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Minani P, Ross A. Strengthening caesarean birth: Sub-Saharan Africa health system evaluation: Scoping review. Afr J Prim Health Care Fam Med 2024; 16:e1-e11. [PMID: 38708736 PMCID: PMC11079335 DOI: 10.4102/phcfm.v16i1.4128] [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: 04/18/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Promoting safe caesarean birth (CB) is a challenge in sub-Saharan Africa (SSA) where maternal and neonatal mortality rates are high due to inadequate maternal health services. Although the CB rate in SSA is lower than the World Health Organization (WHO) recommendation, it is often associated with high maternal and neonatal mortality. AIM The aim of this scoping review was to report on the extent to which SSA health systems deliver safe CB. METHODS A systematic search across various databases identified 53 relevant studies, comprising 30 quantitative, 10 qualitative and 16 mixed methods studies. RESULTS These studies focused on clinical protocols, training, availability, accreditation, staff credentialing, hospital supervision, support infrastructure, risk factors, surgical interventions and complications related to maternal mortality and stillbirth. CB rates in SSA varied significantly, ranging from less than 1% to a high rate of 29.7%. Both very low as well as high rates contributed to significant maternal and neonatal morbidity. Factors influencing maternal and perinatal mortality include poor referral systems, inadequate healthcare facilities, poor quality of CBs, inequalities in access to maternity care and affordable CB intervention. CONCLUSION The inadequate distribution of healthcare facilities, and limited access to emergency obstetric care impacted the quality of CBs. Early access to quality maternity services with skilled providers is recommended to improve CB safety.Contributions: This scoping review contributes to the body of knowledge motivating for the prioritization of maternal service across SSA.
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Affiliation(s)
- Patrick Minani
- Department of Public Health Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban.
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Weerasingha TK, Ratnayake C, Abeyrathne R, Tennakoon SU. Evidence-based intrapartum care during vaginal births: Direct observations in a tertiary care hospital in Central Sri Lanka. Heliyon 2024; 10:e28517. [PMID: 38571647 PMCID: PMC10988013 DOI: 10.1016/j.heliyon.2024.e28517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/05/2024] Open
Abstract
Background Evidence-based practice (EBP) is an effective approach to improve maternal and newborn outcomes at birth. Objective This study aimed to assess the current intrapartum practices of a tertiary care hospital in Central Province, Sri Lanka, during vaginal births. The benchmark for this assessment was the World Health Organisation's (WHO) recommendations on intrapartum care for a positive childbirth experience. Methods An observational study was conducted at the delivery room of Teaching Hospital, Peradeniya with the participation of 196 labouring women who were selected using systematic random sampling. A non-participant observation checklist covering labour room admission procedures, management of the first, second, and third stages of labour, and immediate care of the newborn and postpartum mother was used for the data collection. The care interventions implemented throughout labour and childbirth were observed and recorded. The data analysis was done using SPSS version 22. Results WHO-recommended practices such as providing privacy (33.2%), offering oral fluids (39.3%), and opioids for pain relief (48.5%) were found to be infrequent. Encouraging correct pushing techniques (77.6%), early breastfeeding (83.2%), regular assessment of vaginal bleeding (91.3%), skin-to-skin contact (93.4%), and using prophylactic uterotonics (100.0%) were found to be frequent. However, labour companionship, use of upright positions during labour, women's choice of birth position, and use of manual or relaxation techniques for pain relief were not observed in hospital intrapartum care. Conclusion The findings of the study indicate that additional attention and monitoring are required to align the current intrapartum care practices with the WHO recommendations. Moreover, the adoption of evidence-based intrapartum care should be encouraged by conveying the standard evidence-based intrapartum care guidelines to the grassroots level healthcare workers to avoid intrapartum interventions.
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Affiliation(s)
| | - Chathura Ratnayake
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Peradeniya, Sri Lanka
| | - R.M. Abeyrathne
- Department of Sociology, Faculty of Arts, University of Peradeniya, Sri Lanka
| | - Sampath U.B. Tennakoon
- Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
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Muwema M, Nankabirwa JI, Edwards G, Nalwadda G, Nangendo J, Okiring J, Obeng-Amoako GO, Mwanja W, Ekong EN, Kalyango JN, Kaye DK. Perinatal care and its association with perinatal death among women attending care in three district hospitals of western Uganda. BMC Pregnancy Childbirth 2024; 24:113. [PMID: 38321398 PMCID: PMC10845583 DOI: 10.1186/s12884-024-06305-5] [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: 02/11/2023] [Accepted: 01/29/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Provision of effective care to all women and newborns during the perinatal period is a viable strategy for achieving the Sustainable Development Goal 3 targets on reducing maternal and neonatal mortality. This study examined perinatal care (antenatal, intrapartum, postpartum) and its association with perinatal deaths at three district hospitals in Bunyoro region, Uganda. METHODS A cross-sectional study was conducted in which a questionnaire was administered consecutively to 872 postpartum women before discharge who had attended antenatal care and given birth in the study hospitals. Data on care received during antenatal, labour, delivery, and postpartum period, and perinatal outcome were extracted from medical records of the enrolled postnatal women using a pre-tested structured tool. The care received from antenatal to 24 h postpartum period was assessed against the standard protocol of care established by World Health Organization (WHO). Poisson regression was used to assess the association between care received and perinatal death. RESULTS The mean age of the women was 25 years (standard deviation [SD] 5.95). Few women had their blood tested for hemoglobin levels, HIV, and Syphilis (n = 53, 6.1%); had their urine tested for glucose and proteins (n = 27, 3.1%); undertook an ultrasound scan (n = 262, 30%); and had their maternal status assessed (n = 122, 14%) during antenatal care as well as had their uterus assessed for contraction and bleeding during postpartum care (n = 63, 7.2%). There were 19 perinatal deaths, giving a perinatal mortality rate of 22/1,000 births (95% Confidence interval [CI] 8.1-35.5). Of these 9 (47.4%) were stillbirths while the remaining 10 (52.6%) were early neonatal deaths. In the antenatal phase, only fetal examination was significantly associated with perinatal death (adjusted prevalence ratio [aPR] = 0.22, 95% CI 0.1-0.6). No significant association was found between perinatal deaths and care during labour, delivery, and the early postpartum period. CONCLUSION Women did not receive all the required perinatal care during the perinatal period. Perinatal mortality rate in Bunyoro region remains high, although it's lower than the national average. The study shows a reduction in the proportion of perinatal deaths for pregnancies where the mother received fetal monitoring. Strategies focused on strengthened fetal status monitoring such as fetal movement counting methods and fetal heart rate monitoring devices during pregnancy need to be devised to reduce the incidence of perinatal deaths. Findings from the study provide valuable information that would support the strengthening of perinatal care services for improved perinatal outcomes.
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Affiliation(s)
- Mercy Muwema
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Joaniter I Nankabirwa
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Grace Edwards
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda
| | - Gorrette Nalwadda
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joanita Nangendo
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gloria Odei Obeng-Amoako
- Department of Nutrition and Food Science, School of Biological Sciences, College of Basic and Applied Sciences, University of Ghana, Legon, Ghana
| | | | - Elizabeth N Ekong
- Department of Nursing and Midwifery, Faculty of Public Health, Nursing and Midwifery, Uganda Christian University, Mukono, Uganda
| | - Joan N Kalyango
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Pharmacy, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Dan K Kaye
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Razakamanana MV, Andrianatoandro VT, Ramiandrisoa TO. Do public health expenditures affect maternal and child health in Madagascar? HEALTH ECONOMICS REVIEW 2023; 13:47. [PMID: 37851126 PMCID: PMC10583307 DOI: 10.1186/s13561-023-00462-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/07/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Previous studies have argued that the relationship between health expenditures and health outcomes is more significant among the poor than the non-poor. However, public spending alone does not improve health status. Quality of governance is considered not only as an important determinant of health outcomes but also of the efficiency of public expenditure on health. In low-income countries, barriers to quality service provision can be observed, which may explain the effects of health expenditures. Therefore, this paper aims to identify the relationship between health expenditures and maternal and child mortality in Madagascar and the potential bottlenecks in the flow of funds for maternal and child health. METHODS Using panel data, fixed and random effect models for the 22 regions of Madagascar over the period 2010 to 2017 were used. Then bottlenecks related to the flow of funds for maternal and child health were identified. RESULTS The results reveal that, on the one hand, funding for maternal health, mainly constituted by equipment endowments for health facilities, significantly contributes to the improvement of maternal health (-0.35; p-value = 0.00). On the other hand, child health financing, often realized through transfers of funds to the health system, does not affect children's health (0.22; p-value = 0.88). The bottleneck analysis illustrates that the transferred funds can suffer from delay or misappropriation and only few parts reach beneficiaries. CONCLUSIONS Equipment endowments contributed more to health improvement and would be more effective than monetary financing.
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Affiliation(s)
- Marilys Victoire Razakamanana
- Centre de Recherche pour le Développement (CRD), Université Catholique de Madagascar Ambatoroka, Catholic University of Madagascar, Antananarivo 101, Ambatoroka, BP, 6059, Madagascar.
| | | | - Tiarinisaina Olivier Ramiandrisoa
- Centre de Recherche pour le Développement (CRD), Université Catholique de Madagascar Ambatoroka, Catholic University of Madagascar, Antananarivo 101, Ambatoroka, BP, 6059, Madagascar
- Centre d'Etudes Economiques (CEE), Université d'Antananarivo, Ambohitsaina , Antananarivo, Madagascar
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Pavalagantharajah S, Negrin AR, Bouzanis K, Joan Lee TS, Miller P, Jones R, Sinnott W, Alvarez E. Facility-Based Maternal Quality of Care Frameworks: A Systematic Review and Best Fit Framework Analysis. Matern Child Health J 2023; 27:1742-1753. [PMID: 37418097 DOI: 10.1007/s10995-023-03702-8] [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] [Accepted: 05/20/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVES The World Health Organization has adopted two main strategies to improve the quality of maternal health: increasing the number of deliveries by skilled birth attendants and increasing access to emergency obstetric care. Despite increased access to care, there continue to be high rates of maternal morbidity and mortality in part due to quality of care. This study aims to identify and summarize existing frameworks for measuring quality of maternal care at a facility-level. METHODS PubMed, Health Systems Evidence, Embase, Global Health, OVID Healthstar, OVID Medline, PsycINFO, and Web of Science were searched for frameworks, tools, theories, or components of frameworks relevant to maternal quality of care in facility-level settings. Title/abstract and full-text screening were completed by two independent reviewers and conflicts resolved through consensus or a third reviewer. RESULTS An initial search resulted in 3182 studies. Fifty-four studies were included in the qualitative analysis. A best fit framework analysis was done using the updated Hulton framework as the conceptual framework. A facility-based maternal quality of care framework is proposed including the following components, separated into provision and experience of care: (1) human resources; (2) infrastructure; (3) equipment, supplies and medicine; (4) evidence and information; (5) referral and networks of care; (6) cultural competence; (7) clinical practice; (8) financing; (9) leadership and governance; (10) cognition; and 11) respect, dignity, equity, and emotional support.
