Msandeni Chiume
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Kamuzu Central Hospital, Lilongwe, Malawi
| | - Steve Adudans
- Academy for Novel Channels in Health and Operations Research (ACANOVA Africa), Nairobi, Kenya
| | - Chinyere Ezeaka
- College of Medicine, University of Lagos, Lagos State, Nigeria
| | - Catherine Paul
- Rice360 Institute for Global Health Technologies, Houston, Texas, USA
| | | | - Gaily Lungu
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nahya Salim
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Evelyn Zimba
- Rice360 Institute for Global Health Technologies, Houston, Texas, USA
| | - Samuel Ngwala
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Alice Tarus
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Christine Bohne
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
- Rice360 Institute for Global Health Technologies, Houston, Texas, USA
| | - David Gathara
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK.
- Kenya Medical Research Institute, Wellcome Trust Research Program, Nairobi, Kenya.
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK.
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Coffey PS, Israel-Ballard K, Meyer L, Mansen K, Agonafir N, Bekere M, Dube Q, Kaberuka G, Kasar J, Kharade A, Maknikar S, Namgyal KC, Nyondo-Mipando AL, Rulisa S, Worku B, Engmann C. The Journey Toward Establishing Inpatient Care for Small and Sick Newborns in Ethiopia, India, Malawi, and Rwanda. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200510. [PMID: 37640484 PMCID: PMC10461708 DOI: 10.9745/ghsp-d-22-00510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/13/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Limited information is available about the approaches used and lessons learned from low- and middle-income countries that have implemented inpatient services for small and sick newborns. We developed descriptive case studies to compare the journeys to establish inpatient newborn care across Ethiopia, India, Malawi, and Rwanda. METHODS A total of 57 interviews with stakeholders in Ethiopia (n=12), India (n=12), Malawi (n=16), and Rwanda (n=17) informed the case studies. Our heuristic data analysis followed a deductive organizing framework approach. We informed our data analysis via targeted literature searches to uncover details related to key events. We used the NEST360 Theory of Change for facility-based care, which reflects the World Health Organization (WHO) Health Systems Framework as a starting point and added, as necessary, in an edit processing format until data saturation was achieved. FINDINGS Results highlight the strategies and innovation used to establish small and sick newborn care by health system building block and by country. We conducted a gap analysis of implementation of WHO Standards for Improving Facility-Based Care. The journeys to establish inpatient newborn care across the 4 countries are similar in terms of trajectory yet unique in their implementation. Unifying themes include leadership and governance at national level to consolidate and coordinate action to improve newborn quality of care, investment to build staff skills on data collection and use, and institutionalization of regular neonatal data reviews to identify gaps and propose relevant strategies. CONCLUSION Efforts to establish and scale inpatient care for small and sick newborns in Ethiopia, India, Malawi, and Rwanda over the last decade have led to remarkable success. These country examples can inspire more nascent initiatives that other low- and middle-income countries may undertake. Documentation should give voice to lived country experience, not all of which is fully captured in existing, peer-reviewed published literature.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Bogale Worku
- Ethiopian Pediatric Society, Addis Ababa, Ethiopia
| | - Cyril Engmann
- PATH, Seattle, WA, USA
- University of Washington, Seattle, WA
- Seattle Children’s Hospital, Seattle, WA
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Mangochi H, Tolhurst R, Simpson V, Kawaza K, Chidziwisano K, Feasey NA, Morse T, MacPherson E. A qualitative study exploring hand hygiene practices in a neonatal unit in Blantyre, Malawi: implications for controlling healthcare-associated infections. Wellcome Open Res 2023; 7:146. [PMID: 37224320 PMCID: PMC10170178 DOI: 10.12688/wellcomeopenres.17793.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/26/2023] Open
Abstract
Background: Neonatal sepsis causes morbidity and mortality in sub-Saharan Africa. Antimicrobial resistance exacerbates outcomes. Poor Infection Prevention and Control practices (IPC) by healthcare workers and caregivers drive infection transmission. The Chatinkha Neonatal Unit in Malawi has experienced Klebsiella pneumoniae outbreaks of neonatal sepsis. We aimed to identify barriers to optimal IPC, focusing on hand hygiene. Methods: We used a focused ethnography to meet the study aim. Combining participant observation over a seven-month period with semi structured interviews with health care workers and patient carers (23) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. To analyse the data, we drew on the framework approach. Results: We found that staff and caregivers had a good understanding and recognition of the importance of ideal IPC, but faced substantial structural limitations and scarce resources, which hindered the implementation of best practices. We present two key themes: (1) structural and health systems barriers that shaped IPC. These included scarce material resources and overwhelming numbers of patients meant the workload was often unmanageable. (2) individual barriers related to the knowledge of frontline workers and caregivers, which were shaped by training and communication practices on the ward. We highlight the importance of addressing both structural and individual barriers to improve IPC practices and reduce the burden of neonatal sepsis in resource-limited settings. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.
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Affiliation(s)
- Helen Mangochi
- Behaviour and Health Group, Malawi Liverpool Wellcome Clinical Programme, Blantyre, Malawi
| | - Rachel Tolhurst
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | | | - Kondwani Kawaza
- Pediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Kamuzu University of Health Sciences,, Blantyre, Malawi
| | - Kondwani Chidziwisano
- Centre for Water, Sanitation, Health and Appropriate Technology Development, Malawi University of Business and Applied Sciences, Blantyre, Malawi
| | - Nicholas A. Feasey
- Behaviour and Health Group, Malawi Liverpool Wellcome Clinical Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Tracy Morse
- Centre for Water, Sanitation, Health and Appropriate Technology Development, Malawi University of Business and Applied Sciences, Blantyre, Malawi
- Department of Civil and Environmental Engineering, University of Strathclyde, Glasgow, UK
| | - Eleanor MacPherson
- Behaviour and Health Group, Malawi Liverpool Wellcome Clinical Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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Jung D, Kim B. The effect of health facility births on newborn mortality in Malawi. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2023:10.1007/s10754-023-09348-x. [PMID: 37010654 DOI: 10.1007/s10754-023-09348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/09/2023] [Indexed: 06/19/2023]
Abstract
We examine the effect of health facility delivery on newborn mortality in Malawi using data from a survey of mothers in the Chimutu district, Malawi. The study exploits labour contraction time as an instrumental variable to overcome endogeneity of health facility delivery. The results show that health facility delivery does not reduce 7-day and 28-day mortality rates. In a low-income country like Malawi where the healthcare quality is severely compromised, we conclude that encouraging health facility delivery may not guarantee positive health outcomes for newborn births.
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Affiliation(s)
- Dawoon Jung
- Korea Institute of Public Finance, Sejong, Republic of Korea
| | - Booyuel Kim
- Department of Environmental Planning, Graduate School of Environmental Studies, Seoul National University, Gwanak-ro 1, Gwanak-gu, Seoul, 08826, Republic of Korea.
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Mangochi H, Tolhurst R, Simpson V, Kawaza K, Chidziwisano K, Feasey NA, Morse T, MacPherson E. A qualitative study exploring hand hygiene practices in a neonatal unit in Blantyre, Malawi: implications for controlling healthcare-associated infections. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.17793.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice. Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging. For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging. Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.
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Mangochi H, Tolhurst R, Simpson V, Kawaza K, Chidziwisano K, Feasey NA, Morse T, MacPherson E. A qualitative study exploring health workers and patient caregivers’ hand hygiene practices in a neonatal unit in Blantyre, Malawi, implications for controlling outbreaks of drug resistant infections. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17793.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice. Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging. For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging. Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.
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Torbica A, Grainger C, Okada E, De Allegri M. How much does it cost to combine supply-side and demand-side RBF approaches in a single intervention? Full cost analysis of the Results Based Financing for Maternal and Newborn Health Initiative in Malawi. BMJ Open 2022; 12:e050885. [PMID: 35440444 PMCID: PMC9020314 DOI: 10.1136/bmjopen-2021-050885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To estimate the economic cost associated with implementing the Results Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi. No specific hypotheses were formulated ex-ante. SETTING Primary and secondary delivery facilities in rural Malawi. PARTICIPANTS Not applicable. The study relied almost exclusively on secondary financial data. INTERVENTION The RBF4MNH Initiative was a results-based financing (RBF) intervention including both a demand and a supply-side component. PRIMARY AND SECONDARY OUTCOME MEASURES Cost per potential and for actual beneficiaries. RESULTS The overall economic cost of the Initiative during 2011-2016 amounted to €12 786 924, equivalent to €24.17 per pregnant woman residing in the intervention districts. The supply side activity cluster absorbed over 40% of all resources, half of which were spent on infrastructure upgrading and equipment supply, and 10% on incentives. Costs for the demand side activity cluster and for verification were equivalent to 14% and 6%, respectively of the Initiative overall cost. CONCLUSION Carefully tracing resource consumption across all activities, our study suggests that the full economic cost of implementing RBF interventions may be higher than what was previously reported in published cost-effectiveness studies. More research is urgently needed to carefully trace the costs of implementing RBF and similar health financing innovations, in order to inform decision-making in low-income and middle-income countries around scaling up RBF approaches.
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Affiliation(s)
- Aleksandra Torbica
- Department of Social and Political Sciences, Centre for Research for Health and Social Care Management, Bocconi University, Milano, Italy
| | | | - Elena Okada
- Options Consultancy Services Ltd, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
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Experiences of Malawian Mothers During Their Infants' Hospitalization. Adv Neonatal Care 2022; 22:E48-E57. [PMID: 34138793 DOI: 10.1097/anc.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospitalization of a newborn infant is stressful for all mothers. Hospitals in Malawi have limited nursing staff and support, so mothers are the primary care providers for their hospitalized infants. Few studies have explored the experience of these mothers as both care providers and mothers. PURPOSE The purpose of this study was to explore the experiences of mothers during the hospitalization of the infant. The goal was to increase knowledge of their primary concerns about the hospital stay. METHODS This was a descriptive qualitative study conducted at Queen Elizabeth Central Hospital in Malawi. Mothers were interviewed prior to their infant's discharge. We used the directed content analysis approach to analyze our data. RESULTS Twenty mothers of preterm or full-term infants were interviewed. The primary concerns were perinatal experiences, the infant's condition and care including breastfeeding, support from family members, and support and care from healthcare providers. Additionally, mothers of preterm infants were concerned about the burdens of kangaroo mother care. IMPLICATION FOR PRACTICE In hospitals that provide limited nursing support to mothers and their infants, it is important to identify a support system for the mother and provide mothers with information on infant care. IMPLICATIONS FOR RESEARCH Future research should identify specific supports and resources in the community and hospital settings that are associated with positive hospital experiences.
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Mathias CT, Mianda S, Ohdihambo JN, Hlongwa M, Singo-Chipofya A, Ginindza TG. Facilitating factors and barriers to kangaroo mother care utilisation in low- and middle-income countries: A scoping review. Afr J Prim Health Care Fam Med 2021; 13:e1-e15. [PMID: 34476975 PMCID: PMC8424722 DOI: 10.4102/phcfm.v13i1.2856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/21/2021] [Accepted: 05/22/2021] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Kangaroo mother care (KMC) has been widely adopted in low-and middle-income countries (LMICs) to minimise low birthweight infants' (LBWIs) adverse outcomes. However, the burden of neonatal and child mortality remains disproportionately high in LMICs. AIM Thus, this scoping review sought to map evidence on the barriers, challenges and facilitators of KMC utilisation by parents of LBWIs (parent of low birthweight infant [PLBWI]) in LMICs. METHODS We searched for studies conducted in LMICs and published in English between January 1990 and August 2020 from SciELO, Google Scholar, JSTOR, LILACS, Academic search complete, PubMed, CINAHL with full text, and Medline databases. We adopted Arksey and O'Malley's framework for conducting scoping reviews. Potential studies were exported to Endnote X7 reference management software for abstract and full article screening. Two independent reviewers did a parallel abstract and full article screening using a standardised form. The results were analysed using thematic content analysis. RESULTS We generated 22 040 studies and after duplicate removal, 42 studies were eligible for full-text screening and 22 studies, most form sub-Saharan Africa, were included in the content analysis. Eight themes emerged from the analysis: access, buy-in, co-ordination and collaboration, medical issues, motivation, social support-gender obligation and empowerment, time and timing and traditional/cultural norms. CONCLUSION Identifying factors affecting KMC may optimise KMC utilisation. Additional studies aiming at identifying influencing factors that affect KMC utilisation amongst PLBWIs' in LMICs need to be conducted to provide evidence-based strategies to enhance practice, inform policy and decision-makers in KMC utilisation amongst the PLBWIs in LMICs and beyond.