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Affiliation(s)
| | | | - Katrina Bouzanis
- Department of Global Health, McMaster University, Hamilton, ON, Canada
| | - Tin-Suet Joan Lee
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Peter Miller
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Rebecca Jones
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - Will Sinnott
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Elizabeth Alvarez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
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Tesfa A, Nakidde C, Akter K, Khatun F, Mwandira K, Lemma S, Seruwagi G, Mwaba K, English M, Daniels-Howell C, Djellouli N, Colbourn T, Marchant T. Individual, organizational and system circumstances, and the functioning of a multi-country implementation-focused network for maternal, newborn and child health: Bangladesh, Ethiopia, Malawi, and Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002115. [PMID: 37428713 DOI: 10.1371/journal.pgph.0002115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/02/2023] [Indexed: 07/12/2023]
Abstract
Better policies, investments, and programs are needed to improve the integration and quality of maternal, newborn, and child health services. Previously, partnerships and collaborations that involved multiple countries with a unified aim have been observed to yield positive results. Since 2017, the WHO and partners have hosted the Quality of Care Network [QCN], a multi-country implementation network focused on improving maternal, neonatal, and child health care. In this paper, we examine the functionality of QCN in different contexts. We focus on implementation circumstances and contexts in four network countries: Bangladesh, Ethiopia, Malawi, and Uganda. In each country, the study was conducted over several consecutive rounds between 2019-2022, employing 227 key informant interviews with major stakeholders and members of the network countries, and 42 facility observations. The collected data were coded using Nvivo-12 software and categorized thematically. The study showed that individual, organizational and system-level circumstances all played an important role in shaping implementation success in network countries, but that these levels were inter-linked. Systems that enabled leadership, motivated and trained staff, and created a positive culture of data use were critical for policy-making including addressing financing issues-to the day-to-day practice improvement at the front line. Some characteristics of QCN actively supported this, for example, shared learning forums for continuous learning, a focus on data and tracking progress, and emphasising the importance of coordinated efforts towards a common goal. However, inadequate system financing and capacity also hampered network functioning, especially in the face of external shocks.
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Affiliation(s)
- Anene Tesfa
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | - Kohenour Akter
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Fatama Khatun
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Seblewengel Lemma
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Gloria Seruwagi
- School of Public Health, Makerere University, Kampala, Uganda
| | - Kasonde Mwaba
- Institute for Global Health, University College, London, United Kingdom
| | - Mike English
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Nehla Djellouli
- Institute for Global Health, University College, London, United Kingdom
| | - Tim Colbourn
- Institute for Global Health, University College, London, United Kingdom
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Christiansen AMH, Sørensen BL, Boas IM, Bedesa T, Fekede W, Nielsen HS, Lund S. The impact of the Safe Delivery Application on knowledge and skills managing postpartum haemorrhage in a low resource setting: a cluster randomized controlled trial in West Wollega region, Ethiopia. Reprod Health 2023; 20:91. [PMID: 37328731 PMCID: PMC10273743 DOI: 10.1186/s12978-023-01635-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/05/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Postpartum haemorrhage is one of the leading causes of maternal mortality in low-income countries. Improving health workers' competencies in obstetric emergencies in low-income settings, has been recognized as an important factor in preventing maternal mortality and morbidity. mHealth interventions in maternal and newborn health care has shown the potential to improve health service delivery. Strong study designs such as randomized controlled trials are missing to estimate the effectiveness of the mHealth interventions. METHODS Between August 2013 and August 2014, 70 health facilities in West Wollega Region, Ethiopia were included and randomized to intervention or control in a cluster randomized controlled trial. At intervention facilities birth attendants were provided with a smartphone with the SDA installed. Of 176 midwives and "health extension workers," 130 completed at 12 months follow-up. At baseline and after 6- and 12-months participants were assessed. Knowledge was tested by a Key Feature Questionnaire, skills by an Objective Structured Assessment of Technical Skills in a structured role-play scenario. RESULTS Baseline skills scores were low and comparable with a median of 12/100 in the intervention and the control group. After 6 months skills had doubled in the intervention group (adjusted mean difference 29.6; 95% CI 24.2-35.1 compared to 1·8; 95% CI - 2.7 to 6.3 in the control group). At 12 months skills had further improved in the intervention group (adjusted mean difference 13.3; 95% CI 8.3-18.3 compared to 3.1; 95% CI - 1.0 to 7.3 in the control group). Knowledge scores also significantly improved in the intervention group compared to the control (adjusted mean difference after 12 months 8.5; 95% CI 2.0-15.0). CONCLUSION The Safe Delivery App more than doubled clinical skills for managing postpartum haemorrhage among birth attendants making it an attractive tool to reduce maternal mortality. TRIAL REGISTRATION Clinicaltrial.gov Identifier NCT01945931. September 5, 2013.
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Affiliation(s)
| | - Bjarke Lund Sørensen
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
- Department of Obstetrics and Gynecology, University Hospital Zealand, Sygehusvej 10, 4000, Roskilde, Denmark
| | - Ida Marie Boas
- Maternity Foundation, Forbindelsesvej 3, 2100, Copenhagen Ø, Denmark
| | - Tariku Bedesa
- Maternity Foundation, Forbindelsesvej 3, 2100, Copenhagen Ø, Denmark
| | | | - Henriette Svarre Nielsen
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark.
| | - Stine Lund
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neonatology, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Asim M, Hameed W, Khan B, Saleem S, Avan BI. Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:GHSP-D-22-00267. [PMID: 36853644 PMCID: PMC9972373 DOI: 10.9745/ghsp-d-22-00267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 11/28/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Respectful maternity care (RMC) during childbirth is an integral component of quality of care. However, women's experiences of mistreatment are prevalent in many low- and middle-income countries. This is a complex phenomenon that has not been well explored from a behavioral science perspective. We aimed to understand the behavioral drivers of mistreatment during childbirth among maternity care staff at public health facilities in the Sindh province of Pakistan. METHODS Applying the COM-B (capability-opportunity-motivation that leads to behavior change) model, we conducted semistructured in-depth interviews among clinical and nonclinical staff in public health facilities in Thatta and Sujawal, Sindh, Pakistan. Data were analyzed using thematic deductive analysis, and findings were synthesized using the COM-B model. RESULTS We identified several behavioral drivers of mistreatment during childbirth: (1) institutional guidelines on RMC and training opportunities were absent, resulting in a lack of providers' knowledge and skills; (2) facilities lacked the infrastructure to maintain patient privacy and confidentiality and did not permit males as birth companions; (3) lack of provider performance monitoring system and patient feedback mechanism contributed to providers not feeling appreciated or recognized. Staff bias against patients from lower castes contributed to patient abuse and mistreatment. The perspectives of clinical and nonclinical staff overlapped regarding potential drivers of mistreatment during childbirth. CONCLUSIONS Addressing mistreatment during childbirth requires improving the knowledge and capacity of maternity staff on RMC and psychosocial support to enhance their understanding of RMC. At the health facility level, governance and accountability mechanisms in routine supervision and monitoring of staff need to be improved. Patients' feedback should be incorporated for continuous improvement in providing maternity care services that meet patients' preferences and needs.
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Affiliation(s)
- Muhammad Asim
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Waqas Hameed
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Bushra Khan
- Department of Psychology, University of Karachi, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Bilal Iqbal Avan
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Pieterse P. Conducting rapid research to aid the design of a health systems governance intervention in the Somali Region of Ethiopia. FRONTIERS IN SOCIOLOGY 2022; 7:947970. [PMID: 36159163 PMCID: PMC9492999 DOI: 10.3389/fsoc.2022.947970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/04/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The rapid research described in this chapter was conducted as an assignment for a UN agency in Ethiopia's Somali Region. The agency's aim was support the implementation of an interim citizen engagement intervention, with a view of supporting of the Ethiopian Government's Citizen Score Card at primary healthcare facilities and hospitals in future. Many health facilities in Somali Region struggle with budget shortages related to ineffective budget planning and budget execution at woreda health office levels. In this context, an intervention to first improve budget accountability, through the implementation of citizen audits, was proposed. METHODOLOGY The rapid study focused on five woredas (districts) within Somali Region, where interviews were conducted with the heads of woreda health offices. In the same five woredas, directors of healthcare facilities were interviewed and offices and healthcare facilities were observed. The framework of assessment and analysis was based on health systems literature on fragile and conflict affected states guided the questions for the health authorities and health facility management. FINDINGS The research yielded five distinct mini case studies covering woreda health office planning and budgeting capacity and support (or lack thereof), and related impressions of challenges regarding healthcare delivery at health facilities in the same five woredas. RESULTS The findings demonstrated that the capacity for healthcare planning and budgeting Somali Region at woreda level varied significantly and that little guidance was available from regional level health authorities. Frontline health services clearly suffered from budget shortages as a result. CONCLUSION The research provided an evidence base for the delay of the roll-out of the Community Scorecard implementation across Somali Region. In a context whereby health facilities remain under-resourced due to budgeting constraints, a citizen-service provider-focused accountability intervention would have been of limited utility. The rapid case study research, conducted by condensing the usual case study research process, allowed for the production of evidence that was "robust enough" to demonstrate heterogeneity and challenges regarding budgeting quality across the five research sites. This evidence clearly transcended the hitherto anecdotal evidence that woreda-level health budget planning remains an area that faces significant shortcomings.
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Dhakal P, Mohammad KI, Creedy DK, Gamble J, Newnham E, McInnes R. Midwifery and nursing students' perceptions of respectful maternity care and witnessing of disrespect and abuse: A comparative study from Nepal and Jordan. Midwifery 2022; 112:103426. [PMID: 35839569 DOI: 10.1016/j.midw.2022.103426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/21/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To compare Nepalese and Jordanian midwifery and nursing students' perceptions of respectful maternity care (RMC) and witnessing of disrespect and abuse; and determine factors that predict scores on a scale measuring perceptions of RMC. DESIGN A descriptive, comparative design was used. SETTING Recruitment took place from two medical colleges in Nepal and one University in Jordan. METHODS A convenience sample of students (n = 276) enrolled in a Bachelor or Diploma level midwifery or nursing degree who were undertaking or had recently completed their midwifery clinical placement were recruited. The online or hard copy survey included the Students' Perceptions of Respectful Maternity Care (SPRMC) Scale and nine questions on witnessing different types of disrespect and abuse. FINDINGS Nepalese students were slightly older (mean = 23.68 years) than Jordanian students (mean = 21.36). Mean duration of clinical placement was longer for Jordanian students (11.24 compared to 6.28 weeks). However, mean number of births observed was higher among Nepalese students (19.6 compared to 18.62). Overall, perceptions of RMC were more positive among Jordanian students (t (199.97) = 6.68, p < 0.001). A multiple regression analysis found that duration of clinical placement (beta = 0.22, p < 0.001), witnessing disrespect and abuse (beta = 0.11, p = 0.08) and age (beta = -0.14, p = 0.03) explained 12.2% of variance in SPMRC scores. Compared to students in Nepal, all Jordanian students had observed non-consented care during their clinical practicum. However, Nepalese students were more likely to observe poor adherence to women's privacy and confidentiality. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE This is the first study to compare midwifery and nursing students' perceptions of RMC across two middle-income countries. Although Jordanian students held more positive perceptions of RMC than those in Nepal, more had witnessed different forms of disrespect and abuse. Variations in students' perceptions of RMC and witnessing of abuse across countries highlight the need for assessment of workplace cultures to inform the development of tailored education and practice interventions for students, clinicians, and managers. Future research needs to explore how to best support students to consistently offer RMC and how to improve the experiences of childbearing women.
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Affiliation(s)
- Prativa Dhakal
- School of Nursing and Midwifery, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131, Australia.
| | | | - Debra K Creedy
- School of Nursing and Midwifery, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131, Australia
| | - Jenny Gamble
- School of Nursing, Midwifery and Allied Health, Coventry University, United Kingdom
| | - Elizabeth Newnham
- School of Nursing and Midwifery, University of Newcastle, New South Wales, Australia
| | - Rhona McInnes
- School of Nursing and Midwifery, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131, Australia
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Nishimwe A, Conco DN, Nyssen M, Ibisomi L. A mixed-method study exploring experiences, perceptions, and acceptability of using a safe delivery mHealth application in two district hospitals in Rwanda. BMC Nurs 2022; 21:176. [PMID: 35787679 PMCID: PMC9251926 DOI: 10.1186/s12912-022-00951-w] [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: 01/14/2022] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Innovative use of mobile health (mHealth) technology in timely management of childbirth complications is a promising strategy, but its evidence base is limited. The Safe Delivery mHealth Application (SDA) is one of the recent mhealth applications (loaded in smartphones) which is a clinical decision support and training tool for basic emergency obstetric and newborn care (BEmONC). This paper describes, the health providers' experiences, perceptions, and acceptability of using the SDA, as well as the perceptions of key stakeholders. METHODS A mixed-methods approach was utilized. Quantitative methods consisted of a self-reported acceptability survey, administered to 54 nurses and midwives, including questions on their usage and perceptions of the SDA. Descriptive statistics were employed to analyze the survey data. Qualitative methods included two focus group discussions with 24 nurses and midwives, and six key informant interviews with stakeholders (maternity matrons, responsible for maternal and child health, and district hospital managers). Thematic analysis was performed and selected quotations used to illustrate themes. The study took place in two district hospitals in Rwanda. RESULTS Quantitative results found that 31 (57.4%) participants used the SDA four to six times per week. Many participants felt more confident (53.7%) and better at their job (40.7%) since having the SDA. Likert scale survey responses (1-5, 1 = Strongly Disagree, 5 = Strongly Agree) indicated general agreement that SDA is easy to use (Mean = 4.46), is an effective decision support tool (4.63), and training tool (4.65). Qualitative results included themes on perceived usefulness; professional growth acquired through the use of the SDA; SDA, an empowering, intuitive, and user-friendly technology; desired SDA features and functions; benefits of SDA as perceived by key informants, and future use of the SDA. CONCLUSIONS The nurses and midwives perceive the SDA as having improved their ability to manage childbirth complications. Key stakeholders also perceive the SDA as a useful tool with a reasonable cost and recommend its implementation in routine practices. This study deepens the understanding of the potential benefits of mHealth such as the SDA in low-income settings, like Rwanda. It also provides more evidence on the impact of mHealth in assuring quality BEmONC.
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Affiliation(s)
- Aurore Nishimwe
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 1 Smuts Avenue, 2000, Braamfontein, South Africa. .,School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda.
| | - Daphney Nozizwe Conco
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 1 Smuts Avenue, 2000, Braamfontein, South Africa
| | - Marc Nyssen
- Department of Biomedical Statistics and Informatics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Latifat Ibisomi
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 1 Smuts Avenue, 2000, Braamfontein, South Africa.,Nigerian Institute of Medical Research, 6 Edmund Cres, Yaba, Lagos, Nigeria
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12
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Muwema M, Kaye DK, Edwards G, Nalwadda G, Nangendo J, Okiring J, Mwanja W, Ekong EN, Kalyango JN, Nankabirwa JI. Perinatal care in Western Uganda: Prevalence and factors associated with appropriate care among women attending three district hospitals. PLoS One 2022; 17:e0267015. [PMID: 35639711 PMCID: PMC9154186 DOI: 10.1371/journal.pone.0267015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/31/2022] [Indexed: 11/25/2022] Open
Abstract
Background Perinatal mortality remains high globally and remains an important indicator of the quality of a health care system. To reduce this mortality, it is important to provide the recommended care during the perinatal period. We assessed the prevalence and factors associated with appropriate perinatal care (antenatal, intrapartum, and postpartum) in Bunyoro region, Uganda. Results from this study provide valuable information on the perinatal care services and highlight areas of improvement for better perinatal outcomes. Methods A cross sectional survey was conducted among postpartum mothers attending care at three district hospitals in Bunyoro. Following consent, a questionnaire was administered to capture the participants’ demographics and data on care received was extracted from their antenatal, labour, delivery, and postpartum records using a pre-tested structured tool. The care received by women was assessed against the standard protocol established by World Health Organization (WHO). Poisson regression with robust standard errors was used to assess factors associated with appropriate postpartum care. Results A total of 872 mothers receiving care at the participating hospitals between March and June 2020 were enrolled in the study. The mean age of the mothers was 25 years (SD = 5.95). None of the mothers received appropriate antenatal or intrapartum care, and only 3.8% of the participants received appropriate postpartum care. Factors significantly associated with appropriate postpartum care included mothers being >35 years of age (adjusted prevalence ratio [aPR] = 11.9, 95% confidence interval [CI] 2.8–51.4) and parity, with low parity (2–3) and multiparous (>3) mothers less likely to receive appropriate care than prime gravidas (aPR = 0.3, 95% CI 0.1–0.9 and aPR = 0.3, 95% CI 0.1–0.8 respectively). Conclusions Antenatal, intrapartum, and postpartum care received by mothers in this region remains below the standard recommended by WHO, and innovative strategies across the continuum of perinatal care need to be devised to prevent mortality among the mothers. The quality of care also needs to be balanced for all mothers irrespective of the age and parity.
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Affiliation(s)
- Mercy Muwema
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Dan K. Kaye
- Department of Obstetrics and Gynecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grace Edwards
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda
| | - Gorrette Nalwadda
- Department of Nursing, School of Health Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joanita Nangendo
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Elizabeth N. Ekong
- Department of Nursing, Faculty of Health Sciences, Uganda Christian University, Uganda
| | - Joan N. Kalyango
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Pharmacy, School of Health Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joaniter I. Nankabirwa
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
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Taha Z, Wikkeling-Scott L. Review of Kangaroo Mother Care in the Middle East. Nutrients 2022; 14:nu14112266. [PMID: 35684066 PMCID: PMC9182704 DOI: 10.3390/nu14112266] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/16/2022] Open
Abstract
Mothers and newborns have a natural physiological requirement to be together immediately after birth. A newborn has a keen sense of smell and will instinctively seek out the mother’s nipple and begin breastfeeding if placed skin-to-skin with her. This practice is known as Kangaroo Mother Care (KMC). It was first suggested in 1978 and has been recommended by the World Health Organization (WHO) as a means to ensure successful breastfeeding. It is well documented that KMC is associated with positive breastfeeding outcomes, particularly in cases where breastfeeding is exclusive and, on average, continued for 3 months or longer. Studies of infant nutrition and breastfeeding have shown the importance of immediate, uninterrupted skin-to-skin contact between newborn and mother following vaginal birth. This practice is also recommended for mothers who give birth via cesarean section, once the newborn is stable. The rate of breastfeeding is still suboptimal in Middle Eastern countries, in light of the WHO’s recommendation that mothers should exclusively breastfeed for the first six months and continue breastfeeding for up to two years. To increase the rate of breastfeeding, practices should be promoted that have been shown to improve outcomes, such as KMC. However, little is known about this important practice in the region. The aim of this study was to shed light on KMC-related studies conducted in the Middle East between January 2010 and January 2022. Specifically, this review examines breastfeeding practice rates for the first 6 months of birth, and evidence of KMC practices, by country and type of study design. The research terms used for this review were “skin to skin”, “Skin to skin contact”, and “Kangaroo Mother Care”, focusing on “Middle East”, “Eastern Mediterranean”, “Arabian Gulf”, “Arab”, and “GCC”.
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Affiliation(s)
- Zainab Taha
- Department of Health Sciences, College of Natural and Health Sciences, Zayed University, Abu Dhabi P.O. Box 144534, United Arab Emirates
- Correspondence: ; Tel.: +971-2-5993111; Fax: +971-2-4434847
| | - Ludmilla Wikkeling-Scott
- School of Community Health and Policy, Portage Campus, Morgan State University, 1700 E. Cold Spring Lane, Baltimore, MD 21201, USA;
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Clarke‐Deelder E, Eliakimu E, Mbatia R, Bohren MA, Mashasi I, Larson E. Measuring user experience of care among caregivers of sick children: validation and descriptive analysis in a sample of 75 health facilities in rural Tanzania. Trop Med Int Health 2022; 27:317-329. [DOI: 10.1111/tmi.13730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Emma Clarke‐Deelder
- Department of Epidemiology and Public Health Swiss Tropical and Public Health Institute Basel Switzerland
| | - Eliudi Eliakimu
- Health Quality Assurance Unit Ministry of Health, Community Development Gender, Elderly and Children Dodoma Tanzania
| | | | - Meghan A. Bohren
- Gender and Women’s Health Unit Centre for Health Equity School of Population and Global Health University of Melbourne Melbourne Australia
| | - Irene Mashasi
- Management and Development for Health Dar es Salaam Tanzania
| | - Elysia Larson
- Department of Obstetrics and Gynecology Beth Israel Deaconess Medical Center and Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School Boston USA
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15
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Dong K, Jameel B, Gagliardi AR. How is patient-centred care conceptualized in obstetrical health? comparison of themes from concept analyses in obstetrical health- and patient-centred care. Health Expect 2022; 25:823-839. [PMID: 35026046 PMCID: PMC9122412 DOI: 10.1111/hex.13434] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/24/2021] [Accepted: 12/31/2021] [Indexed: 11/28/2022] Open
Abstract
Background Due to gender inequities that exist for women of childbearing age, there exists a need to deliver care tailored to their needs and preferences. Patient‐centred care (PCC) can be used to meet these needs. This review aims to compare patient care delivery between PCC and obstetrical care. This can help us address how PCC should be delivered to women before, during and after pregnancy versus how it is delivered to patients regardless of sex. Methods A review of literature was conducted on MEDLINE, EMBASE, CINAHL and SCOPUS for English PCC and high‐quality perinatal reviews published between 2010 and 2021. The data were analysed using a modified Walker and Avant framework. Results A total of 2138 unique studies were identified, with 11 PCC and 9 high‐quality obstetrical care studies included. Common defining features between PCC and obstetrical care include respect and dignity, informed decision‐making, therapeutic alliance, effective communication, social relationships and autonomy. PCC‐specific features were holistic care, empowerment, individualized care, coordinated care and empathy. Unique high‐quality obstetrical care themes included continuity of care, privacy and confidentiality, provider education and status, physical environment and equitable maternal care. Conclusions There are shared defining attributes between PCC and obstetrical care, including respect and dignity, informed decision‐making, the therapeutic alliance, effective communication, social relationships and autonomy. However, there remain unique defining attributes for high‐quality obstetrical care and PCC. This highlights the need for a unique approach to obstetrical care. More research on care for different physiological conditions in women is needed to address patient care that addresses different parts of the lifespan and develop frameworks that can influence health policy, patient care and health system evaluation. Patient or Public Contribution This study was one part of a larger, multicomponent study of how to implement PCC for women across the lifespan. While we did not specifically consult or involve women in this dual concept analysis, our larger study (content analysis of clinical guidelines and government policies, qualitative interviews with women and clinicians, Delphi study to prioritize consensus recommendations for achieving PCC for women) was guided by the experiences and input of a 50+ women advisory panel.