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Affiliation(s)
- Christina T Mathias
- Discipline of Public Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban.
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Chanie ES, Alemu AY, Mekonen DK, Melese BD, Minuye B, Hailemeskel HS, Asferie WN, Bayih WA, Munye T, Birlie TA, Amare AT, Tibebu NS, Tiruneh CM, Legas G, Gebre Eyesus FA, Belay DM. Impact of respiratory distress syndrome and birth asphyxia exposure on the survival of preterm neonates in East Africa continent: systematic review and meta-analysis. Heliyon 2021; 7:e07256. [PMID: 34189307 PMCID: PMC8215220 DOI: 10.1016/j.heliyon.2021.e07256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/21/2021] [Accepted: 06/03/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Several kinds of researches are available on preterm mortality in the East Africa continent; however, it is inconsistent and inconclusive, which requires the pooled evidence to recognize the burden in general. PURPOSE To collect and synthesis evidence on preterm mortality and identify factors in the East Africa continent. METHODS PubMed, Google Scholar, Hinary, Cochrane library, research gate, and institutional repositories were retrieved to identity eligible articles through Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The articles were selected if the publication period is between 2010-2021 G.C. Data were extracted by a standardized JBI data extraction format for mortality rate and stratified the associated factors. Then exported to STATA 14 for further analysis. I2 and Egger's tests were employed to estimate the heterogeneity and publication bias respectively. Subgroup analysis based on country, study design, year of publication, and the sample size was also examined. RESULT This meta-analysis included 32 articles with a total of 21,405 study participants. The pooled mortality rate among preterm in the East Africa continent was found to be 19.2% (95% CI (confidence interval (16.0-22.4)). Regarding the study design, the mortality rate was found to be 18.1%, 19.4%, and 19.7% concerning the prospective cohort, retrospective cohort, and cross-sectional studies. The pooled odds of mortality among preterm with respiratory distress syndrome decreased survival by nearly three folds [AOR (Adjusted odds ratio = 3.2; 95% CI: 22, 4.6)] as compared to their counterparts. Similarly, preterm neonates presented with birth asphyxia were nearly three times higher in death as compared with preterm without birth asphyxia [AOR = 2.6; 95% CI: 1.9, 3.4]. CONCLUSION Preterm mortality was found to be unacceptably high in Eastern Africa continent.Fortunately, the main causes of death were found to be respiratory distress syndrome and birth asphyxia which are preventable and treatable hence early detection and timely management of this problem are highly recommended to improve preterm survival.
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Affiliation(s)
- Ermias Sisay Chanie
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Abebew Yeshambel Alemu
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Demewoze Kefale Mekonen
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Biruk Demissie Melese
- Department of Environmental Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Binyam Minuye
- Department of Maternity and Neonatal Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Habtamu Shimels Hailemeskel
- Department of Maternity and Neonatal Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Worku Necho Asferie
- Department of Maternity and Neonatal Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Wubet Alebachew Bayih
- Department of Maternity and Neonatal Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tigabu Munye
- Department of Adult Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tekalign Amera Birlie
- Department of Adult Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Abraham Tsedalu Amare
- Department of Adult Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Nigusie Selomon Tibebu
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Chalie Marew Tiruneh
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Getasew Legas
- Department of Psychiatric, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Demeke Mesfin Belay
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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12
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Iroh Tam PY, Musicha P, Kawaza K, Cornick J, Denis B, Freyne B, Everett D, Dube Q, French N, Feasey N, Heyderman R. Emerging Resistance to Empiric Antimicrobial Regimens for Pediatric Bloodstream Infections in Malawi (1998-2017). Clin Infect Dis 2020; 69:61-68. [PMID: 30277505 PMCID: PMC6579959 DOI: 10.1093/cid/ciy834] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/28/2018] [Indexed: 11/14/2022] Open
Abstract
Background The adequacy of the World Health Organization’s Integrated Management of Childhood Illness (IMCI) antimicrobial guidelines for the treatment of suspected severe bacterial infections is dependent on a low prevalence of antimicrobial resistance (AMR). We describe trends in etiologies and susceptibility patterns of bloodstream infections (BSI) in hospitalized children in Malawi. Methods We determined the change in the population-based incidence of BSI in children admitted to Queen Elizabeth Central Hospital, Blantyre, Malawi (1998–2017). AMR profiles were assessed by the disc diffusion method, and trends over time were evaluated. Results A total 89643 pediatric blood cultures were performed, and 10621 pathogens were included in the analysis. Estimated minimum incidence rates of BSI for those ≤5 years of age fell from a peak of 11.4 per 1000 persons in 2002 to 3.4 per 1000 persons in 2017. Over 2 decades, the resistance of Gram-negative pathogens to all empiric, first-line antimicrobials (ampicillin/penicillin, gentamicin, ceftriaxone) among children ≤5 years increased from 3.4% to 30.2% (P < .001). Among those ≤60 days, AMR to all first-line antimicrobials increased from 7.0% to 67.7% (P < .001). Among children ≤5 years, Klebsiella spp. resistance to all first-line antimicrobial regimens increased from 5.9% to 93.7% (P < .001). Conclusions The incidence of BSI among hospitalized children has decreased substantially over the last 20 years, although gains have been offset by increases in Gram-negative pathogens’ resistance to all empiric first-line antimicrobials. There is an urgent need to address the broader challenge of adapting IMCI guidelines to the local setting in the face of rapidly-expanding AMR in childhood BSI.
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Affiliation(s)
- Pui-Ying Iroh Tam
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, United Kingdom
| | - Patrick Musicha
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, United Kingdom
| | | | - Jenifer Cornick
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Institute of Infection and Global Health, University of Liverpool, United Kingdom
| | - Brigitte Denis
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Institute of Infection and Global Health, University of Liverpool, United Kingdom
| | - Dean Everett
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,The Queens Medical Research Institute, University of Edinburgh, United Kingdom
| | - Queen Dube
- University of Malawi College of Medicine, Blantyre
| | - Neil French
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Institute of Infection and Global Health, University of Liverpool, United Kingdom
| | - Nicholas Feasey
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, United Kingdom
| | - Robert Heyderman
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,University College London, United Kingdom
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13
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Mathias CT, Mianda S, Ginindza TG. Facilitating factors and barriers to accessibility and utilization of kangaroo mother care service among parents of low birth weight infants in Mangochi District, Malawi: a qualitative study. BMC Pediatr 2020; 20:355. [PMID: 32727459 PMCID: PMC7390197 DOI: 10.1186/s12887-020-02251-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 07/20/2020] [Indexed: 11/21/2022] Open
Abstract
Background Kangaroo Mother Care (KMC) is one of the interventions widely used in low-income countries to manage Low Birth Weight Infants (LBWIs), a global leading cause of neonatal and child mortality. LBWI largely contributes to neonatal mortality in Malawi despite the country strengthening and implementing KMC, nationwide, to enhance the survival of LBWIs. This qualitative study aimed to assess the facilitating factors and barriers to accessibility and utilization of KMC service by the parent of low birth weight infants (PLBWIs) in Mangochi District, Malawi. Methods Two focused group discussions assessed factors facilitating and hindering the accessibility and utilization of KMC service were conducted in April 2018 that reached out to (N = 12) participants; (n:6) PLBWI practicing KMC at Mangochi district hospital (MDH) referred from four health facilities and (n:6) high-risk pregnant mothers (HRPMs) visiting antenatal care (ANC) clinic at MDH. The availability of KMC at MDH was assessed using KMC availability checklist. The study used purposive, convenient and simple random sampling to identify eligible participants. Thematic analysis was used to analyze the findings. Results Sixteen themes emerged on facilitating factors and barriers to accessibility and utilization of KMC service by the PLBWIs. The identified themes included; availability of KMC providers, social factor (social support and maternal love), timing of KMC information, knowledge on KMC, health linkage systems, recognition of LBWIs, safety on the use of KMC, preference of LBWI’s care practice, lived experience on KMC practice, KMC expert clients, perceived causes of LBWI births, cultural/traditional factors, religious beliefs, health-seeking behavior, women empowerment and quality of care. Conclusions Although KMC was available in some of the health facilities, integration of KMC messages in ANC guidelines, community awareness and in sensitization of any health intervention may enhance KMC accessibility and utilization by the targeted population.
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Affiliation(s)
- Christina T Mathias
- Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Science, University of KwaZulu-Natal, 2nd Floor George Campbell Building, Mazisi Kunene Road, Durban, 4041, South Africa.
| | - Solange Mianda
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Themba G Ginindza
- Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Science, University of KwaZulu-Natal, 2nd Floor George Campbell Building, Mazisi Kunene Road, Durban, 4041, South Africa
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14
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Alderman H, Nguyen PH, Menon P. Progress in reducing child mortality and stunting in India: an application of the Lives Saved Tool. Health Policy Plan 2020; 34:667-675. [PMID: 31529050 PMCID: PMC6880331 DOI: 10.1093/heapol/czz088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 12/03/2022] Open
Abstract
The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005–6 (NFHS-3) for the base year and NHFS-4 2015–16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool.
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Affiliation(s)
- Harold Alderman
- Division of Poverty, Health and Nutrition, International Food Policy Research Institute (IFPRI), 1201 I Street NW, Washington, DC, USA
| | - Phuong Hong Nguyen
- Division of Poverty, Health and Nutrition, International Food Policy Research Institute (IFPRI), 1201 I Street NW, Washington, DC, USA
| | - Purnima Menon
- Division of Poverty, Health and Nutrition, International Food Policy Research Institute (IFPRI), 1201 I Street NW, Washington, DC, USA
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15
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Kawaza K, Kinshella MLW, Hiwa T, Njirammadzi J, Banda M, Vidler M, Newberry L, Nyondo-Mipando AL, Dube Q, Molyneux E, Goldfarb DM. Assessing quality of newborn care at district facilities in Malawi. BMC Health Serv Res 2020; 20:227. [PMID: 32183795 PMCID: PMC7079536 DOI: 10.1186/s12913-020-5065-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/02/2020] [Indexed: 11/18/2022] Open
Abstract
Background Malawi is celebrated as one of the few countries in sub-Saharan Africa to meet the Millennium Development Goal of reducing under-5 mortality by two-thirds between 1990 and 2015. However, within this age range neonatal mortality rates are the slowest to decline, even though rates of facility births are increasing. Examining the quality of neonatal care at district-level facilities where most deliveries occur is warranted. Objective The objective of this paper is to evaluate the quality of neonatal care in three district hospitals and one primary health centre in southern Malawi as well as to report the limitations and lessons learned on using the WHO integrated quality of care assessment tool. Methods These facility assessments were part of the “Integrating a neonatal healthcare package for Malawi” project, a part of the Innovating for Maternal and Child Health in Africa (IMCHA) initiative. The WHO integrated quality of care assessment tool was used to assess quality of care and availability and quantity of supplies and resources. The modules on infrastructure, neonatal care and labour and delivery were included. Facility assessments were administered in November 2017 and aspects of care were scored on a Likert scale from one to five (a score of 5 indicating compliance with WHO standards of care; one as lowest indicating inadequate care). Results The continuum of labour, delivery and neonatal care were assessed to identify areas that required improvements to meet standards of care. Critical areas for improvements included infection control (mean score 2.9), equipment, supplies and setup for newborn care in the labor ward (2.3), in the surgical theater (3.3), and nursery (3.4 nursery facilities, 3.0 supplies and equipment), as well as for management of sick newborns (3.2), monitoring and follow-up (3.6). Only one of the 12 domains, laboratory, met the standards of care with only minor improvements needed (4.0). Conclusion The WHO integrated quality of care assessment tool is a validated tool that can shed light on the complex quality of care challenges faced by district-level health facilities. The results reveal that the quality of care needs improvement, particularly for sick and vulnerable newborns.
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Affiliation(s)
- Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi. .,College of Medicine, IMCHA Project, Blantyre, Malawi.
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Tamanda Hiwa
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Jenala Njirammadzi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Mwai Banda
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Laura Newberry
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- College of Medicine, IMCHA Project, Blantyre, Malawi.,Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- College of Medicine, IMCHA Project, Blantyre, Malawi.,Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Elizabeth Molyneux
- College of Medicine, IMCHA Project, Blantyre, Malawi.,Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
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16
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An Observational Study on Early Dyadic Interactive Behaviors of Mothers With Early-Preterm, Late-Preterm, and Full-Term Infants in Malawi. Adv Neonatal Care 2020; 20:90-99. [PMID: 31764211 DOI: 10.1097/anc.0000000000000673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mother-infant interactions are necessary for infant growth and development. However, preterm birth is associated with less positive mother-infant interactions than full-term birth. Malawi has the highest preterm birth rate in the world, but studies of the mother-infant relationship in Malawi are limited and studies that observed mother-infant interactions could not be located. PURPOSE This study explored mother-infant interactions among Malawian mothers of early-preterm, late-preterm, and full-term infants. METHODS This observational study explored maternal and infant interactive behaviors. We recruited 83 mother-infant dyads (27 early-preterm, 29 late-preterm, and 27 full-term dyads). FINDINGS Mothers of early-preterm infants looked at and rocked their infants less, and their infants looked at their mothers less, than mothers of either late-preterm infants or full-term infants. The infants in all groups were asleep most of the time, which contributed to low levels of interactive behaviors. Factors that were related to infant behaviors included marital status, maternal occupation, maternal education, infant medical complications, infant gender, history of neonatal deaths, and multiple births. IMPLICATIONS FOR PRACTICE Our findings provide evidence about the need to encourage mothers to engage interactive behaviors with their infants. IMPLICATIONS FOR RESEARCH Future studies of factors that contribute to positive interactions in Malawi are needed.
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17
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Haley CA, Brault MA, Mwinga K, Desta T, Ngure K, Kennedy SB, Maimbolwa M, Moyo P, Vermund SH, Kipp AM. Promoting progress in child survival across four African countries: the role of strong health governance and leadership in maternal, neonatal and child health. Health Policy Plan 2019; 34:24-36. [PMID: 30698696 PMCID: PMC6479825 DOI: 10.1093/heapol/czy105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2018] [Indexed: 11/12/2022] Open
Abstract
Despite numerous international and national efforts, only 12 countries in the World Health Organization's African Region met the Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across sub-Saharan Africa, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia and Zambia were chosen to represent countries making substantial progress towards MDG#4, while Kenya and Zimbabwe represented countries making less progress. Our individual case studies suggested that strong health governance and leadership (HGL) was a significant driver of the greater success in Liberia and Zambia compared with Kenya and Zimbabwe. To elucidate specific components of national HGL that may have substantially influenced the pace of reductions in child mortality, we conducted a cross-country analysis of national policies and strategies pertaining to maternal, neonatal and child health (MNCH) and qualitative interviews with individuals working in MNCH in each of the four study countries. The three aspects of HGL identified in this study which most consistently contributed to the different progress towards MDG#4 among the four study countries were (1) establishing child survival as a top national priority backed by a comprehensive policy and strategy framework and sufficient human, financial and material resources; (2) bringing together donors, strategic partners, health and non-health stakeholders and beneficiaries to collaborate in strategic planning, decision-making, resource-allocation and coordination of services; and (3) maintaining accountability through a 'monitor-review-act' approach to improve MNCH. Although child mortality in sub-Saharan Africa remains high, this comparative study suggests key health leadership and governance factors that can facilitate reduction of child mortality and may prove useful in tackling current Sustainable Development Goals.
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Affiliation(s)
- Connie A Haley
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Marie A Brault
- Department of Anthropology, University of Connecticut, 354 Mansfield Road, Storrs, CT, USA
| | - Kasonde Mwinga
- World Health Organization, Regional Office for Africa, Cite du Djoue, Brazzaville, Congo
| | - Teshome Desta
- World Health Organization, Inter-country Support Team for East and Southern Africa, Harare, Zimbabwe
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Stephen B Kennedy
- University of Liberia-Pacific Institute for Research & Evaluation (UL-PIRE) Africa Center, University of Liberia, Monrovia, Liberia
| | | | - Precious Moyo
- Collaborative Research Program, University of Zimbabwe/University of California, San Francisco, Harare, Zimbabwe
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, USA
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
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18
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Developing a Contextually Appropriate Integrated Hygiene Intervention to Achieve Sustained Reductions in Diarrheal Diseases. SUSTAINABILITY 2019. [DOI: 10.3390/su11174656] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diarrheal disease in under-five children remains high in Sub-Saharan Africa; primarily attributed to environmental pathogen exposure through poorly managed water, sanitation, and hygiene (WASH) pathways, including foods. This formative study in rural Malawi used a theoretical base to determine the personal, social, environmental, and psychosocial factors that are to be considered in the development of an integrated intervention for WASH and food hygiene. Using a mixed methods approach, a stakeholder analysis was followed by data collection pertaining to 1079 children between the ages of four to 90 weeks: observations (n = 79); assessment of risks, attitudes, norms and self-regulation (RANAS) model (n = 323); structured questionnaires (n = 1000); focus group discussions (n = 9); and, in-depth interviews (n = 9) (PACTR201703002084166). We identified four thematic areas for the diarrheal disease intervention: hand washing with soap; food hygiene; feces management (human and animal); and, water management. The contextual issues included: the high level of knowledge on good hygiene practices not reflected in observed habits; inclusion of all family members incorporating primary caregivers (female) and financial controllers (male); and, endemic poverty as a significant barrier to hygiene infrastructure and consumable availability. The psychosocial factors identified for intervention development included social norms, abilities, and self-regulation. The resulting eight-month context specific intervention to be evaluated is described.
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19
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Nonyane BA, Chimbalanga E. Efforts to alter the trajectory of neonatal mortality in Malawi: evaluating relative effects of access to maternal care services and birth history risk factors. J Glob Health 2018; 8:020419. [PMID: 30356473 PMCID: PMC6181331 DOI: 10.7189/jogh.08.020419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The neonatal mortality rate (NMR) in Malawi has remained stagnant at around 27 per 1000 live births over the last 15 years, despite an increase in the uptake of targeted health care interventions. We used the nationally representative 2015/16 Demographic Health Survey data set to evaluate the effect of two types of maternal exposures, namely, lack of access to maternal or intra-partum care services and birth history factors, on the risk of neonatal mortality. METHODS A causal inference approach was used to estimate a population attributable risk parameter for each exposure, adjusting for co-exposures and household, maternal and child-specific covariates. The maternal exposures evaluated were unmet family planning needs, less than 4+ antenatal care visits, lack of institutional delivery or skilled birth attendance, having prior neonatal mortality, short (8-24 months) birth interval preceding the index birth, first pregnancy, and two or more pregnancy outcomes within the preceding five years of the survey interview. RESULTS We included 9553 women and their most recent live birth within 3 years of the survey. The sample's overall neonatal mortality rate was 18.5 per 1000 live births. The adjusted population attributable risk for first pregnancies was 3.9/1000 (P < 0.001), while non-institutional deliveries and the shortest preceding birth interval (8-24 months) each had an attributable risk of 1.3/1000 (Ps = 0.01). Having 2 or more pregnancy outcomes within the last 5 years had an attributable risk of 3/1000 (P = 0.006). Attending less than 4 ANC visits had, a relatively large attributable risk (2.1/1,000), and it was not statistically significant at alpha level 0.05. CONCLUSIONS Our analysis addresses the gap in the literature on evaluating the effect of these exposures on neonatal mortality in Malawi. It also helps inform programs and current efforts such as the Every Newborn Action 2020 Plan. Increasing access to maternal care interventions has an important role to play in changing the trajectory of neonatal mortality, and women who are at an increased risk may not be receiving adequate care. Recent studies indicate an urgent need to assess gaps in service readiness and quality of care at the antenatal and obstetric care facilities.
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Affiliation(s)
- Bareng As Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emmanuel Chimbalanga
- USAID's ONSE Health Activity, Management Sciences for Health (MSH), Lilongwe, Malawi
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20
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Brault MA, Kennedy SB, Haley CA, Clarke AT, Duworko MC, Habimana P, Vermund SH, Kipp AM, Mwinga K. Factors influencing rapid progress in child health in post-conflict Liberia: a mixed methods country case study on progress in child survival, 2000-2013. BMJ Open 2018; 8:e021879. [PMID: 30327401 PMCID: PMC6196853 DOI: 10.1136/bmjopen-2018-021879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/11/2018] [Accepted: 05/11/2018] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Only 12 countries in the WHO's African region met Millennium Development Goal 4 (MDG 4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country mixed methods study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia was selected for an in-depth case study due to its success in reducing under-five mortality by 73% and thus successfully meeting MDG 4. Liberia's success was particularly notable given the civil war that ended in 2003. We examined some factors contributing to their reductions in under-five mortality. DESIGN A case study mixed methods approach drawing on data from quantitative indicators, national documents and qualitative interviews was used to describe factors that enabled Liberia to rebuild their maternal, neonatal and child health (MNCH) programmes and reduce under-five mortality following the country's civil war. SETTING The interviews were conducted in Monrovia (Montserrado County) and the areas in and around Gbarnga, Liberia (Bong County, North Central region). PARTICIPANTS Key informant interviews were conducted with Ministry of Health officials, donor organisations, community-based organisations involved in MNCH and healthcare workers. Focus group discussions were conducted with women who have experience accessing MNCH services. RESULTS Three prominent factors contributed to the reduction in under-five mortality: national prioritisation of MNCH after the civil war; implementation of integrated packages of services that expanded access to key interventions and promoted intersectoral collaborations; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals. CONCLUSIONS Although Liberia experiences continued challenges related to limited resources, Liberia's effective strategies and rapid progress may provide insights for reducing under-five mortality in other post-conflict settings.
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Affiliation(s)
- Marie A Brault
- Department of Anthropology, University of Connecticut, Storrs, Connecticut, USA
| | - Stephen B Kennedy
- University of Liberia-Pacific Institute for Research and Evaluation (UL-PIRE) Africa Center, University of Liberia, Monrovia, Liberia
| | - Connie A Haley
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Musu C Duworko
- Liberia Country office, World Health Organization, Monrovia, Liberia
| | - Phanuel Habimana
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kasonde Mwinga
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
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21
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Daviaud E, Owen H, Pitt C, Kerber K, Bianchi Jassir F, Barger D, Manzi F, Ekipara-Kiracho E, Greco G, Waiswa P, Lawn JE. Overview, methods and results of multi-country community-based maternal and newborn care economic analysis. Health Policy Plan 2018; 32:i6-i20. [PMID: 28981766 DOI: 10.1093/heapol/czx055] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2017] [Indexed: 11/12/2022] Open
Abstract
Home visits for pregnancy and postnatal care were endorsed by the WHO and partners as a complementary strategy to facility-based care to reduce newborn and maternal mortality. This article aims to synthesise findings and implications from the economic analyses of community-based maternal and newborn care (CBMNC) evaluations in seven countries. The evaluations included five cluster randomized trials (Ethiopia, Ghana, South Africa, Tanzania, Uganda) and programmatic before/after assessments (Bolivia, Malawi). The economic analyses were undertaken using a standardized, comparable methodology the 'Cost of Integrated Newborn Care' Tool, developed by the South African Medical Research Council, with Saving Newborn Lives and a network of African economists. The main driver of costs is the number of community health workers (CHWs), determined by their time availability, as fixed costs per CHW (equipment, training, salary/stipend, supervision and management), independent from the level of activity (number of mothers visited) represented over 96% of economic and financial costs in five of the countries. Unpaid volunteers are not necessarily a cheap option. An integrated programme with multi-purpose paid workers usually has lower costs per visit but requires innovative management, including supervision to ensure that coverage, or quality of care are not compromised since these workers have many other responsibilities apart from maternal and newborn health. If CHWs reach 95% of pregnant women in a standardized 100 000 population, the additional financial cost in all cases would be under USD1 per capita. In five of the six countries, the programme would be highly cost-effective (cost per DALY averted < GDP/capita) by WHO threshold even if they only achieved a reduction of 1 neonatal death per 1000 live births. These results contribute useful information for implementation planning and sustainability of CBMNC programmes.
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Affiliation(s)
- Emmanuelle Daviaud
- Health System Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Helen Owen
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Catherine Pitt
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Fatuma Manzi
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
| | | | - Giulia Greco
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Waiswa
- College of Health Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Joy E Lawn
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
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Verheijen J. The gendered micropolitics of hiding and disclosing: assessing the spread and stagnation of information on two new EMTCT policies in a Malawian village. Health Policy Plan 2018; 32:1309-1315. [PMID: 28981664 DOI: 10.1093/heapol/czx088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2017] [Indexed: 11/13/2022] Open
Abstract
Analysing why certain information spreads-or not-can be highly relevant for understanding an intervention's potential impact. Two recently implemented policy changes related to EMTCT (elimination of mother-to-child transmission of HIV) in the Balaka district of Malawi give ample opportunity to assess how new information trickles through a targeted rural community. One of the policies entails the lifetime provision of ART (anti-retroviral therapy) to all HIV+ pregnant women-a governmental strategy to EMTCT first initiated in Malawi and now being expanded throughout the region. The second new policy concerns a pilot project in which women are financially rewarded for attending antenatal care and delivering in the hospital. An in-depth anthropological approach was used to assess what women in one village community know about the policy changes and how they had come to know about it. Although the policies were implemented more or less at the same time, awareness and knowledge levels among village women differed largely: In case of the first, awareness stagnated at the level of those who directly received the information from health professionals. In the case of the second, highly accurate and up-to-date knowledge had spread throughout the village community. I suggest three reasons for this divergence: (i) perceived talk-worthiness of (issues addressed by) the interventions, (ii) motives for hiding or disclosing involvement in either of the interventions and (iii) the visibility of each intervention, or in other words, the (im)possibility to hide involvement. I argue that these reasons for women's structural silence on one policy change and prompt sharing of information on another follow a distinctly gendered logic. The findings underline that the diffusion of new information is to a great extent shaped by the social particularities of the context in which it is introduced.