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Affiliation(s)
- Kelly Dong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bismah Jameel
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Anna R Gagliardi
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
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16
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Ekblom A, Målqvist M, Gurung R, Rossley A, Basnet O, Bhattarai P, K C A. Factors associated with poor adherence to intrapartum fetal heart monitoring in relationship to intrapartum related death: A prospective cohort study. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000289. [PMID: 36962317 PMCID: PMC10021382 DOI: 10.1371/journal.pgph.0000289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/24/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Poor quality of intrapartum care remains a global health challenge for reducing stillbirth and early neonatal mortality. Despite fetal heart rate monitoring (FHRM) being key to identify fetus at risk during labor, sub-optimal care prevails in low-income settings. The study aims to assess the predictors of suboptimal fetal heart rate monitoring and assess the association of sub-optimal FHRM and intrapartum related deaths. METHOD A prospective cohort study was conducted in 12 hospitals between April 2017 to October 2018. Pregnant women with fetal heart sound present during admission were included. Inferential statistics were used to assess proportion of sub-optimal FHRM. Multi-level logistic regression was used to detect association between sub-optimal FHRM and intrapartum related death. RESULT The study cohort included 83,709 deliveries, in which in more than half of women received suboptimal FHRM (56%). The sub-optimal FHRM was higher among women with obstetric complication than those with no complication (68.8% vs 55.5%, p-value<0.001). The sub-optimal FHRM was higher if partograph was not used than for whom partograph was completely filled (70.8% vs 15.9%, p-value<0.001). The sub-optimal FHRM was higher if the women had no companion during labor than those who had companion during labor (57.5% vs 49.6%, p-value<0.001). After adjusting for background characteristics and intra-partum factors, the odds of intrapartum related death was higher if FHRM was done sub-optimally in reference to women who had FHRM monitored as per protocol (aOR, 1.47; 95% CI; 1.13, 1.92). CONCLUSION Adherence to FHRM as per clinical standards was inadequate in these hospitals of Nepal. Furthermore, there was an increased odds of intra-partum death if FHRM had not been carried out as per clinical standards. FHRM provided as per protocol is key to identify fetuses at risk, and efforts are needed to improve the adherence of quality of care to prevent death.
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Affiliation(s)
- Annette Ekblom
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Mats Målqvist
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Rejina Gurung
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Angela Rossley
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | - Ashish K C
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Society of Public Health Physicians Nepal, Kathmandu, Nepal
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17
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Sharma G, Molla YB, Budhathoki SS, Shibeshi M, Tariku A, Dhungana A, Bajracharya B, Mebrahtu GG, Adhikari S, Jha D, Mussema Y, Bekele A, Khadka N. Analysis of maternal and newborn training curricula and approaches to inform future trainings for routine care, basic and comprehensive emergency obstetric and newborn care in the low- and middle-income countries: Lessons from Ethiopia and Nepal. PLoS One 2021; 16:e0258624. [PMID: 34710115 PMCID: PMC8553030 DOI: 10.1371/journal.pone.0258624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 10/04/2021] [Indexed: 11/23/2022] Open
Abstract
Program managers routinely design and implement specialised maternal and newborn health trainings for health workers in low- and middle-income countries to provide better-coordinated care across the continuum of care. However, in these countries details on the availability of different training packages, skills covered in those training packages and the gaps in their implementation are patchy. This paper presents an assessment of maternal and newborn health training packages to describe differences in training contents and implementation approaches used for a range of training packages in Ethiopia and Nepal. We conducted a mixed-methods study. The quantitative assessment was conducted using a comprehensive assessment questionnaire based on validated WHO guidelines and developed jointly with global maternal and newborn health experts. The qualitative assessment was conducted through key informant interviews with national stakeholders involved in implementing these training packages and working with the Ministries of Health in both countries. Our quantitative analysis revealed several key gaps in the technical content of maternal and newborn health training packages in both countries. Our qualitative results from key informant interviews provided additional insights by highlighting several issues with trainings related to quality, skill retention, logistics, and management. Taken together, our findings suggest four key areas of improvement: first, training materials should be updated based on the content gaps identified and should be aligned with each other. Second, trainings should address actual health worker performance gaps using a variety of innovative approaches such as blended and self-directed learning. Third, post-training supervision and ongoing mentoring need to be strengthened. Lastly, functional training information systems are required to support planning efforts in both countries.
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Affiliation(s)
- Gaurav Sharma
- Society of Public Health Physicians, Kathmandu, Nepal
- * E-mail:
| | - Yordanos B. Molla
- USAID’s Maternal and Child Survival Program/Save the Children, Washington, DC, United States of America
| | | | | | | | - Adhish Dhungana
- USAID’s Maternal and Child Survival Program/Save The Children, Kathmandu, Nepal
| | | | | | | | - Deepak Jha
- Child Health Division, Ministry of Health and Population, Kathmandu, Nepal
| | | | - Abeba Bekele
- USAID’s Maternal and Child Survival Program/Save The Children, Addis Ababa, Ethiopia
| | - Neena Khadka
- USAID’s Maternal and Child Survival Program/Save the Children, Washington, DC, United States of America
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18
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Lacroze E, Bärnighausen T, De Neve JW, Vollmer S, Ratsimbazafy RM, Emmrich PMF, Muller N, Rajemison E, Rampanjato Z, Ratsiambakaina D, Knauss S, Emmrich JV. The 4MOTHERS trial of the impact of a mobile money-based intervention on maternal and neonatal health outcomes in Madagascar: study protocol of a cluster-randomized hybrid effectiveness-implementation trial. Trials 2021; 22:725. [PMID: 34674741 PMCID: PMC8529568 DOI: 10.1186/s13063-021-05694-8] [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: 03/22/2021] [Accepted: 10/07/2021] [Indexed: 11/29/2022] Open
Abstract
Background Mobile money—a service enabling users to receive, store, and send electronic money using mobile phones—has been widely adopted across low- and middle-income economies to pay for a variety of services, including healthcare. However, evidence on its effects on healthcare access and health outcomes are scarce and the possible implications of using mobile money for financing and payment of maternal healthcare services—which generally require large one-time out-of-pocket payments—have not yet been systematically assessed in low-resource settings. The aim of this study is to determine the impact on health outcomes, cost-effectiveness, feasibility, acceptability, and usefulness of mobile phone-based savings and payment service, the Mobile Maternal Health Wallet (MMHW), for skilled healthcare during pregnancy and delivery among women in Madagascar. Methods This is a hybrid effectiveness-implementation type-1 trial, determining the effectiveness of the intervention while evaluating the context of its implementation in Madagascar’s Analamanga region, containing the capital, Antananarivo. Using a stratified cluster randomized design, 61 public-sector primary-care health facilities were randomized within 6 strata to either receive the intervention or not (29 intervention vs. 32 control facilities). The strata were defined by a health facility’s antenatal care visit volume and its capacity to offer facility-based deliveries. The registered pre-specified primary outcomes are (i) delivery at a health facility, (ii) antenatal care visits, and (iii) total healthcare expenditure during pregnancy, delivery, and neonatal period. The registered pre-specified secondary outcomes include additional health outcomes, economic outcomes, and measurements of user experience and satisfaction. Our estimated enrolment number is 4600 women, who completed their pregnancy between July 1, 2020, and December 31, 2021. A series of nested mixed-methods studies will elucidate client and provider perceptions on feasibility, acceptability, and usefulness of the intervention to inform future implementation efforts. Discussion A cluster-randomized, hybrid effectiveness-implementation design allows for a robust approach to determine whether the MMHW is a feasible and beneficial intervention in a resource-restricted public healthcare environment. We expect the results of our study to guide future initiatives and health policy decisions related to maternal and neonatal health and universal healthcare coverage through technology in Madagascar and other countries in sub-Saharan Africa. Trial registration This trial was registered on March 12, 2021: Deutsches Register Klinischer Studien (German Clinical Trials Register), identifier: DRKS00014928. For World Health Organization Trial Registration Data Set see Additional file 1. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05694-8.
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Affiliation(s)
- Etienne Lacroze
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Global Digital Health Lab, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Africa Health Research Institute (AHRI), Mtubatuba, KwaZulu-Natal, South Africa
| | - Jan Walter De Neve
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Sebastian Vollmer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | | | | | - Nadine Muller
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elsa Rajemison
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Global Digital Health Lab, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Zavaniarivo Rampanjato
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Ministry of Public Health of the Republic of Madagascar, Antananarivo, Madagascar
| | - Diana Ratsiambakaina
- Ministry of Public Health of the Republic of Madagascar, Antananarivo, Madagascar
| | - Samuel Knauss
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Global Digital Health Lab, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Charité Global Health and Department of Experimental Neurology and Center for Stroke Research, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Julius Valentin Emmrich
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany. .,Global Digital Health Lab, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Charité Global Health and Department of Experimental Neurology and Center for Stroke Research, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Berlin Institute of Health, Berlin, Germany.