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Affiliation(s)
- Janneke Verheijen
- Department of Cultural Anthropology and Development Sociology, Universiteit Leiden, Koopweg 65, 1402PC Bussum, The Netherlands
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Mathias CT, Mianda S, Ginindza TG. Evidence of the factors that influence the utilisation of Kangaroo Mother Care by parents with low-birth-weight infants in low- and middle-income countries (LMICs): a scoping review protocol. Syst Rev 2018; 7:55. [PMID: 29622026 PMCID: PMC5887207 DOI: 10.1186/s13643-018-0714-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 03/20/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The Sustainable Development Goal (SDG) 3 emphasises on reducing neonatal deaths caused by low birth weight (LBW) complications by the implementation and utilisation of Kangaroo Mother Care (KMC) in low- and middle-income countries (LMICs). Despite the empirical evidence of KMC optimising low-birth-weight infants' (LBWIs') survival, its advantages and the LMICs implementing the service, studies have shown that LBW infant deaths occurring in LMICs are largely contributing to global child mortality. The aim of this scoping review is to map out the literature on barriers, challenges and facilitators of KMC utilisation by parents with LBWIs. METHODS AND ANALYSIS This scoping review will use Endnote X7 reference management software to manage articles. The review search strategy will use SCIELO and LILACS databases. Other databases will be used via EBSCOHost search engine and these are Academic search complete, CINAHL with full text, Education source, Health source: Nursing/Academic Edition, Medline with full text and Medline. We will also use Google Scholar, JSTOR, Open grey search engines and reference lists. A two-phase search mapping out process will be done. In phase 1, one reviewer will perform the title screening and removal of duplicates. Two reviewers will do a parallel abstract screening according to eligibility criteria. Phase 2 will involve the reading of full articles and exclusion of articles, in accordance with the eligibility criteria. Data extraction from the articles will be done by two reviewers independently and parallel to the data extraction form. The data quality assessment of the eligible studies will be done using the Mixed Method Appraisal Tool (MMAT). The extraction of the synthesised results and thematic content analysis of the studies will be done by NVIVO version 10. DISCUSSION We expect to find studies on barriers, challenges and facilitating factors of KMC utilisation by parents with LBWIs in LMICs. The review outcomes will guide future research and practice and inform policy. The findings will be disseminated in print, electronic and conference presentations related to maternal child and neonatal health.
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Affiliation(s)
- Christina T Mathias
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
| | - Solange Mianda
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Themba G Ginindza
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Carvajal-Aguirre L, Mehra V, Amouzou A, Khan SM, Vaz L, Guenther T, Kalino M, Zaka N. Does health facility service environment matter for the receipt of essential newborn care? Linking health facility and household survey data in Malawi. J Glob Health 2018; 7:020508. [PMID: 29423185 PMCID: PMC5804506 DOI: 10.7189/jogh.07.020508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Health facility service environment is an important factor for newborns survival and well–being in general and in particular in high mortality settings such as Malawi where despite high coverage of essential interventions, neonatal mortality remains high. The aim of this study is to assess whether the quality of the health service environment at birth is associated with quality of care received by the newborn. Methods We used data from the Malawi Millennium Development Goals Endline household survey conducted as part of MICS survey program and Service Provision Assessment Survey carried out in 2014. The analysis is based on 6218 facility births that occurred during the past 2 years. Descriptive statistics, bivariate and multivariate random effect models are used to assess the association of health facility service readiness score for normal deliveries and newborn care with newborns receiving appropriate newborn care, defined for this analysis as receiving 5 out of 6 recommended interventions during the first 2 days after birth. Results Newborns in districts with top facility service readiness score have 1.5 higher odds of receiving appropriate newborn care (adjusted odds ratio (aOR) = 1.52, 95% confidence interval CI = 1.19–1.95, P = 0.001), as compared to newborns in districts with a lower facility score after adjusting for potential confounders. Newborns in the Northern region were two times more likely to receive 5 newborn care interventions as compared to newborns in the Southern region (aOR = 2.06, 95% CI = 1.50–2.83, P < 0.001). Living in urban or rural areas did not have an impact on receiving appropriate newborn care. Conclusions There is need to increase the level of service readiness across all facilities, so that all newborns irrespective of the health facility, district or region of delivery are able to receive all recommended essential interventions. Investments in health systems in Malawi should concentrate on increasing training and availability of health staff in facilities that offer normal delivery and newborn care services at all levels in the country.
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Affiliation(s)
| | - Vrinda Mehra
- Data and Analytics, Data Research and Policy, UNICEF, New York, New York, USA
| | - Agbessi Amouzou
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Shane M Khan
- Data and Analytics, Data Research and Policy, UNICEF, New York, New York, USA
| | - Lara Vaz
- Saving Newborn Lives, Save the Children, Washington, DC, USA
| | - Tanya Guenther
- Saving Newborn Lives, Save the Children, Washington, DC, USA
| | | | - Nabila Zaka
- Program Division, UNICEF, New York, New York, USA
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Winter R, Yourkavitch J, Wang W, Mallick L. Assessment of health facility capacity to provide newborn care in Bangladesh, Haiti, Malawi, Senegal, and Tanzania. J Glob Health 2018; 7:020509. [PMID: 29423186 PMCID: PMC5804038 DOI: 10.7189/jogh.07.020509] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Despite the importance of health facility capacity to provide comprehensive care, the most widely used indicators for global monitoring of maternal and child health remain contact measures which assess women’s use of services only and not the capacity of health facilities to provide those services; there is a gap in monitoring health facilities’ capacity to provide newborn care services in low and middle income countries. Methods In this study we demonstrate a measurable framework for assessing health facility capacity to provide newborn care using open access, nationally–representative Service Provision Assessment (SPA) data from the Demographic Health Surveys Program. In particular, we examine whether key newborn–related services are available at the facility (ie, service availability, measured by the availability of basic emergency obstetric care (BEmOC) signal functions, newborn signal functions, and routine perinatal services), and whether the facility has the equipment, medications, training and knowledge necessary to provide those services (ie, service readiness, measured by general facility requirements, equipment, medicines and commodities, and guidelines and staffing) in five countries with high levels of neonatal mortality and recent SPA data: Bangladesh, Haiti, Malawi, Senegal, and Tanzania. Findings In each country, we find that key services and commodities needed for comprehensive delivery and newborn care are missing from a large percentage of facilities with delivery services. Of three domains of service availability examined, scores for routine care availability are highest, while scores for newborn signal function availability are lowest. Of four domains of service readiness examined, scores for general requirements and equipment are highest, while scores for guidelines and staffing are lowest. Conclusions Both service availability and readiness tend to be highest in hospitals and facilities in urban areas, pointing to substantial equity gaps in the availability of essential newborn care services for rural areas and for people accessing lower–level facilities. Together, the low levels of both service availability and readiness across the five countries reinforce the vital importance of monitoring health facility capacity to provide care. In order to save newborn lives and improve equity in child survival, not only does women’s use of services need to increase, but facility capacity to provide those services must also be enhanced.
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Affiliation(s)
- Rebecca Winter
- Department of Health, The District of Columbia, Washington DC, USA
| | | | | | - Lindsay Mallick
- The DHS Program, Avenir Health, Glastonbury, Connecticut, USA
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26
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Seward N, Neuman M, Colbourn T, Osrin D, Lewycka S, Azad K, Costello A, Das S, Fottrell E, Kuddus A, Manandhar D, Nair N, Nambiar B, Shah More N, Phiri T, Tripathy P, Prost A. Effects of women's groups practising participatory learning and action on preventive and care-seeking behaviours to reduce neonatal mortality: A meta-analysis of cluster-randomised trials. PLoS Med 2017; 14:e1002467. [PMID: 29206833 PMCID: PMC5716527 DOI: 10.1371/journal.pmed.1002467] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 11/01/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization recommends participatory learning and action (PLA) in women's groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women's groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction. METHODS AND FINDINGS We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women's group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women's groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02-4.22; I2 = 63.7%, 95% CI 4.4%-86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25-2.82; 67.6%, 16.1%-87.5%), birth attendant washing hands prior to delivery (1.87, 1.19-2.95; 79%, 53.8%-90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09-1.99; 68.0%, 29.2%-85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02-1.60; 0.0%, 0%-79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77-1.38; I2 = 86.3%, 95% CI 73.8%-92.8%), facility delivery (1.02, 0.93-1.12; 21.4%, 0%-65.8%), initiating breastfeeding within 1 hour (1.08, 0.85-1.39; 76.6%, 50.9%-88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93-1.48; 72.9%, 37.8%-88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women's groups and context-specific effects. CONCLUSIONS This meta-analysis suggests that women's groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents.
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Affiliation(s)
- Nadine Seward
- Institute for Global Health, University College London, London, United Kingdom
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Melissa Neuman
- Institute for Global Health, University College London, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - David Osrin
- Institute for Global Health, University College London, London, United Kingdom
| | - Sonia Lewycka
- Nuffield Department of Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
| | - Sushmita Das
- Society for Nutrition, Education & Health Action, Mumbai, India
| | - Edward Fottrell
- Institute for Global Health, University College London, London, United Kingdom
| | - Abdul Kuddus
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, United Kingdom
| | - Neena Shah More
- Society for Nutrition, Education & Health Action, Mumbai, India
| | - Tambosi Phiri
- Parent and Child Health Initiative Trust, Lilongwe, Malawi
| | | | - Audrey Prost
- Institute for Global Health, University College London, London, United Kingdom
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Kipp AM, Maimbolwa M, Brault MA, Kalesha-Masumbu P, Katepa-Bwalya M, Habimana P, Vermund SH, Mwinga K, Haley CA. Improving access to child health services at the community level in Zambia: a country case study on progress in child survival, 2000-2013. Health Policy Plan 2017; 32:603-612. [PMID: 28453711 PMCID: PMC5964895 DOI: 10.1093/heapol/czw141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2016] [Indexed: 11/17/2022] Open
Abstract
Reductions in under-five mortality in Africa have not been sufficient to meet the Millennium Development Goal #4 (MDG#4) of reducing under-five mortality by two-thirds by 2015. Nevertheless, 12 African countries have met MDG#4. We undertook a four country study to examine barriers and facilitators of child survival prior to 2015, seeking to better understand variability in success across countries. The current analysis presents indicator, national document, and qualitative data from key informants and community women describing the factors that have enabled Zambia to successfully reduce under-five mortality over the last 15 years and achieve MDG#4. Results identified a Zambian national commitment to ongoing reform of national health strategic plans and efforts to ensure universal access to effective maternal, neonatal and child health (MNCH) interventions, creating an environment that has promoted child health. Zambia has also focused on bringing health services as close to the family as possible through specific community health strategies. This includes actively involving community health workers to provide health education, basic MNCH services, and linking women to health facilities, while supplementing community and health facility work with twice-yearly Child Health Weeks. External partners have contributed greatly to Zambia’s MNCH services, and their relationships with the government are generally positive. As government funding increases to sustain MNCH services, national health strategies/plans are being used to specify how partners can fill gaps in resources. Zambia’s continuing MNCH challenges include basic transportation, access-to-care, workforce shortages, and financing limitations. We highlight policies, programs, and implementation that facilitated reductions in under-five mortality in Zambia. These findings may inform how other countries in the African Region can increase progress in child survival in the post-MDG period.
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Affiliation(s)
- Aaron M Kipp
- Vanderbilt Institute for Global Health.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Marie A Brault
- Department of Anthropology, University of Connecticut, Storrs, CT, USA
| | | | | | - Phanuel Habimana
- World Health Organization/Regional Office for Africa, Brazzaville, Congo
| | - Sten H Vermund
- Vanderbilt Institute for Global Health.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kasonde Mwinga
- World Health Organization/Regional Office for Africa, Brazzaville, Congo
| | - Connie A Haley
- Vanderbilt Institute for Global Health.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Musicha P, Cornick JE, Bar-Zeev N, French N, Masesa C, Denis B, Kennedy N, Mallewa J, Gordon MA, Msefula CL, Heyderman RS, Everett DB, Feasey NA. Trends in antimicrobial resistance in bloodstream infection isolates at a large urban hospital in Malawi (1998-2016): a surveillance study. THE LANCET. INFECTIOUS DISEASES 2017; 17:1042-1052. [PMID: 28818544 PMCID: PMC5610140 DOI: 10.1016/s1473-3099(17)30394-8] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 05/31/2017] [Accepted: 06/15/2017] [Indexed: 01/22/2023]
Abstract
Background Bacterial bloodstream infection is a common cause of morbidity and mortality in sub-Saharan Africa, yet few facilities are able to maintain long-term surveillance. The Malawi-Liverpool-Wellcome Trust Clinical Research Programme has done sentinel surveillance of bacteraemia since 1998. We report long-term trends in bloodstream infection and antimicrobial resistance from this surveillance. Methods In this surveillance study, we analysed blood cultures that were routinely taken from adult and paediatric patients with fever or suspicion of sepsis admitted to Queen Elizabeth Central Hospital, Blantyre, Malawi from 1998 to 2016. The hospital served an urban population of 920 000 in 2016, with 1000 beds, although occupancy often exceeds capacity. The hospital admits about 10 000 adults and 30 000 children each year. Antimicrobial susceptibility tests were done by the disc diffusion method according to British Society of Antimicrobial Chemotherapy guidelines. We used the Cochran-Armitage test for trend to examine trends in rates of antimicrobial resistance, and negative binomial regression to examine trends in icidence of bloodstream infection over time. Findings Between Jan 1, 1998, and Dec 31, 2016, we isolated 29 183 pathogens from 194 539 blood cultures. Pathogen detection decreased significantly from 327·1/100 000 in 1998 to 120·2/100 000 in 2016 (p<0·0001). 13 366 (51·1%) of 26 174 bacterial isolates were resistant to the Malawian first-line antibiotics amoxicillin or penicillin, chloramphenicol, and co-trimoxazole; 68·3% of Gram-negative and 6·6% of Gram-positive pathogens. The proportions of non-Salmonella Enterobacteriaceae with extended spectrum beta-lactamase (ESBL) or fluoroquinolone resistance rose significantly after 2003 to 61·9% in 2016 (p<0·0001). Between 2003 and 2016, ESBL resistance rose from 0·7% to 30·3% in Escherichia coli, from 11·8% to 90·5% in Klebsiella spp and from 30·4% to 71·9% in other Enterobacteriaceae. Similarly, resistance to ciprofloxacin rose from 2·5% to 31·1% in E coli, from 1·7% to 70·2% in Klebsiella spp and from 5·9% to 68·8% in other Enterobacteriaceae. By contrast, more than 92·0% of common Gram-positive pathogens remain susceptible to either penicillin or chloramphenicol. Meticillin-resistant Staphylococcus aureus (MRSA) was first reported in 1998 at 7·7% and represented 18·4% of S aureus isolates in 2016. Interpretation The rapid expansion of ESBL and fluoroquinolone resistance among common Gram-negative pathogens, and the emergence of MRSA, highlight the growing challenge of bloodstream infections that are effectively impossible to treat in this resource-limited setting. Funding Wellcome Trust, H3ABionet, Southern Africa Consortium for Research Excellence (SACORE).
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Affiliation(s)
- Patrick Musicha
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; College of Medicine, University of Malawi, Blantyre, Malawi; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Jennifer E Cornick
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Naor Bar-Zeev
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Neil French
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Clemens Masesa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Brigitte Denis
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Neil Kennedy
- College of Medicine, University of Malawi, Blantyre, Malawi; Queen's University, Belfast, UK
| | - Jane Mallewa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; College of Medicine, University of Malawi, Blantyre, Malawi
| | - Melita A Gordon
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Chisomo L Msefula
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; College of Medicine, University of Malawi, Blantyre, Malawi
| | - Robert S Heyderman
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Division of Infection and Immunity, University College London, London, UK
| | - Dean B Everett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Nicholas A Feasey
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK.
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Brault MA, Ngure K, Haley CA, Kabaka S, Sergon K, Desta T, Mwinga K, Vermund SH, Kipp AM. The introduction of new policies and strategies to reduce inequities and improve child health in Kenya: A country case study on progress in child survival, 2000-2013. PLoS One 2017; 12:e0181777. [PMID: 28763454 PMCID: PMC5538680 DOI: 10.1371/journal.pone.0181777] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 07/06/2017] [Indexed: 11/19/2022] Open
Abstract
As of 2015, only 12 countries in the World Health Organization’s AFRO region had met Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Kenya was one of the countries selected for an in-depth case study due to its insufficient progress in reducing under-five mortality, with only a 28% reduction between 1990 and 2013. This paper presents indicators, national documents, and qualitative data describing the factors that have both facilitated and hindered Kenya’s efforts in reducing child mortality. Key barriers identified in the data were widespread socioeconomic and geographic inequities in access and utilization of maternal, neonatal, and child health (MNCH) care. To reduce these inequities, Kenya implemented three major policies/strategies during the study period: removal of user fees, the Kenya Essential Package for Health, and the Community Health Strategy. This paper uses qualitative data and a policy review to explore the early impacts of these efforts. The removal of user fees has been unevenly implemented as patients still face hidden expenses. The Kenya Essential Package for Health has enabled construction and/or expansion of healthcare facilities in many areas, but facilities struggle to provide Emergency Obstetric and Neonatal Care (EmONC), neonatal care, and many essential medicines and commodities. The Community Health Strategy appears to have had the most impact, improving referrals from the community and provision of immunizations, malaria prevention, and Prevention of Mother-to-Child Transmission of HIV. However, the Community Health Strategy is limited by resources and thus also unevenly implemented in many areas. Although insufficient progress was made pre-2015, with additional resources and further scale-up of new policies and strategies Kenya can make further progress in child survival.
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Affiliation(s)
- Marie A. Brault
- University of Connecticut, Department of Anthropology, Storrs, Connecticut, United States of America
| | - Kenneth Ngure
- Jomo Kenyatta University of Agriculture and Technology, School of Public Health, Nairobi, Kenya
| | - Connie A. Haley
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | | | - Kibet Sergon
- World Health Organization/Kenya Country Office, Nairobi, Kenya
| | - Teshome Desta
- WHO Inter-country Support Team for East and Southern Africa, Harare, Zimbabwe
| | | | - Sten H. Vermund
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Aaron M. Kipp
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
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Haley CA, Vermund SH, Moyo P, Kipp AM, Madzima B, Kanyowa T, Desta T, Mwinga K, Brault MA. Impact of a critical health workforce shortage on child health in Zimbabwe: a country case study on progress in child survival, 2000-2013. Health Policy Plan 2017; 32:613-624. [PMID: 28064212 PMCID: PMC5406757 DOI: 10.1093/heapol/czw162] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2016] [Indexed: 12/15/2022] Open
Abstract
Despite notable progress reducing global under-five mortality rates, insufficient progress in most sub-Saharan African nations has prevented the achievement of Millennium Development Goal four (MDG#4) to reduce under-five mortality by two-thirds between 1990 and 2015. Country-level assessments of factors underlying why some African countries have not been able to achieve MDG#4 have not been published. Zimbabwe was included in a four-country study examining barriers and facilitators of under-five survival between 2000 and 2013 due to its comparatively slow progress towards MDG#4. A review of national health policy and strategy documents and analysis of qualitative data identified Zimbabwe's critical shortage of health workers and diminished opportunities for professional training and education as an overarching challenge. Moreover, this insufficient health workforce severely limited the availability, quality, and utilization of life-saving health services for pregnant women and children during the study period. The impact of these challenges was most evident in Zimbabwe's persistently high neonatal mortality rate, and was likely compounded by policy gaps failing to authorize midwives to deliver life-saving interventions and to ensure health staff make home post-natal care visits soon after birth. Similarly, the lack of a national policy authorizing lower-level cadres of health workers to provide community-based treatment of pneumonia contributed to low coverage of this effective intervention and high child mortality. Zimbabwe has recently begun to address these challenges through comprehensive policies and strategies targeting improved recruitment and retention of experienced senior providers and by shifting responsibility of basic maternal, neonatal and child health services to lower-level cadres and community health workers that require less training, are geographically broadly distributed, and are more cost-effective, however the impact of these interventions could not be assessed within the scope and timeframe of the current study.
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Affiliation(s)
- Connie A Haley
- Vanderbilt Institute for Global Health, Departments of 2Medicine and 3Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Departments of 2Medicine and 3Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Precious Moyo
- University of Zimbabwe-University of California San Francisco Collaborative Research Programme, Harare, Zimbabwe
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Departments of 2Medicine and 3Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bernard Madzima
- Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - Trevor Kanyowa
- World Health Organization/Zimbabwe Country Office, Harare, Zimbabwe
| | - Teshome Desta
- World Health Organization/Inter-country Support Team for East and Southern Africa, Harare, Zimbabwe
| | - Kasonde Mwinga
- World Health Organization/Regional Office for Africa, Brazzaville, Congo
| | - Marie A Brault
- Department of Anthropology, University of Connecticut, Storrs, CT, USA
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Kozuki N, Oseni L, Mtimuni A, Sethi R, Rashidi T, Kachale F, Rawlins B, Gupta S. Health facility service availability and readiness for intrapartum and immediate postpartum care in Malawi: A cross-sectional survey. PLoS One 2017; 12:e0172492. [PMID: 28301484 PMCID: PMC5354363 DOI: 10.1371/journal.pone.0172492] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 02/05/2017] [Indexed: 01/08/2023] Open
Abstract
This analysis seeks to identify strengths and gaps in the existing facility capacity for intrapartum and immediate postpartum fetal and neonatal care, using data collected as a part of Malawi’s Helping Babies Breath program evaluation. From August to September 2012, the Maternal and Child Health Integrated Program (MCHIP) conducted a cross-sectional survey in 84 Malawian health facilities to capture current health facility service availability and readiness and health worker capacity and practice pertaining to labor, delivery, and immediate postpartum care. The survey collected data on availability of equipment, supplies, and medications, and health worker knowledge and performance scores on intrapartum care simulation and actual management of real clients at a subset of facilities. We ran linear regression models to identify predictors of high simulation performance of routine delivery care and management of asphyxiated newborns across all facilities surveyed. Key supplies for infection prevention and thermal care of the newborn were found to be missing in many of the surveyed facilities. At the health center level, 75% had no clinician trained in basic emergency obstetric care or newborn care and 39% had no midwife trained in the same. We observed that there were no proportional increases in available transport and staff at a facility as catchment population increased. In simulations of management of newborns with breathing problems, health workers were able to complete a median of 10 out of 16 tasks for a full-term birth case scenario and 20 out of 30 tasks for a preterm birth case scenario. Health workers who had more years of experience appeared to perform worse. Our study provides a benchmark and highlights gaps for future evaluations and studies as Malawi continues to make strides in improving facility-based care. Further progress in reducing the burden of neonatal and fetal death in Malawi will be partly predicated on guaranteeing properly equipped and staffed facilities in addition to ensuring the presence of skilled health workers.
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Affiliation(s)
- Naoko Kozuki
- Department of International Health, Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, United States of America
| | | | | | - Reena Sethi
- Jhpiego, Washington, DC, United States of America
| | | | | | | | - Shivam Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, United States of America
- * E-mail:
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Moise IK, Kalipeni E, Jusrut P, Iwelunmor JI. Assessing the reduction in infant mortality rates in Malawi over the 1990–2010 decades. Glob Public Health 2016; 12:757-779. [DOI: 10.1080/17441692.2016.1239268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Imelda K. Moise
- Department of Geography and Regional Studies, University of Miami, Coral Gables, FL, USA
| | - Ezekiel Kalipeni
- Department of Geography & GIScience, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Poonam Jusrut
- Department of Geography & GIScience, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Juliet I. Iwelunmor
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
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Singh NS, Huicho L, Afnan-Holmes H, John T, Moran AC, Colbourn T, Grundy C, Matthews Z, Maliqi B, Mathai M, Daelmans B, Requejo J, Lawn JE. Countdown to 2015 country case studies: systematic tools to address the "black box" of health systems and policy assessment. BMC Public Health 2016; 16 Suppl 2:790. [PMID: 27634035 PMCID: PMC5025822 DOI: 10.1186/s12889-016-3402-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Evaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons. METHODS International experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990-2015) and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies. RESULTS The Policy and Programme Timeline tool shows that Tanzania's RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies. The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania (15.4 vs. 7.1/10,000 population, respectively), although both are below the 22.8 WHO minimum threshold. CONCLUSIONS These are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.