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Umoren R, Bucher S, Hippe DS, Ezenwa BN, Fajolu IB, Okwako FM, Feltner J, Nafula M, Musale A, Olawuyi OA, Adeboboye CO, Asangansi I, Paton C, Purkayastha S, Ezeaka CV, Esamai F. eHBB: a randomised controlled trial of virtual reality or video for neonatal resuscitation refresher training in healthcare workers in resource-scarce settings. BMJ Open 2021; 11:e048506. [PMID: 34433598 PMCID: PMC8390148 DOI: 10.1136/bmjopen-2020-048506] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 08/05/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the impact of mobile virtual reality (VR) simulations using electronic Helping Babies Breathe (eHBB) or video for the maintenance of neonatal resuscitation skills in healthcare workers in resource-scarce settings. DESIGN Randomised controlled trial with 6-month follow-up (2018-2020). SETTING Secondary and tertiary healthcare facilities. PARTICIPANTS 274 nurses and midwives assigned to labour and delivery, operating room and newborn care units were recruited from 20 healthcare facilities in Nigeria and Kenya and randomised to one of three groups: VR (eHBB+digital guide), video (video+digital guide) or control (digital guide only) groups before an in-person HBB course. INTERVENTIONS eHBB VR simulation or neonatal resuscitation video. MAIN OUTCOMES Healthcare worker neonatal resuscitation skills using standardised checklists in a simulated setting at 1 month, 3 months and 6 months. RESULTS Neonatal resuscitation skills pass rates were similar among the groups at 6-month follow-up for bag-and-mask ventilation (BMV) skills check (VR 28%, video 25%, control 22%, p=0.71), objective structured clinical examination (OSCE) A (VR 76%, video 76%, control 72%, p=0.78) and OSCE B (VR 62%, video 60%, control 49%, p=0.18). Relative to the immediate postcourse assessments, there was greater retention of BMV skills at 6 months in the VR group (-15% VR, p=0.10; -21% video, p<0.01, -27% control, p=0.001). OSCE B pass rates in the VR group were numerically higher at 3 months (+4%, p=0.64) and 6 months (+3%, p=0.74) and lower in the video (-21% at 3 months, p<0.001; -14% at 6 months, p=0.066) and control groups (-7% at 3 months, p=0.43; -14% at 6 months, p=0.10). On follow-up survey, 95% (n=65) of respondents in the VR group and 98% (n=82) in the video group would use their assigned intervention again. CONCLUSION eHBB VR training was highly acceptable to healthcare workers in low-income to middle-income countries and may provide additional support for neonatal resuscitation skills retention compared with other digital interventions.
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Affiliation(s)
- Rachel Umoren
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Sherri Bucher
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | | | | | | | - John Feltner
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | | | | | - Olubukola A Olawuyi
- Department of Paediatrics, University of Lagos College of Medicine, Lagos, Nigeria
| | | | | | - Chris Paton
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford, UK
| | - Saptarshi Purkayastha
- Department of BioHealth Informatics, Indiana University-Purdue University at Indianapolis, Indianapolis, Indiana, USA
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Pessa Valente E, Barbone F, de Melo E Lima TR, de Mascena Diniz Maia PFC, Vezzini F, Tamburlini G. Quality of maternal and newborn hospital care in Brazil: a quality improvement cycle using the WHO assessment and quality tool. Int J Qual Health Care 2021; 33:6146808. [PMID: 33619561 DOI: 10.1093/intqhc/mzab028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/09/2021] [Accepted: 02/20/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Increasing efforts toward quality improvement (QI) are necessary in low- and middle-income countries (LMICs) to reduce maternal and perinatal mortality and morbidity and to promote respectful care. In Brazil, perinatal health indicators are below targets in several states despite universal access to perinatal services and very high rates of institutional births, indicating poor quality of care (QoC) as a key issue to be addressed. However, research efforts to develop and test QoC improvement interventions are scarce. OBJECTIVES We assessed the effects of a 1-year comprehensive QI cycle using a World Health Organization (WHO) assessment and quality tool on maternal and newborn care at hospital level and documented QIs obtained after a 1-year comprehensive QI cycle. METHODS Uncontrolled, unblinded, pre-post study carried out in six maternity hospitals in Pernambuco, Brazil, accounting for 29 128 live births in 2014. A standards-based and participatory approach based on a WHO quality assessment and improvement tool for maternal and neonatal care at hospital level was used. A national team of assessors supervised by international experts carried out baseline and final assessments. An action plan was developed and implemented to address key quality gaps emerging from the baseline assessment and from two supportive supervision visits. RESULTS At baseline, hospitals presented a variety of quality gaps, the majority common to all participating centers. Gaps in case management of normal and complicated deliveries and in respectful and holistic care were predominant, in both teaching/tertiary and secondary care hospitals. After one year, several improvements were observed, particularly in respectful care during labor and at delivery, in case management of normal labor and delivery and in neonatal care. CONCLUSIONS A systematic participatory approach based on a WHO tool produced important QIs in a relatively short time and should be considered for use for large-scale QI programs in Brazil and other LMICs. Its comprehensive, peer-to-peer and action-oriented nature and its capability to document QI over time and to build a QI culture represent important comparative advantages over other QI interventions.
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Affiliation(s)
- Emanuelle Pessa Valente
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Via dell'Istria 65/1, Trieste, Friuli Venezia Giulia Region 34137, Italy
| | - Fabio Barbone
- Scientific Direction, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Via dell'Istria 65/1, Trieste, Friuli Venezia Giulia Region 34137, Italy
| | - Tereza Rebecca de Melo E Lima
- Post graduation department, doctorate on integral medicine, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Rua dos Coelhos, 300 - Boa Vista, Recife, Pernambuco 50070-902, Brazil.,Medicine course department, Faculdade Pernambucana de Saúde (FPS), av. Mal. Mascarenhas de Morais, 4861 - Imbiribeira, Recife - Pernambuco 51150-000, Pernambuco, Brazil
| | - Paula Ferdinanda Conceiçîo de Mascena Diniz Maia
- Medicine course department, Faculdade Pernambucana de Saúde (FPS), av. Mal. Mascarenhas de Morais, 4861 - Imbiribeira, Recife - Pernambuco 51150-000, Pernambuco, Brazil.,Pediatric department, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235 - Cidade Universitària, Recife - Pernambuco 50670-901, Brazil
| | - Francesca Vezzini
- Post graduation department, doctorate on integral medicine, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Rua dos Coelhos, 300 - Boa Vista, Recife, Pernambuco 50070-902, Brazil.,Dottorato di Ricerca in Scienze della Riproduzione e dello Sviluppo, Università degli Studi di Trieste, Piazzale Europa, Trieste 34127, Italy
| | - Giorgio Tamburlini
- Dottorato di Ricerca in Scienze della Riproduzione e dello Sviluppo, Università degli Studi di Trieste, Piazzale Europa, Trieste 34127, Italy.,Director, Centro per la Salute del Bambino, Via Nocolò de Rin, 19, Trieste, Friuli Venezia Giulia Region 34143, Italy
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Javadi D, Ssempebwa J, Isunju JB, Yevoo L, Amu A, Nabiwemba E, Pfeiffer M, Agyepong I, Severi L. Implementation research on sustainable electrification of rural primary care facilities in Ghana and Uganda. Health Policy Plan 2021; 35:ii124-ii136. [PMID: 33156941 PMCID: PMC7646723 DOI: 10.1093/heapol/czaa077] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 11/13/2022] Open
Abstract
Access to energy is essential for resilient health systems; however, strengthening energy infrastructure in rural health facilities remains a challenge. In 2015–19, ‘Powering Healthcare’ deployed solar energy solutions to off-grid rural health facilities in Ghana and Uganda to improve the availability of maternal and child health services. To explore the links between health facility electrification and service availability and use, the World Health Organization (WHO), in partnership with Dodowa Health Research Centre and Makerere University School of Public Health, carried out an implementation research study. The objectives of this study were to (1) capture changes in service availability and readiness, (2) describe changes in community satisfaction and use and (3) examine the implementation factors of sustainable electrification that affect these changes. Data were collected through interviews with over 100 key informants, focus group discussions with over 800 community members and health facility assessment checklist adapted from the WHO’s Service Availability and Readiness Assessment tool. Implementation factors were organized using Normalization Process Theory constructs. The study found that access to energy is associated with increased availability of health services, access to communication technologies, appropriate storage of vaccines and medicines, enhanced health worker motivation and increased community satisfaction. Implementation factors associated with improved outcomes include stakeholder engagement activities to promote internalization, provision of materials and information to encourage participation, and establishment of relationships to support integration. Barriers to achieving outcomes are primarily health systems challenges—such as drug stockouts, lack of transportation and poor amenities—that continue to affect service availability, readiness and use, even where access to energy is available. However, through appropriate implementation and integration of sustainable electrification, strengthened energy infrastructure can be leveraged to catalyze investment in other components of functioning health systems. Improving access to energy in health facilities is, therefore, necessary but not sufficient for strengthening health systems.
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Affiliation(s)
- Dena Javadi
- Alliance for Health Policy and Systems Research, World Health Organization, 20 Ave Appia, Geneva 1211, Switzerland
| | - John Ssempebwa
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Kampala, Uganda
| | - John Bosco Isunju
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Kampala, Uganda
| | - Lucy Yevoo
- Ghana Health Service, Dodowa Health Research Center, Hospital Road, Matetse, Ghana
| | - Alberta Amu
- Ghana Health Service, Dodowa Health Research Center, Hospital Road, Matetse, Ghana
| | - Elizabeth Nabiwemba
- Department of Community Health and Behavioural Science, Makerere University School of Public Health, New Mulago Hill Road, Kampala, Uganda
| | - Michaela Pfeiffer
- Department of Public Health Environmental and Social Determinants of Health, World Health Organization, 20 Ave Appia, Geneva 1211, Switzerland
| | - Irene Agyepong
- Ghana Health Service, Dodowa Health Research Center, Hospital Road, Matetse, Ghana.,Ghana College of Physicians and Surgeons, Public Health Department, 54 independence Ave, Accra, Ghana
| | - Luc Severi
- Sustainable Energy for All, 1750 Pennsylvania Ave, Washington, DC, USA
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22
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Mbugua S, Gitaka J, Gitau T, Odwe G, Mwaura P, Liambila W, Ndwiga C, K'Oduol K, Warren C, Abuya T. Family and provider perceptions of quality of care in the management of sick young infants in primary healthcare settings in four counties of Kenya. BMJ Open Qual 2021; 10:bmjoq-2020-001125. [PMID: 34233958 PMCID: PMC8264895 DOI: 10.1136/bmjoq-2020-001125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 06/28/2021] [Indexed: 11/06/2022] Open
Abstract
Background Understanding the perceptions of quality of care given to sick young infants in primary healthcare settings is key for developing strategies for effective uptake and utilisation of possible severe bacterial infection guidelines. The purpose of this study is to assess families and providers’ perceptions of care given to sick young infants at primary healthcare facilities in four diverse counties in Kenya. Methods A cross-sectional qualitative design involving 37 in-depth interviews and 39 focus group discussions with very young (15–18 years), young (19–24 years) and older (25–45 years) caregivers of young infants aged 0–59 days; and key informant interviews with community-based and facility-based front-line health providers (14) in primary healthcare facilities. Qualitative data were captured using audio tapes and field notes, transcribed, translated and exported into QSR NVivo V.12 for analysis. A thematic framework approach was adopted to classify and analyse data. Results Perceived care given to sick young infants was described around six domains of the WHO framework for the quality of maternal and newborn healthcare: evidence-based practices for routine and emergency care; functional referral systems; effective communication; respect and preservation of dignity; availability of competent, motivated human resources; and availability of physical resources. Views of caregivers and providers regarding sick young infant care in primary healthcare settings were similar across the four sites. Main hindrance to sick young infant care includes stockout of essential drugs, limited infrastructure, lack of functional referral system, inadequate providers which led to delays in receiving treatment, inadequate provider skills and poor provider attitudes. Despite these challenges, motivation and teamwork of health providers were key tenets in care provision. Conclusion The findings underscore the need to prioritise improving quality of sick young infant services at primary healthcare settings by building capacity of providers through training, ensuring continuous supply of essential medicines and equipment and improving infrastructure including referral.