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Affiliation(s)
- Neha S. Singh
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Luis Huicho
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Instituto Nacional de Salud del Niño, Lima, Peru
| | | | - Theopista John
- World Health Organisation, PO Box 9292, Dar es Salaam, Tanzania
| | - Allisyn C. Moran
- US Agency for International Development, Bureau of Global Health, Office of Health, Infectious Disease and Nutrition, Washington DC, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, SW7 2AZ UK
| | - Chris Grundy
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Zoe Matthews
- Division of Social Statistics and Demography, University of Southampton, Highfield, Southampton SO17 1BJ UK
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva 27, 1211 Switzerland
| | - Matthews Mathai
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva 27, 1211 Switzerland
| | - Bernadette Daelmans
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva 27, 1211 Switzerland
| | - Jennifer Requejo
- Partnership for Maternal, Newborn & Child Health, Geneva 27, 1211 Switzerland
| | - Joy E. Lawn
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - On behalf of the Countdown to 2015 Health Systems and Policies Technical Working Group
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Instituto Nacional de Salud del Niño, Lima, Peru
- Independent consultant, London, UK
- World Health Organisation, PO Box 9292, Dar es Salaam, Tanzania
- US Agency for International Development, Bureau of Global Health, Office of Health, Infectious Disease and Nutrition, Washington DC, USA
- Institute for Global Health, University College London, London, SW7 2AZ UK
- Division of Social Statistics and Demography, University of Southampton, Highfield, Southampton SO17 1BJ UK
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva 27, 1211 Switzerland
- Partnership for Maternal, Newborn & Child Health, Geneva 27, 1211 Switzerland
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Doherty T, Zembe W, Ngandu N, Kinney M, Manda S, Besada D, Jackson D, Daniels K, Rohde S, van Damme W, Kerber K, Daviaud E, Rudan I, Muniz M, Oliphant NP, Zamasiya T, Rohde J, Sanders D. Assessment of Malawi's success in child mortality reduction through the lens of the Catalytic Initiative Integrated Health Systems Strengthening programme: Retrospective evaluation. J Glob Health 2016; 5:020412. [PMID: 26649176 PMCID: PMC4652924 DOI: 10.7189/jogh.05.020412] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Malawi is estimated to have achieved its Millennium Development Goal (MDG) 4 target. This paper explores factors influencing progress in child survival in Malawi including coverage of interventions and the role of key national policies. Methods We performed a retrospective evaluation of the Catalytic Initiative (CI) programme of support (2007–2013). We developed estimates of child mortality using four population household surveys undertaken between 2000 and 2010. We recalculated coverage indicators for high impact child health interventions and documented child health programmes and policies. The Lives Saved Tool (LiST) was used to estimate child lives saved in 2013. Results The mortality rate in children under 5 years decreased rapidly in the 10 CI districts from 219 deaths per 1000 live births (95% confidence interval (CI) 189 to 249) in the period 1991–1995 to 119 deaths (95% CI 105 to 132) in the period 2006–2010. Coverage for all indicators except vitamin A supplementation increased in the 10 CI districts across the time period 2000 to 2013. The LiST analysis estimates that there were 10 800 child deaths averted in the 10 CI districts in 2013, primarily attributable to the introduction of the pneumococcal vaccine (24%) and increased household coverage of insecticide–treated bednets (19%). These improvements have taken place within a context of investment in child health policies and scale up of integrated community case management of childhood illnesses. Conclusions Malawi provides a strong example for countries in sub–Saharan Africa of how high impact child health interventions implemented within a decentralised health system with an established community–based delivery platform, can lead to significant reductions in child mortality.
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Affiliation(s)
- Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa ; School of Public Health, University of the Western Cape, Cape Town, South Africa ; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Wanga Zembe
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Nobubelo Ngandu
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Mary Kinney
- Saving Newborn Lives/Save the Children, Cape Town, South Africa
| | - Samuel Manda
- Biostatistics Research Unit, South African Medical Research Council, Pretoria, South Africa ; School of Mathematics, Statistics and Computer Science, University of Kwazulu-Natal, Durban, South Africa
| | - Donela Besada
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Debra Jackson
- School of Public Health, University of the Western Cape, Cape Town, South Africa ; UNICEF, United Nations Plaza, New York, NY, USA
| | - Karen Daniels
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sarah Rohde
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Wim van Damme
- School of Public Health, University of the Western Cape, Cape Town, South Africa ; Institute of Tropical Medicine, Antwerp, Belgium
| | - Kate Kerber
- Saving Newborn Lives/Save the Children, Cape Town, South Africa
| | - Emmanuelle Daviaud
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Igor Rudan
- Centre for Global Health Research and Global Health Academy, University of Edinburgh Medical School, Edinburgh, Scotland, UK
| | - Maria Muniz
- UNICEF, United Nations Plaza, New York, NY, USA
| | | | | | - Jon Rohde
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa ; School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - David Sanders
- School of Public Health, University of the Western Cape, Cape Town, South Africa ; School of Child and Adolescent Health, Faculty of Health Sciences, University of Cape Town, Rondebosch, South Africa
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Doctor HV. Assessing Antenatal Care and Newborn Survival in Sub-Saharan Africa within the Context of Renewed Commitments to Save Newborn Lives. AIMS Public Health 2016; 3:432-447. [PMID: 29546174 PMCID: PMC5689808 DOI: 10.3934/publichealth.2016.3.432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/23/2016] [Indexed: 11/18/2022] Open
Abstract
Antenatal care (ANC) is one of the key interventions of the Every Newborn action plan to improve newborn health and prevent stillbirths by 2035. However, little is known about its relationship with neonatal mortality in sub-Saharan Africa since the 1990s. We use data from 54 Demographic and Health Survey (DHS) from 27 countries to make comparisons of neonatal mortality by ANC attendance. Each country had two surveys that were categorized as 'earliest surveys' (i.e. conducted since 1990 but before 2010) and 'latest surveys' (from 2010 to 2014). Multi-level logistic regression model and meta-analysis were applied on 1.1 million births that occurred among women in the 5 years preceding the surveys. Overall neonatal mortality rate (NMR) was 37.7 (95% CI, 37.4-38.1) deaths per 1000 live births; NMR in the earliest surveys were 46.0 (95% CI, 45.4-46.7) and 33.4 (95% CI, 33.0-33.8) deaths per 1000 live births in the latest surveys. The overall NMR was also 10% higher than expected NMR (37.7 vs 34.3 deaths per 1000 live births). NMR was 2.2 times higher among births of women with no ANC compared to those who had at least one ANC visit (42.5 vs 19.6 per 1000 live births). After adjusting for place of delivery, maternal age at birth, relative household wealth, residence, mother's education, marital status, birth order, sex of child, and period of survey, the overall odds ratio (OR) demonstrated that women with at least one ANC visit were 48% less likely to report neonatal deaths (OR: 0.52; 95% CI: 0.47-0.57) than women who did not receive ANC. NMR was 27% less likely to occur during the latest surveys than during the earliest surveys (OR: 0.73; 95% CI: 0.71-0.75). We discuss these results within the context of calls for continued efforts to deploy interventions aimed at improving the quality of maternal and newborn care.
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Affiliation(s)
- Henry V Doctor
- World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, 11371, Egypt
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McConnell M, Ettenger A, Rothschild CW, Muigai F, Cohen J. Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya. BMC Pregnancy Childbirth 2016; 16:136. [PMID: 27260500 PMCID: PMC4893209 DOI: 10.1186/s12884-016-0914-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 05/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since the 2009 WHO and UNICEF recommendation that women receive home-based postnatal care within the first three days after birth, a growing number of low-income countries have explored integrating postnatal home visit interventions into their maternal and newborn health strategies. This randomized trial evaluates a pilot program in which community health workers (CHWs) visit or call new mothers three days after delivery in peri-urban Kiambu County, Kenya. METHODS Participants were individually randomized to one of three groups: 1) early postnatal care three days after delivery provided in-person with a CHW using a simple checklist, 2) care provided by phone with a CHW using the same checklist, or 3) a standard of care group. Surveys were conducted ten days and nine weeks postnatal to measure outcomes related to compliance with referrals, self-reported health problems for mother and baby, care-seeking behaviors, and postnatal knowledge and practices around the recognition of danger signs, feeding, nutrition, infant care and family planning. RESULTS The home visit administration of the checklist increased the likelihood that women recognized postnatal problems for themselves and their babies and increased the likelihood that they sought care to address those problems identified for the child. In both the home visit and mobile phone implementation of the checklist, actions taken for postnatal problems happened earlier, particularly for infants. Knowledge was found to be high across all groups, with limited evidence that the checklist impacted knowledge and postnatal practices around the recognition of danger signs, feeding, nutrition, infant care and family planning. CONCLUSION We find evidence that CHW-administered postnatal checklists can lead to better recognition of postnatal problems and more timely care-seeking. Furthermore, our results suggest that CHWs can affordably deliver many of the benefits of postnatal checklists. TRIAL REGISTRATION ClinicalTrials.gov NCT02104635 ; registered April 2, 2014.
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Affiliation(s)
- Margaret McConnell
- Harvard T. H. Chan School of Public Health, Building 1, Room 1217, 665 Huntington Ave, Boston, MA, 02115, USA.
| | | | | | - Faith Muigai
- Jacaranda Health, P.O. Box 42844 - 00100, Nairobi, Kenya
| | - Jessica Cohen
- Harvard T. H. Chan School of Public Health, Building 1, Room 1217, 665 Huntington Ave, Boston, MA, 02115, USA
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Shiffman J. Network advocacy and the emergence of global attention to newborn survival. Health Policy Plan 2016; 31 Suppl 1:i60-73. [PMID: 26405157 PMCID: PMC4954559 DOI: 10.1093/heapol/czv092] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2015] [Indexed: 12/26/2022] Open
Abstract
Globally 2.9 million babies die each year before reaching 28 days of life. Over the past quarter century, neonatal mortality has declined at a slower pace than post-neonatal under-five mortality: in consequence newborns now comprise 44% of all deaths to children under five years. Despite high numbers of newborn deaths, global organizations and national governments paid little attention to the issue until 2000, and resources, while growing since then, remain inadequate. This study examines the factors behind these patterns of policy attention: the delayed emergence of attention, its sudden appearance in 2000, its growth thereafter, but the dearth of resources to date. Drawing on a framework on global health networks grounded in collective action theory, the study finds that a newborn survival network helped to shift perceptions about the problem's severity and tractability, contributing to the rise of global attention. Its efforts were facilitated by pressure on governments to achieve the child survival Millennium Development Goal and by growing awareness that the neonatal period constituted a growing percentage of under-five mortality, a fact the network publicized. The network's relatively recent emergence, its predominantly technical rather than political composition and strategies, and its inability to date to find a framing of the issue that has convinced national political leaders of the issue's urgency, in part explain the insufficiency of resources. However, since 2010 a number of non-health oriented inter-governmental organizations have begun to pay attention to the issue, and several countries with high neonatal mortality have created national plans, developments which augur well for the future. The study points to two broader implications concerning how neglected global health issues come to attract attention: priority emerges from a confluence of factors, rather than any single cause; and growth in priority may depend on the creation of a broader political coalition that extends beyond the largely technically oriented actors who may first press for attention to a problem.
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Affiliation(s)
- Jeremy Shiffman
- Department of Public Administration and Policy, School of Public Affairs, American University, 4400 Massachusetts Ave., NW, Washington, DC 20016-8070, USA
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Tanzania's countdown to 2015: an analysis of two decades of progress and gaps for reproductive, maternal, newborn, and child health, to inform priorities for post-2015. LANCET GLOBAL HEALTH 2016; 3:e396-409. [PMID: 26087986 DOI: 10.1016/s2214-109x(15)00059-5] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/16/2015] [Accepted: 03/19/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Tanzania is on track to meet Millennium Development Goal (MDG) 4 for child survival, but is making insufficient progress for newborn survival and maternal health (MDG 5) and family planning. To understand this mixed progress and to identify priorities for the post-2015 era, Tanzania was selected as a Countdown to 2015 case study. METHODS We analysed progress made in Tanzania between 1990 and 2014 in maternal, newborn, and child mortality, and unmet need for family planning, in which we used a health systems evaluation framework to assess coverage and equity of interventions along the continuum of care, health systems, policies and investments, while also considering contextual change (eg, economic and educational). We had five objectives, which assessed each level of the health systems evaluation framework. We used the Lives Saved Tool (LiST) and did multiple linear regression analyses to explain the reduction in child mortality in Tanzania. We analysed the reasons for the slower changes in maternal and newborn survival and family planning, to inform priorities to end preventable maternal, newborn, and child deaths by 2030. FINDINGS In the past two decades, Tanzania's population has doubled in size, necessitating a doubling of health and social services to maintain coverage. Total health-care financing also doubled, with donor funding for child health and HIV/AIDS more than tripling. Trends along the continuum of care varied, with preventive child health services reaching high coverage (≥85%) and equity (socioeconomic status difference 13-14%), but lower coverage and wider inequities for child curative services (71% coverage, socioeconomic status difference 36%), facility delivery (52% coverage, socioeconomic status difference 56%), and family planning (46% coverage, socioeconomic status difference 22%). The LiST analysis suggested that around 39% of child mortality reduction was linked to increases in coverage of interventions, especially of immunisation and insecticide-treated bednets. Economic growth was also associated with reductions in child mortality. Child health programmes focused on selected high-impact interventions at lower levels of the health system (eg, the community and dispensary levels). Despite its high priority, implementation of maternal health care has been intermittent. Newborn survival has gained attention only since 2005, but high-impact interventions are already being implemented. Family planning had consistent policies but only recent reinvestment in implementation. INTERPRETATION Mixed progress in reproductive, maternal, newborn, and child health in Tanzania indicates a complex interplay of political prioritisation, health financing, and consistent implementation. Post-2015 priorities for Tanzania should focus on the unmet need for family planning, especially in the Western and Lake regions; addressing gaps for coverage and quality of care at birth, especially in rural areas; and continuation of progress for child health. FUNDING Government of Canada, Foreign Affairs, Trade, and Development; US Fund for UNICEF; and the Bill & Melinda Gates Foundation.