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Affiliation(s)
- Samuel Mbugua
- Nursing Education, Leadership, Management and Research, Mount Kenya University, Thika, Kenya
| | - Jesse Gitaka
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | - Tabither Gitau
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | | | - Peter Mwaura
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
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Nishimwe A, Nyssen M, Ibisomi L, Nozizwe Conco D. Clinical decision making in basic emergency obstetric and newborn care among nurses and midwives: the role of the safe delivery mhealth application_pre-post-intervention study (research protocol). Inform Health Soc Care 2021; 46:126-135. [PMID: 33427540 DOI: 10.1080/17538157.2020.1869007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Most maternal and newborn deaths in low-income countries, including Rwanda, are attributable to preventable causes. Timely access to Basic Emergency Obstetric and Newborn Care (BEmONC) guidelines to support clinical decisions could lead to better obstetric care thus reduction of maternal and newborn deaths. Besides, innovative methods such as the usage and reference to healthcare guidelines using mobile devices (mhealth) may support clinical decision making. However, there is little evidence about mhealth that focuses on the clinical decision support process. This proposal aims to investigate the effect of the Safe Delivery mhealth Application(SDA) on nurses' and midwives' clinical decision making, so as to inform mhealth interventions for work in specific contexts. The study adopts a quasi-experimental design. Convergent parallel mixed - methods will be used to collect, analyze and interpret data. A pre-intervention assessment of the BEmONC outcomes: Apgar score and PPH progressions, and related knowledge, skills, and perceptions of nurses and midwives will be conducted. The intervention will take place in two district hospitals in Rwanda and entails the implementation of the SDA for six months. Six months' post-intervention, the effect of the SDA on BEmONC outcomes and the nurses' and midwives' knowledge and skills will be evaluated.
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Affiliation(s)
- Aurore Nishimwe
- School of Health Sciences, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, South Africa
| | - Marc Nyssen
- Department of Biomedical Statistics and Informatics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Latifat Ibisomi
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, South Africa.,Nigerian Institute of Medical Research, Lagos, Yaba, Nigeria
| | - Daphney Nozizwe Conco
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, South Africa
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Mirbaha-Hashemi F, Tayefi B, Rampisheh Z, Tehrani-Banihashemi A, Ramezani M, Khalili N, Pournik O, Taghizadeh-Asl R, Habibelahi A, Heidarzadeh M, Moradi-Lakeh M. Progress towards Every Newborn Action Plan (ENAP) implementation in Iran: obstacles and bottlenecks. BMC Pregnancy Childbirth 2021; 21:379. [PMID: 34001015 PMCID: PMC8127274 DOI: 10.1186/s12884-021-03800-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 04/13/2021] [Indexed: 12/03/2022] Open
Abstract
Background Neonatal mortality accounts for more than 47% of deaths among children under five globally but proper care at and around the time of birth could prevent about two-thirds of these deaths. The Every Newborn Action Plan (ENAP) offers a plan and vision to improve and achieve equitable and high-quality care for mothers and newborns. We applied the bottleneck analysis tool offered by ENAP to identify obstacles and bottlenecks hindering the scale-up of newborn care across seven health system building blocks. Methods We applied the every newborn bottleneck analysis tool to identify obstacles hindering the scale-up of newborn care across seven health system building blocks. We used qualitative methods to collect data from five medical universities and their corresponding hospitals in three provinces. We also interviewed other national experts, key informants, and stakeholders in neonatal care. In addition, we reviewed and qualitatively analyzed the performance report of neonatal care and services from 16 medical universities around the country. Results We identified many challenges and bottlenecks in the scale-up of newborn care in Iran. The major obstacles included but were not limited to the lack of a single leading and governing entity for newborn care, insufficient financial resources for neonatal care services, insufficient number of skilled health professionals, and inadequate patient transfer. Conclusions To address identified bottlenecks in neonatal health care in Iran, some of our recommendations were as follows: establishing a single national authorizing and leading entity, allocating specific budget to newborn care, matching high-quality neonatal health care providers to the needs of all urban and rural areas, maintaining clear policies on the distribution of NICUs to minimize the need for patient transfer, and using the available and reliable private sector NICU ambulances for safe patient transfer. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03800-x.
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Affiliation(s)
- Fariba Mirbaha-Hashemi
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Batool Tayefi
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Rampisheh
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Tehrani-Banihashemi
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mozhdeh Ramezani
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Narjes Khalili
- Preventive Medicine and Public Health Research Center, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Pournik
- Statistics and Information Technology Management, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Abbas Habibelahi
- Neonatal Health Office, Ministry of Health and Medical Education, Tehran, Iran
| | - Mohammad Heidarzadeh
- Neonatal Health Office, Ministry of Health and Medical Education, Tehran, Iran.,Department of Neonatology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maziar Moradi-Lakeh
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Hemmat Freeway, Next to Milad Tower, Tehran, Iran.
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Irimu G, Aluvaala J, Malla L, Omoke S, Ogero M, Mbevi G, Waiyego M, Mwangi C, Were F, Gathara D, Agweyu A, Akech S, English M. Neonatal mortality in Kenyan hospitals: a multisite, retrospective, cohort study. BMJ Glob Health 2021; 6:e004475. [PMID: 34059493 PMCID: PMC8169483 DOI: 10.1136/bmjgh-2020-004475] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Most of the deaths among neonates in low-income and middle-income countries (LMICs) can be prevented through universal access to basic high-quality health services including essential facility-based inpatient care. However, poor routine data undermines data-informed efforts to monitor and promote improvements in the quality of newborn care across hospitals. METHODS Continuously collected routine patients' data from structured paper record forms for all admissions to newborn units (NBUs) from 16 purposively selected Kenyan public hospitals that are part of a clinical information network were analysed together with data from all paediatric admissions ages 0-13 years from 14 of these hospitals. Data are used to show the proportion of all admissions and deaths in the neonatal age group and examine morbidity and mortality patterns, stratified by birth weight, and their variation across hospitals. FINDINGS During the 354 hospital months study period, 90 222 patients were admitted to the 14 hospitals contributing NBU and general paediatric ward data. 46% of all the admissions were neonates (aged 0-28 days), but they accounted for 66% of the deaths in the age group 0-13 years. 41 657 inborn neonates were admitted in the NBUs across the 16 hospitals during the study period. 4266/41 657 died giving a crude mortality rate of 10.2% (95% CI 9.97% to 10.55%), with 60% of these deaths occurring on the first-day of admission. Intrapartum-related complications was the single most common diagnosis among the neonates with birth weight of 2000 g or more who died. A threefold variation in mortality across hospitals was observed for birth weight categories 1000-1499 g and 1500-1999 g. INTERPRETATION The high proportion of neonatal deaths in hospitals may reflect changing patterns of childhood mortality. Majority of newborns died of preventable causes (>95%). Despite availability of high-impact low-cost interventions, hospitals have high and very variable mortality proportions after stratification by birth weight.
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Affiliation(s)
- Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Jalemba Aluvaala
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Sylvia Omoke
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - George Mbevi
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Mary Waiyego
- Health Services, Nairobi Metropolitan Services, Nairobi, Kenya
| | - Caroline Mwangi
- Division of Neonatal and Child Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Fred Were
- Kenya Paediatric Research Consortium (KEPRECON), Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Ambrose Agweyu
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Oxford, Oxfordshire, UK
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Bolan N, Cowgill KD, Walker K, Kak L, Shaver T, Moxon S, Lincetto O. Human Resources for Health-Related Challenges to Ensuring Quality Newborn Care in Low- and Middle-Income Countries: A Scoping Review. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:160-176. [PMID: 33795367 PMCID: PMC8087437 DOI: 10.9745/ghsp-d-20-00362] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND A critical shortage of health workers with needed maternal and newborn competencies remains a major challenge for the provision of quality care for mothers and newborns, particularly in low- and middle-income countries. Supply-side challenges related to human resources for health (HRH) worsen shortages and can negatively affect health worker performance and quality of care. This review scoped country-focused sources to identify and map evidence on HRH-related challenges to quality facility-based newborn care provision by nurses and midwives. METHODS Evidence for this review was collected iteratively, beginning with pertinent World Health Organization documents and extending to articles identified via database and manual reference searches and country reports. Evidence from country-focused sources from 2000 onward was extracted using a data extraction tool that was designed iteratively; thematic analysis was used to map the 10 categories of HRH challenges. FINDINGS A total of 332 peer-reviewed articles were screened, of which 22 met inclusion criteria. Fourteen additional sources were added from manual reference search and gray literature sources. Evidence has been mapped into 10 categories of HRH-related challenges: (1) lack of health worker data and monitoring; (2) poor health worker preservice education; (3) lack of HW access to evidence-based practice guidelines, continuing education, and continuing professional development; (4) insufficient and inequitable distribution of health workers and heavy workload; (5) poor retention, absenteeism, and rotation of experienced staff; (6) poor work environment, including low salary; (7) limited and poor supervision; (8) low morale, motivation, and attitude, and job dissatisfaction; (9) weaknesses of policy, regulations, management, leadership, governance, and funding; and (10) structural and contextual barriers. CONCLUSION The mapping provides needed insight that informed new World Health Organization strategies and supporting efforts to address the challenges identified and strengthen human resources for neonatal care, with the ultimate goal of improving newborn care and outcomes.
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Affiliation(s)
- Nancy Bolan
- Office of Global Health, University of Maryland School of Nursing, Baltimore, MD, USA.
| | - Karen D Cowgill
- University of Washington Department of Global Health, Seattle, WA, USA
| | - Karen Walker
- The George Institute for Global Health, Newtown, Australia
| | - Lily Kak
- U.S. Agency for International Development, Washington, DC, USA
| | - Theresa Shaver
- Social Solutions International, Inc., Washington, DC, USA
| | - Sarah Moxon
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Chang KT, Hossain P, Sarker M, Montagu D, Chakraborty NM, Sprockett A. Translating international guidelines for use in routine maternal and neonatal healthcare quality measurement. Glob Health Action 2021; 13:1783956. [PMID: 32657252 PMCID: PMC7480423 DOI: 10.1080/16549716.2020.1783956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Improving facility-based quality for maternal and neonatal care is the key to reducing morbidity and mortality rates in low- and middle-income countries. Recent guidance from WHO and others has produced a large number of indicators to choose from to track quality. OBJECTIVE To explore how to translate complex global maternal and neonatal health standards into actionable application at the facility level. METHODS We applied a two-step process as an example of how the 352 indicators in WHO's 2016 Standards for Improving Quality of Maternal and Newborn Care in Health Facilities might be reduced to only those with the strongest evidence base, associated with outcomes, and actionable by facility managers. We applied Hill criteria and assessed whether indicators were within the control of facility managers. We next conducted a rapid review of supporting literature and applied GRADE analysis, retaining those with scores of 'moderate' or 'high'. To understand the utility and barriers to measuring this limited set of indicators in practice, we undertook a case study of hypothetical measurement application in two districts in Bangladesh, interviewing 25 clinicians, managers, and other stakeholders. RESULTS From the initial 352 indicators, 56 were retained. The 56 indicators were used as a base for interviews. Respondents emphasized the practical challenges to the use of complex guides and the need for parsimonious and actionable sets of quality indicators. CONCLUSIONS This work offers one way to move towards a reduced quality indicator set, beginning from current WHO guidance. Despite study limitations, this work provides evidence of the need for reduced and evidence-based sets of quality indicators if guides are to be used to improve quality in practice. We hope that future research will build on and refine our efforts. Measuring quality effectively so that evidence guides and improves practice is the first step to assuring safe maternal and neonatal care.