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Zembe-Mkabile WZ, Jackson D, Sanders D, Besada D, Daniels K, Zamasiya T, Doherty T. The 'community' in community case management of childhood illnesses in Malawi. Glob Health Action 2016; 9:29177. [PMID: 26823049 PMCID: PMC4731424 DOI: 10.3402/gha.v9.29177] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 12/04/2015] [Accepted: 12/07/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Malawi has achieved a remarkable feat in reducing its under-5 mortality in time to meet its MDG 4 target despite high levels of poverty, low female literacy rates, recurrent economic crises, a severe shortage of human resources for health, and poor health infrastructure. The country's community-based delivery platform (largely headed by Health Surveillance Assistants, or HSAs) has been well established since the 1960s, although their tasks and responsibilities have evolved from surveillance to health promotion and prevention, and more recently to include curative services. However, the role of and the form that community involvement takes in community-based service delivery in Malawi is unclear. DESIGN A qualitative rapid appraisal approach was utilised to explore the role of community involvement in the HSA programme in Malawi to better understand how the various community providers intersect to support the delivery of integrated community case management by HSAs. Twelve focus group discussions and 10 individual interviews were conducted with HSAs, HSA supervisors, mothers, members of village health committees (VHCs), senior Ministry of Health officials, district health teams, and implementing partners. RESULTS Our findings reveal that HSAs are often deployed to areas outside of their village of residence as communities are not involved in selecting their own HSAs in Malawi. Despite this lack of involvement in selection, the high acceptance of the HSAs by community members and community accountability structures such as VHCs provide the programme with legitimacy and credibility. CONCLUSIONS This study provides insight into how community involvement plays out in the context of a government-managed professionalised community service delivery platform. It points to the need for further research to look at the impact of removing the role of HSA selection and deployment from the community and placing it at the central level.
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Affiliation(s)
- Wanga Z Zembe-Mkabile
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa;
| | - Debra Jackson
- School of Public Health, University of the Western Cape, Bellville, South Africa.,Knowledge Management & Implementation Research Unit, UNICEF, New York, USA
| | - David Sanders
- School of Public Health, University of the Western Cape, Bellville, South Africa.,School of Child and Adolescent Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Donela Besada
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Karen Daniels
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health, University of the Western Cape, Bellville, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Kanyuka M, Ndawala J, Mleme T, Chisesa L, Makwemba M, Amouzou A, Borghi J, Daire J, Ferrabee R, Hazel E, Heidkamp R, Hill K, Martínez Álvarez M, Mgalula L, Munthali S, Nambiar B, Nsona H, Park L, Walker N, Daelmans B, Bryce J, Colbourn T. Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study. LANCET GLOBAL HEALTH 2016; 4:e201-14. [PMID: 26805586 DOI: 10.1016/s2214-109x(15)00294-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 11/26/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Several years in advance of the 2015 endpoint for the Millennium Development Goals (MDGs), Malawi was already thought to be one of the few countries in sub-Saharan Africa likely to meet the MDG 4 target of reducing under-5 mortality by two-thirds between 1990 and 2015. Countdown to 2015 therefore selected the Malawi National Statistical Office to lead an in-depth country case study, aimed mainly at explaining the country's success in improving child survival. METHODS We estimated child and neonatal mortality for the years 2000-14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. We documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing. FINDINGS The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths (90% CI 234-262) per 1000 livebirths in 1990 to 71 deaths (58-83) in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1-59 months age group; neonatal mortality declined more slowly (from 50 to 23 deaths per 1000 livebirths), representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators have increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280,000 children's lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The amount of funding allocated to the health sector has increased substantially, particularly to child health and HIV and from external sources, but remains below internationally agreed targets. Key policies to address the major causes of child mortality and deliver high-impact interventions at scale throughout Malawi began in the late 1990s and intensified in the latter half of the 2000s and into the 2010s, backed by health-sector-wide policies to improve women's and children's health. INTERPRETATION This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. Our findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth. The Government of Malawi was among the first in sub-Saharan Africa to adopt evidence-based policies and implement programmes at scale to prevent unnecessary child deaths. Much remains to be done, building on this success and extending it to higher proportions of the population and targeting continued high neonatal mortality rates. FUNDING Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.
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Affiliation(s)
| | | | - Tiope Mleme
- Malawi National Statistics Office, Zomba, Malawi
| | | | | | | | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Rufus Ferrabee
- University College London, Institute for Global Health, London, UK; Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Elizabeth Hazel
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rebecca Heidkamp
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kenneth Hill
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Melisa Martínez Álvarez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Leslie Mgalula
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Spy Munthali
- Chancellor College, University of Malawi, Zomba, Malawi
| | - Bejoy Nambiar
- University College London, Institute for Global Health, London, UK
| | | | - Lois Park
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Neff Walker
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bernadette Daelmans
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Jennifer Bryce
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tim Colbourn
- University College London, Institute for Global Health, London, UK.
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Joos O, Silva R, Amouzou A, Moulton LH, Perin J, Bryce J, Mullany LC. Evaluation of a mHealth Data Quality Intervention to Improve Documentation of Pregnancy Outcomes by Health Surveillance Assistants in Malawi: A Cluster Randomized Trial. PLoS One 2016; 11:e0145238. [PMID: 26731401 PMCID: PMC4701446 DOI: 10.1371/journal.pone.0145238] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/30/2015] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND While community health workers are being recognized as an integral work force with growing responsibilities, increased demands can potentially affect motivation and performance. The ubiquity of mobile phones, even in hard-to-reach communities, has facilitated the pursuit of novel approaches to support community health workers beyond traditional modes of supervision, job aids, in-service training, and material compensation. We tested whether supportive short message services (SMS) could improve reporting of pregnancies and pregnancy outcomes among community health workers (Health Surveillance Assistants, or HSAs) in Malawi. METHODS AND FINDINGS We designed a set of one-way SMS that were sent to HSAs on a regular basis during a 12-month period. We tested the effectiveness of the cluster-randomized intervention in improving the complete documentation of a pregnancy. We defined complete documentation as a pregnancy for which a specific outcome was recorded. HSAs in the treatment group received motivational and data quality SMS. HSAs in the control group received only motivational SMS. During baseline and intervention periods, we matched reported pregnancies to reported outcomes to determine if reporting of matched pregnancies differed between groups and by period. The trial is registered as ISCTRN24785657. CONCLUSIONS Study results show that the mHealth intervention improved the documentation of matched pregnancies in both the treatment (OR 1.31, 95% CI: 1.10-1.55, p<0.01) and control (OR 1.46, 95% CI: 1.11-1.91, p = 0.01) groups relative to the baseline period, despite differences in SMS content between groups. The results should be interpreted with caution given that the study was underpowered. We did not find a statistically significant difference in matched pregnancy documentation between groups during the intervention period (OR 0.94, 95% CI: 0.63-1.38, p = 0.74). mHealth applications have the potential to improve the tracking and data quality of pregnancies and pregnancy outcomes, particularly in low-resource settings.
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Affiliation(s)
- Olga Joos
- Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Romesh Silva
- Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Statistics Division, Economic and Social Commission for Western Asia, United Nations, Beirut, Lebanon
| | - Agbessi Amouzou
- Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- UNICEF, New York, New York, United States of America
| | - Lawrence H. Moulton
- Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jamie Perin
- Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jennifer Bryce
- Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Luke C. Mullany
- International Center for Maternal and Neonatal Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Moxon SG, Lawn JE, Dickson KE, Simen-Kapeu A, Gupta G, Deorari A, Singhal N, New K, Kenner C, Bhutani V, Kumar R, Molyneux E, Blencowe H. Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth 2015; 15 Suppl 2:S7. [PMID: 26391335 PMCID: PMC4577807 DOI: 10.1186/1471-2393-15-s2-s7] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Preterm birth is the leading cause of child death worldwide. Small and sick newborns require timely, high-quality inpatient care to survive. This includes provision of warmth, feeding support, safe oxygen therapy and effective phototherapy with prevention and treatment of infections. Inpatient care for newborns requires dedicated ward space, staffed by health workers with specialist training and skills. Many of the estimated 2.8 million newborns that die every year do not have access to such specialised care. METHODS The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" (or factors that hinder the scale up) of maternal-newborn intervention packages. For this paper, we used quantitative and qualitative methods to analyse the bottleneck data, and combined these with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for inpatient care of small and sick newborns. RESULTS Inpatient care of small and sick newborns is an intervention package highlighted by all country workshop participants as having critical health system challenges. Health system building blocks with the highest graded (significant or major) bottlenecks were health workforce (10 out of 12 countries) and health financing (10 out of 12 countries), followed by community ownership and partnership (9 out of 12 countries). Priority actions based on solution themes for these bottlenecks are discussed. CONCLUSIONS Whilst major bottlenecks to the scale-up of quality inpatient newborn care are present, effective solutions exist. For all countries included, there is a critical need for a neonatal nursing cadre. Small and sick newborns require increased, sustained funding with specific insurance schemes to cover inpatient care and avoid catastrophic out-of-pocket payments. Core competencies, by level of care, should be defined for monitoring of newborn inpatient care, as with emergency obstetric care. Rather than fatalism that small and sick newborns will die, community interventions need to create demand for accessible, high-quality, family-centred inpatient care, including kangaroo mother care, so that every newborn can survive and thrive.
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Affiliation(s)
- Sarah G Moxon
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Saving Newborn Lives, Save the Children, Washington DC, 20036, USA
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Saving Newborn Lives, Save the Children, Washington DC, 20036, USA
| | - Kim E Dickson
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, 10017, NY, USA
| | - Aline Simen-Kapeu
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, 10017, NY, USA
| | - Gagan Gupta
- UNICEF, India 73, Lodi Estate New Delhi, 110 003, India
| | - Ashok Deorari
- Department of Pediatrics, WHO Collaborating Centre for Education & Research in Newborn Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Nalini Singhal
- University of Calgary, 2888, Shaganappi Trail NW, Calgary, Alberta, T3B 6C8, Canada
| | - Karen New
- The University of Queensland, Brisbane, Qld, 4029, Australia
| | - Carole Kenner
- Council of International Neonatal Nurses, Dean of School of Nursing, Health and Exercise Science, The College of New Jersey, Ewing, NJ, 08628-0718, USA
| | - Vinod Bhutani
- Stanford University School of Medicine, 291 Campus Drive, Li Ka Shing Building, Stanford, CA, 94305-5101, USA
| | - Rakesh Kumar
- India Ministry of Health & Family Welfare, Government of India, Nirman Bhawan, New Delhi, 110108, India
| | | | - Hannah Blencowe
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Saving Newborn Lives, Save the Children, Washington DC, 20036, USA
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Vesel L, Bergh AM, Kerber KJ, Valsangkar B, Mazia G, Moxon SG, Blencowe H, Darmstadt GL, de Graft Johnson J, Dickson KE, Ruiz Peláez JG, von Xylander SR, Lawn JE. Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth 2015; 15 Suppl 2:S5. [PMID: 26391115 PMCID: PMC4577801 DOI: 10.1186/1471-2393-15-s2-s5] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up. METHODS The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC. RESULTS Marked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks. CONCLUSIONS There are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.
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Affiliation(s)
- Linda Vesel
- Innovations for Maternal, Newborn and Child Health, Concern Worldwide US, 355 Lexington Avenue, New York, NY 10017, USA
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY 10017, USA
| | - Anne-Marie Bergh
- MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria, Private Bag X323, Arcadia 0007, Pretoria, South Africa
| | - Kate J Kerber
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
| | - Bina Valsangkar
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
| | - Goldy Mazia
- USAID's Maternal and Child Survival Program, 455 Massachusetts Avenue NW, Suite 1000, Washington, DC 20001, USA
| | - Sarah G Moxon
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Hannah Blencowe
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Joseph de Graft Johnson
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
- USAID's Maternal and Child Survival Program, 455 Massachusetts Avenue NW, Suite 1000, Washington, DC 20001, USA
| | - Kim E Dickson
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY 10017, USA
| | - Juan Gabriel Ruiz Peláez
- School of Medicine, Pontificia Universidad Javeriana, Carrera 7 No 40-62, Bogotá, Colombia
- Fundación Canguro, Calle 56A No 50-36 - Bloque A13, Apto 416, Pablo VI Azul, Bogotá, Colombia
- Hospital Universitario San Ignacio, Carrera 7 No 40-62, Bogotá, Colombia
| | - Severin Ritter von Xylander
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
| | - Joy E Lawn
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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Sitrin D, Guenther T, Waiswa P, Namutamba S, Namazzi G, Sharma S, Ashish KC, Rubayet S, Bhadra S, Ligowe R, Chimbalanga E, Sewell E, Kerber K, Moran A. Improving newborn care practices through home visits: lessons from Malawi, Nepal, Bangladesh, and Uganda. Glob Health Action 2015; 8:23963. [PMID: 25843490 PMCID: PMC4385207 DOI: 10.3402/gha.v8.23963] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 09/08/2014] [Accepted: 10/08/2014] [Indexed: 11/14/2022] Open
Abstract
Background Nearly all newborn deaths occur in low- or middle-income countries. Many of these deaths could be prevented through promotion and provision of newborn care practices such as thermal care, early and exclusive breastfeeding, and hygienic cord care. Home visit programmes promoting these practices were piloted in Malawi, Nepal, Bangladesh, and Uganda. Objective This study assessed changes in selected newborn care practices over time in pilot programme areas in four countries and evaluated whether women who received home visits during pregnancy were more likely to report use of three key practices. Design Using data from cross-sectional surveys of women with live births at baseline and endline, the Pearson chi-squared test was used to assess changes over time. Generalised linear models were used to assess the relationship between the main independent variable – home visit from a community health worker (CHW) during pregnancy (0, 1–2, 3+) – and use of selected practices while controlling for antenatal care, place of delivery, and maternal age and education. Results There were statistically significant improvements in practices, except applying nothing to the cord in Malawi and early initiation of breastfeeding in Bangladesh. In Malawi, Nepal, and Bangladesh, women who were visited by a CHW three or more times during pregnancy were more likely to report use of selected practices. Women who delivered in a facility were also more likely to report use of selected practices in Malawi, Nepal, and Uganda; association with place of birth was not examined in Bangladesh because only women who delivered outside a facility were asked about these practices. Conclusion Home visits can play a role in improving practices in different settings. Multiple interactions are needed, so programmes need to investigate the most appropriate and efficient ways to reach families and promote newborn care practices. Meanwhile, programmes must take advantage of increasing facility delivery rates to ensure that all babies benefit from these practices.
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Affiliation(s)
| | | | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Sarah Namutamba
- School of Public Health, Makerere University, Kampala, Uganda
| | | | | | | | | | - Subrata Bhadra
- National Institute of Population Research and Training, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | | | | | - Elizabeth Sewell
- Department of Neonatology, Children's National Medical Center, Washington, DC, USA
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Kerber K, Peterson S, Waiswa P. Special issue: newborn health in Uganda. Glob Health Action 2015; 8:27574. [PMID: 25843501 PMCID: PMC4385224 DOI: 10.3402/gha.v8.27574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Stefan Peterson
- Makerere University, Kampala, Uganda
- Karolinska Institutet, Stockholm, Sweden
- Uppsala University, Uppsala, Sweden
- Iganga/Mayuge Health Demographic Surveillance Site, Kampala, Uganda
| | - Peter Waiswa
- Makerere University, Kampala, Uganda
- Karolinska Institutet, Stockholm, Sweden
- Iganga/Mayuge Health Demographic Surveillance Site, Kampala, Uganda
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Colbourn T, Pulkki-Brännström AM, Nambiar B, Kim S, Bondo A, Banda L, Makwenda C, Batura N, Haghparast-Bidgoli H, Hunter R, Costello A, Baio G, Skordis-Worrall J. Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2015; 13:1. [PMID: 25649323 PMCID: PMC4299571 DOI: 10.1186/s12962-014-0028-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/18/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale. METHODS Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $. RESULTS The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi. CONCLUSIONS Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.
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Affiliation(s)
- Tim Colbourn
- />UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
| | - Anni-Maria Pulkki-Brännström
- />UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
- />Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden
| | - Bejoy Nambiar
- />UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
| | - Sungwook Kim
- />UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
| | - Austin Bondo
- />Parent and Child Health Initiative (PACHI), Amina House, Western Wing – Second Floor, Capital City, P.O. Box 31686, Lilongwe 3, Malawi
| | - Lumbani Banda
- />Parent and Child Health Initiative (PACHI), Amina House, Western Wing – Second Floor, Capital City, P.O. Box 31686, Lilongwe 3, Malawi
| | - Charles Makwenda
- />Parent and Child Health Initiative (PACHI), Amina House, Western Wing – Second Floor, Capital City, P.O. Box 31686, Lilongwe 3, Malawi
| | - Neha Batura
- />UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
| | | | - Rachael Hunter
- />Research Department of Primary Care & Population Health, UCL Priment Clinical Trials Unit, Royal Free Campus, London, NW3 2PF UK
| | - Anthony Costello
- />UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
| | - Gianluca Baio
- />Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
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Posttraumatic stress symptoms in mothers of preterm infants. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2015. [DOI: 10.1016/j.ijans.2015.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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48
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Perceptions and experiences of community members on caring for preterm newborns in rural Mangochi, Malawi: a qualitative study. BMC Pregnancy Childbirth 2014; 14:399. [PMID: 25444374 PMCID: PMC4264332 DOI: 10.1186/s12884-014-0399-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 11/19/2014] [Indexed: 11/16/2022] Open
Abstract
Background The number of preterm birth is increasing worldwide, especially in low income countries. Malawi has the highest incidence of preterm birth in the world, currently estimated at 18.1 percent. The aim of this study was to explore the perceived causes of preterm birth, care practices for preterm newborn babies and challenges associated with preterm birth among community members in Mangochi District, southern Malawi. Methods We conducted 14 focus group discussions with the following groups of participants: mothers (n = 4), fathers (n = 6) and grandmothers (n = 4) for 110 participants. We conducted 20 IDIs with mothers to preterm newborns (n = 10), TBAs (n = 6) and traditional healers (n = 4). A discussion guide was used to facilitate the focus group and in-depth interview sessions. Data collection took place between October 2012 and January 2013. We used content analysis to analyze data. Results Participants mentioned a number of perceptions of preterm birth and these included young and old maternal age, heredity, sexual impurity and maternal illness during pregnancy. Provision of warmth was the most commonly reported component of care for preterm newborns. Participants reported several challenges to caring for preterm newborns such as lack of knowledge on how to provide care, poverty, and the high time burden of care leading to neglect of household, farming and business duties. Women had the main responsibility for caring for preterm newborns. Conclusion In this community, the reported poor care practices for preterm newborns were associated with poverty and lack of knowledge of how to properly care for these babies at home. Action is needed to address the current care practices for preterm babies among the community members.
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Singh K, Brodish P, Suchindran C. A regional multilevel analysis: can skilled birth attendants uniformly decrease neonatal mortality? Matern Child Health J 2014; 18:242-249. [PMID: 23504132 DOI: 10.1007/s10995-013-1260-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Globally 40 % of deaths to children under-five occur in the very first month of life with three-quarters of these deaths occurring during the first week of life. The promotion of delivery with a skilled birth attendant (SBA) is being promoted as a strategy to reduce neonatal mortality. This study explored whether SBAs had a protective effect against neonatal mortality in three different regions of the world. The analysis pooled data from nine diverse countries for which recent Demographic and Health Survey data were available. Multilevel logistic regression was used to understand the influence of skilled delivery on two outcomes-neonatal mortality during the first week of life and during the first day of life. Control variables included age, parity, education, wealth, residence (urban/rural), geographic region (Africa, Asia and Latin America/Caribbean), antenatal care and tetanus immunization. The direction of the effect of skilled delivery on neonatal mortality was dependent on geographic region. While having a SBA at delivery was protective against neonatal mortality in Latin America/Caribbean, in Asia there was only a protective effect for births in the first week of life. In Africa SBAs were associated with higher neonatal mortality for both outcomes, and the same was true for deaths on the first day of life in Asia. Many women in Africa and Asia deliver at home unless a complication occurs, and thus skilled birth attendants may be seeing more women with complications than their unskilled counterparts. In addition there are issues with the definition of a SBA with many attendants in both Africa and Asia not actually having the needed training and equipment to prevent neonatal mortality. Considerable investment is needed in terms of training and health infrastructure to enable these providers to save the youngest lives.
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Affiliation(s)
- Kavita Singh
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, CB# 8120, Chapel Hill, NC, 27516, USA. .,MEASURE Evaluation/Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul Brodish
- MEASURE Evaluation/Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chirayath Suchindran
- MEASURE Evaluation/Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Dickson KE, Simen-Kapeu A, Kinney MV, Huicho L, Vesel L, Lackritz E, de Graft Johnson J, von Xylander S, Rafique N, Sylla M, Mwansambo C, Daelmans B, Lawn JE. Every Newborn: health-systems bottlenecks and strategies to accelerate scale-up in countries. Lancet 2014; 384:438-54. [PMID: 24853600 DOI: 10.1016/s0140-6736(14)60582-1] [Citation(s) in RCA: 231] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Universal coverage of essential interventions would reduce neonatal deaths by an estimated 71%, benefit women and children after the first month, and reduce stillbirths. However, the packages with the greatest effect (care around birth, care of small and ill newborn babies), have low and inequitable coverage and are the most sensitive markers of health system function. In eight of the 13 countries with the most neonatal deaths (55% worldwide), we undertook a systematic assessment of bottlenecks to essential maternal and newborn health care, involving more than 600 experts. Of 2465 bottlenecks identified, common constraints were found in all high-burden countries, notably regarding the health workforce, financing, and service delivery. However, bottlenecks for specific interventions might differ across similar health systems. For example, the implementation of kangaroo mother care was noted as challenging in the four Asian country workshops, but was regarded as a feasible aspect of preterm care by respondents in the four African countries. If all high-burden countries achieved the neonatal mortality rates of their region's fastest progressing countries, then the mortality goal of ten or fewer per 1000 livebirths by 2035 recommended in this Series and the Every Newborn Action Plan would be exceeded. We therefore examined fast progressing countries to identify strategies to reduce neonatal mortality. We identified several key factors: (1) workforce planning to increase numbers and upgrade specific skills for care at birth and of small and ill newborn babies, task sharing, incentives for rural health workers; (2) financial protection measures, such as expansion of health insurance, conditional cash transfers, and performance-based financing; and (3) dynamic leadership including innovation and community empowerment. Adapting from the 2005 Lancet Series on neonatal survival and drawing on this Every Newborn Series, we propose a country-led, data-driven process to sharpen national health plans, seize opportunities to address the quality gap for care at birth and care of small and ill newborn babies, and systematically scale up care to reach every mother and newborn baby, particularly the poorest.
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Affiliation(s)
| | | | - Mary V Kinney
- Saving Newborn Lives, Save the Children, Cape Town, South Africa
| | - Luis Huicho
- Universidad Peruana Cayetano Heredia, Universidad Nacional Mayor de San Marcos and Instituto Nacional de Salud del Niño, Lima, Peru
| | | | - Eve Lackritz
- Global Alliance for Preventing Prematurity and Stillbirths, Seattle, WA, USA
| | | | - Severin von Xylander
- Maternal, Child and Adolescent Health Department, World Health Organization, Geneva, Switzerland
| | | | - Mariame Sylla
- UNICEF, West and Central Africa Regional Office, Dakar, Senegal
| | | | - Bernadette Daelmans
- Maternal, Child and Adolescent Health Department, World Health Organization, Geneva, Switzerland
| | - Joy E Lawn
- Saving Newborn Lives, Save the Children, Cape Town, South Africa; Centre for Maternal Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK
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