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Affiliation(s)
| | - Puspita Hossain
- James P. Grant School of Public Health, BRAC University , Dhaka, Bangladesh
| | - Malabika Sarker
- James P. Grant School of Public Health, BRAC University , Dhaka, Bangladesh.,Heidelberg Institute of Global Health, University of Heidelberg , Germany
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Bogren M, Banu A, Parvin S, Chowdhury M, Erlandsson K. Findings from a context specific accreditation assessment at 38 public midwifery education institutions in Bangladesh. Women Birth 2021; 34:e76-e83. [DOI: 10.1016/j.wombi.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/30/2020] [Accepted: 06/25/2020] [Indexed: 01/05/2023]
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Nishimwe A, Ibisomi L, Nyssen M, Conco DN. The effect of an mLearning application on nurses' and midwives' knowledge and skills for the management of postpartum hemorrhage and neonatal resuscitation: pre-post intervention study. HUMAN RESOURCES FOR HEALTH 2021; 19:14. [PMID: 33499870 PMCID: PMC7836484 DOI: 10.1186/s12960-021-00559-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/14/2021] [Indexed: 05/31/2023]
Abstract
BACKGROUND Globally, mobile learning (mLearning) tools have attracted considerable attention as a means of continuous training for healthcare workers. Rwanda like other low-resource settings with scarce in-service training opportunities requires innovative approaches that adapt technology to context to improve healthcare workers' knowledge and skills. One such innovation is the safe delivery application (SDA), a smartphone mLearning application for Basic Emergency Obstetric and Neonatal Care (BEmONC) content. This study assessed the effect of the SDA intervention on nurses' and midwives' knowledge and skills for the management of postpartum hemorrhage (PPH) and neonatal resuscitation (NR). METHODS The study used a pre-post test design to compare knowledge and skills of nurses and midwives in the management of PPH and NR at two measurement points: immediately prior to SDA intervention and after 6 months of SDA intervention. The intervention took place in two district hospitals in Rwanda and included 54 participants. A paired-sample t-test was used to measure the pre-post intervention, mean knowledge and skills scores differences. Confidence intervals (CIs) and effect size were calculated. A t-test and a one-way Anova were used to test for potential confounders. RESULTS The analysis included 54 participants. Knowledge scores and skills scores on PPH management and NR increased significantly from baseline to endline measurements. The mean difference for PPH knowledge is 17.1 out of 100; 95% CI 14.69 to 19.49 and 2.6% for PPH skills; 95% CI 1.01 to 4.25. The mean difference for NR knowledge is 19.1 out of 100; 95% CI 16.31 to 21.76 and 5.5% for NR skills; 95% CI 3.66 to 7.41. Increases were unaffected by participants' attendance to in-service training 6 months prior and during SDA intervention and previous smartphone use. However, pre- and post-intervention skills scores were significantly different by years of experience in obstetric care. CONCLUSION The SDA intervention improved the knowledge and skills of nurses and midwives on the management of PPH and NR as long as 6 months after SDA introduction. The results are highly relevant in low-income countries like Rwanda, where quality of delivery care is challenged by a lack of in-service continuous training for healthcare providers.
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Affiliation(s)
- Aurore Nishimwe
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 1 Smuts Avenue, Braamfontein, 2000, South Africa.
- School of Health Sciences/College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda.
| | - Latifat Ibisomi
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 1 Smuts Avenue, Braamfontein, 2000, South Africa
- Nigerian Institute of Medical Research, 6 Edmund Cres, Yaba, Lagos, Nigeria
| | - Marc Nyssen
- Department of Biomedical Statistics and Informatics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Daphney Nozizwe Conco
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 1 Smuts Avenue, Braamfontein, 2000, South Africa
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Mungai IG, Baghel SS, Soni S, Vagela S, Sharma M, Diwan V, Tamhankar AJ, Lundborg CS, Pathak A. Identifying the know-do gap in evidence-based neonatal care practices among informal health care providers-a cross-sectional study from Ujjain, India. BMC Health Serv Res 2020; 20:966. [PMID: 33087124 PMCID: PMC7576775 DOI: 10.1186/s12913-020-05805-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background More than a quarter of global neonatal deaths are reported from India, and a large proportion of these deaths are preventable. However, in the absence of robust public health care systems in several states in India, informal health care providers (IHCPs) with no formal medical education are the first contact service providers. The aim of this study was to assess the knowledge of IHCPs in basic evidence-based practices in neonatal care in Ujjain district and investigated factors associated with differences in levels of knowledge. Methods A cross-sectional survey was conducted using a questionnaire with multiple-choice questions covering the basic elements of neonatal care. The total score of the IHCPs was calculated. Multivariate quantile regression model was used to look for association of IHCPs knowledge score with: the practitioners’ age, years of experience, number of patients treated per day, and whether they attended children in their practice. Results Of the 945 IHCPs approached, 830 (88%) participated in the study. The mean ± SD score achieved was 22.3 ± 7.7, with a median score of 21 out of maximum score of 48. Although IHCPs could identify key tenets of enhancing survival chances of neonates, they scored low on the specifics of cord care, breastfeeding, vitamin K use to prevent neonatal hemorrhage, and identification and care of low-birth-weight babies. The practitioners particularly lacked knowledge about neonatal resuscitation, and only a small proportion reported following up on immunizations. Results of quantile regression analysis showed that more than 5 years of practice experience and treating more than 20 patients per day had a statistically significant positive association with the knowledge score at higher quantiles (q75th and q90th) only. IHCPs treating children had significantly better scores across quantiles accept at the highest quantile (90th). Conclusions The present study highlighted that know-do gap exists in evidence-based practices for all key areas of neonatal care tested among the IHCPs. The study provides the evidence that some IHCPs do possess knowledge in basic evidence-based practices in neonatal care, which could be built upon by future educational interventions. Targeting IHCPs can be an innovative way to reach a large rural population in the study setting and to improve neonatal care services.
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Affiliation(s)
- Isaac Gikandi Mungai
- Department of Global Public Health-Health Systems and Policy (HSP): Medicines Focusing Antibiotics, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Sumit Singh Baghel
- Department of Pediatrics, RD Gardi Medical College, Ujjain, MP, 456010, India
| | - Shuchi Soni
- Department of Pediatrics, RD Gardi Medical College, Ujjain, MP, 456010, India
| | - Shailja Vagela
- Department of Pediatrics, RD Gardi Medical College, Ujjain, MP, 456010, India
| | - Megha Sharma
- Department of Global Public Health-Health Systems and Policy (HSP): Medicines Focusing Antibiotics, Karolinska Institutet, 17177, Stockholm, Sweden.,Department of Pharmacology, RD Gardi Medical College, Ujjain, MP, 4560101, India
| | - Vishal Diwan
- Department of Global Public Health-Health Systems and Policy (HSP): Medicines Focusing Antibiotics, Karolinska Institutet, 17177, Stockholm, Sweden.,National Institute for Research in Environmental Health (NIREH), Bhopal, MP, India
| | - Ashok J Tamhankar
- Department of Global Public Health-Health Systems and Policy (HSP): Medicines Focusing Antibiotics, Karolinska Institutet, 17177, Stockholm, Sweden.,Indian Initiative for Management of Antibiotic Resistance, Department of Environmental Medicine, R.D. Gardi Medical College, Ujjain, 456006, India
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health-Health Systems and Policy (HSP): Medicines Focusing Antibiotics, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Ashish Pathak
- Department of Global Public Health-Health Systems and Policy (HSP): Medicines Focusing Antibiotics, Karolinska Institutet, 17177, Stockholm, Sweden. .,Department of Pediatrics, RD Gardi Medical College, Ujjain, MP, 456010, India. .,Department of Women and Children's Health, International Maternal and Child Health Unit, Uppsala University, SE-751 85, Uppsala, Sweden.
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Oosthuizen SJ, Bergh AM, Grimbeek J, Pattinson RC. CLEVER maternity care: A before-and-after study of women's experience of childbirth in Tshwane, South Africa. Afr J Prim Health Care Fam Med 2020; 12:e1-e8. [PMID: 33181878 PMCID: PMC7669945 DOI: 10.4102/phcfm.v12i1.2560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 11/25/2022] Open
Abstract
Background Birthing care matters to women and some women experience mistreatment during childbirth. Aim To determine the effect the ‘CLEVER Maternity Care’ package, a multi-faceted intervention to improve respectful, quality obstetric care. Setting Ten midwife-led obstetric units in Tshwane health district, South Africa; five intervention and five control units. Methods We conducted an anonymous baseline and end-line survey to measure the change in women’s perceptions and experiences of childbirth care after the implementation of the CLEVER package. A convenience sample of women returning for a postnatal follow-up visit was obtained at baseline (n = 653) and after implementation of CLEVER (n = 679). Results Six survey items were selected as proxies for respectful clinical care. There was no significant change in proportions of responses regarding one question, and with regard to patients receiving attention within 15 min of arrival, both the intervention and control group units showed a significant increase in positive responses (odds ratios of 8.4 and 6.1, respectively, and p values of 0.0001 and 0.0007). For the remaining four items (asking permission before doing an examination, positive communication, respectful treatment and overall satisfaction), only the intervention group showed a significant positive change (odds ratios ranging from 2.4 to 4.3; p ≤ 0.0018), with no significant change for the control group (odds ratios between 1.0 and 1.8; p ≥ 0.0736). Conclusion After the implementation of CLEVER Maternity Care, women reported a more positive experience of childbirth. The CLEVER intervention is a potential strategy for addressing respectful, quality obstetric care that warrants further investigation.
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Affiliation(s)
- Sarie J Oosthuizen
- Tshwane District Health and Department of Family Medicine, University of Pretoria, Pretoria, South Africa; and, Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; and, UP/SAMRC Unit for Maternal and Infant Health Care Strategies, Faculty of Health Sciences, University of Pretoria, Pretoria.
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Shimoda K, Leshabari S, Horiuchi S. Self-reported disrespect and abuse by nurses and midwives during childbirth in Tanzania: a cross-sectional study. BMC Pregnancy Childbirth 2020; 20:584. [PMID: 33023499 PMCID: PMC7542114 DOI: 10.1186/s12884-020-03256-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 09/15/2020] [Indexed: 11/17/2022] Open
Abstract
Background Facility-based childbirth has increased globally. Unfortunately, there have also been reports of women experiencing disrespect and abuse by healthcare providers during childbirth. This study aimed to measure the prevalence of self-reported disrespect and abuse (D&A) by healthcare providers of women during childbirth in health facilities in Tanzania, and to clarify the factors related to D&A. Methods A cross-sectional survey was conducted in public health facilities of three regions in Tanzania from September 2016 to October 2016. Nurses and midwives who had ever conducted deliveries completed a 22-item section about D&A and three sections about working conditions and environment. A model for predicting D&A based on several factors such as their characteristics, working conditions, and working environment was developed by conducting multiple regression analysis. Results Thirty public health facilities in three regions within Tanzania were selected to reflect different levels of hospitals. Among 456 participants (nurses, midwives, and nursing assistants), 439 were included in the analysis. Average number of self-reported D&A out of 22 items was five, and nearly all participants (96.1%) reported enacting one form of D&A at the least and two forms of D&A at the most. About 25–44% of D&A items were in the forms related to women’s experiences with childbirth psychologically. Moreover, at least 10–30% of the participants enacted some form of D&A which could directly affect the well-being of mothers and babies. D&A scores increased with an increase in ‘working hours per week’ and ‘taking a break during evening shifts’. D&A scores decreased with an increase in the scores of the ‘two components of the Index of Working Satisfaction (professional status and interaction between nurses)’, and ‘any type of supervision for new nurse-midwives’. Conclusion Most studies about D&A of healthcare providers previously focused on the reports of women. To our knowledge, this is the first report that focused on D&A reported by healthcare providers. Working conditions and systems including personal relationships with colleagues were both positively and negatively related to D&A of healthcare providers rather than the provider’s individual and facility structural characteristics.
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Affiliation(s)
- Kana Shimoda
- Graduate School of Nursing Science, St. Luke's International University, 10-1 Akashi-cho, Chuo-ku, Tokyo, 104-0044, Japan.
| | - Sebalda Leshabari
- School of Nursing, Muhimbili University of Health and Allied Sciences, P.O. Box 65004, Dar es Salaam, Tanzania
| | - Shigeko Horiuchi
- Graduate School of Nursing Science, St. Luke's International University, 10-1 Akashi-cho, Chuo-ku, Tokyo, 104-0044, Japan
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Asefa A, Morgan A, Gebremedhin S, Tekle E, Abebe S, Magge H, Kermode M. Mitigating the mistreatment of childbearing women: evaluation of respectful maternity care intervention in Ethiopian hospitals. BMJ Open 2020; 10:e038871. [PMID: 32883738 PMCID: PMC7473661 DOI: 10.1136/bmjopen-2020-038871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES There is a lack of evidence on approaches to mitigating mistreatment during facility-based childbirth. This study compares the experiences of mistreatment reported by childbearing women before and after implementation of a respectful maternity care intervention. DESIGN A pre-post study design was undertaken to quantify changes in women's experiences of mistreatment during facility-based childbirth before and after the respectful maternity care intervention. INTERVENTION A respectful maternity care intervention was implemented in three hospitals in southern Ethiopia between December 2017 and September 2018 and it included training of service providers, placement of wall posters in labour rooms and post-training supportive visits for quality improvement. OUTCOME MEASURES A 25-item questionnaire asking women about mistreatment experiences was administered to 388 women (198 in the pre-intervention, 190 in the post-intervention). The outcome variable was the number of mistreatment components experienced by women, expressed as a score out of 25. Multilevel mixed-effects Poisson modelling was used to assess the change in mistreatment score from pre-intervention to post-intervention periods. RESULTS The number of mistreatment components experienced by women was reduced by 18% when the post-intervention group was compared with the pre-intervention group (adjusted regression coefficient (Aβ)=0.82, 95% CI 0.74 to 0.91). Women who had a complication during pregnancy (Aβ=1.17, 95% CI 1.01 to 1.34) and childbirth (Aβ=1.16, 95% CI 1.03 to 1.32) experienced a greater number of mistreatment components. On the other hand, women who gave birth by caesarean birth after trial of vaginal birth (Aβ=0.76, 95% CI 0.63 to 0.92) and caesarean birth without trial of vaginal birth (Aβ=0.68, 95% CI 0.47 to 0.98) experienced a lesser number of mistreatment components compared with those who had vaginal birth. CONCLUSIONS Women reported significantly fewer mistreatment experiences during childbirth following implementation of the intervention. Given the variety of factors that lead to mistreatment in health facilities, interventions designed to mitigate mistreatment need to involve structural changes.
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Affiliation(s)
- Anteneh Asefa
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Alison Morgan
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Samson Gebremedhin
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ephrem Tekle
- Maternal and Child Health Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | | | - Hema Magge
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
- Division of Global Health Equity, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michelle Kermode
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Gama SGND, Viellas EF, Medina ET, Angulo-Tuesta A, Silva CKRTD, Silva SDD, Santos YRP, Esteves-Pereira AP. Delivery care by obstetric nurses in maternity hospitals linked to the Rede Cegonha, Brazil - 2017. CIENCIA & SAUDE COLETIVA 2020; 26:919-929. [PMID: 33729347 DOI: 10.1590/1413-81232021263.28482020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/03/2020] [Indexed: 11/22/2022] Open
Abstract
This study aimed to assess whether nurses' presence in delivery care in maternity hospitals linked to the Rede Cegonha program promotes access to best obstetric practices during labor and delivery. We conducted an evaluative study in 2017 in all 606 SUS maternity hospitals that joined this strategic policy in all Brazilian states. We collected data from maternity hospital managers and puerperae. The analysis was performed at two levels: hospital with or without a nurse in delivery care; and professionals that attended vaginal delivery, whether doctors or nurses. We used best practices and interventions for vaginal deliveries and cesarean section rates as dependent variables. We included 5.016 subjects for analyses of vaginal deliveries and 9.692 to calculate cesarean section rates. Multiple regressions were adjusted for geographic region, maternity hospital size, and puerperae skin color and parity. Maternity hospitals with nurses in delivery care used more the partograph and less oxytocin, lithotomy, episiotomy, and cesarean section. Deliveries attended by nurses had more frequent use of the partograph and a lower likelihood of lithotomy and episiotomy. The inclusion of nurses in vaginal delivery care has successfully brought women closer to a more physiological and respectful delivery.
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Affiliation(s)
| | - Elaine Fernandes Viellas
- Escola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
| | | | | | | | | | - Yammê Ramos Portella Santos
- Escola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
| | - Ana Paula Esteves-Pereira
- Escola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
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Lama TP, Munos MK, Katz J, Khatry SK, LeClerq SC, Mullany LC. Assessment of facility and health worker readiness to provide quality antenatal, intrapartum and postpartum care in rural Southern Nepal. BMC Health Serv Res 2020; 20:16. [PMID: 31906938 PMCID: PMC6945781 DOI: 10.1186/s12913-019-4871-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023] Open
Abstract
Background Increased coverage of antenatal care and facility births might not improve maternal and newborn health outcomes if quality of care is sub-optimal. Our study aimed to assess the facility readiness and health worker knowledge required to provide quality maternal and newborn care. Methods Using an audit tool and interviews, respectively, facility readiness and health providers’ knowledge of maternal and immediate newborn care were assessed at all 23 birthing centers (BCs) and the District hospital in the rural southern Nepal district of Sarlahi. Facility readiness to perform specific functions was assessed through descriptive analysis and comparisons by facility type (health post (HP), primary health care center (PHCC), private and District hospital). Knowledge was compared by facility type and by additional skilled birth attendant (SBA) training. Results Infection prevention items were lacking in more than one quarter of facilities, and widespread shortages of iron/folic acid tablets, injectable ampicillin/gentamicin, and magnesium sulfate were a major barrier to facility readiness. While parenteral oxytocin was commonly provided, only the District hospital was prepared to perform all seven basic emergency obstetric and newborn care signal functions. The required number of medical doctors, nurses and midwives were present in only 1 of 5 PHCCs. Private sector SBAs had significantly lower knowledge of active management of third stage of labor and correct diagnosis of severe pre-eclampsia. While half of the health workers had received the mandated additional two-month SBA training, comparison with the non-trained group showed no significant difference in knowledge indicators. Conclusions Facility readiness to provide quality maternal and newborn care is low in this rural area of Nepal. Addressing the gaps by facility type through regular monitoring, improving staffing and supply chains, supervision and refresher trainings is important to improve quality.
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Affiliation(s)
- Tsering P Lama
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD, 21205, USA
| | - Melinda K Munos
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD, 21205, USA
| | - Joanne Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD, 21205, USA
| | - Subarna K Khatry
- Nepal Nutrition Intervention Project - Sarlahi (NNIPS), Kathmandu, Nepal
| | - Steven C LeClerq
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD, 21205, USA.,Nepal Nutrition Intervention Project - Sarlahi (NNIPS), Kathmandu, Nepal
| | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Suite W5009C, Baltimore, MD, 21205, USA.
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Tello JE, Barbazza E, Waddell K. Review of 128 quality of care mechanisms: A framework and mapping for health system stewards. Health Policy 2020; 124:12-24. [PMID: 31791717 PMCID: PMC6946442 DOI: 10.1016/j.healthpol.2019.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 10/29/2019] [Accepted: 11/18/2019] [Indexed: 12/30/2022]
Abstract
Health system stewards have the critical task to identify quality of care deficiencies and resolve underlying system limitations. Despite a growing evidence-base on the effectiveness of certain mechanisms for improving quality of care, frameworks to facilitate the oversight function of stewards and the use of mechanisms to improve outcomes remain underdeveloped. This review set out to catalogue a wide range of quality of care mechanisms and evidence on their effectiveness, and to map these in a framework along two dimensions: (i) governance subfunctions; and (ii) targets of quality of care mechanisms. To identify quality of care mechanisms, a series of searches were run in Health Systems Evidence and PubMed. Additional grey literature was reviewed. A total of 128 quality of care mechanisms were identified. For each mechanism, searches were carried out for systematic reviews on their effectiveness. These findings were mapped in the framework defined. The mapping illustrates the range and evidence for mechanisms varies and is more developed for some target areas such as the health workforce. Across the governance sub-functions, more mechanisms and with evidence of effectiveness are found for setting priorities and standards and organizing and monitoring for action. This framework can support system stewards to map the quality of care mechanisms used in their systems and to uncover opportunities for optimization backed by systems thinking.
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Affiliation(s)
- Juan E Tello
- Integrated Prevention and Control of NCDs Programme, Division of NCDs and Promoting Health through the Life-Course, WHO Regional Office for Europe, Copenhagen, Denmark.
| | - Erica Barbazza
- Academic UMC, Department of Public Health, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; WHO European Centre for Primary Health Care, Almaty, Kazakhstan.
| | - Kerry Waddell
- McMaster Health Forum, McMaster University, Hamilton, Canada; WHO European Centre for Primary Health Care, Almaty, Kazakhstan.
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Copestake J, Theuss M, Brownie S, Davies G, Burke E, Mukuru M, Kyakuwaire H, Edwards G. Recently graduated midwives in Uganda: Self-perceived achievement, wellbeing and work prospects. Midwifery 2019; 82:102596. [PMID: 31887471 DOI: 10.1016/j.midw.2019.102596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 10/21/2019] [Accepted: 12/02/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE to investigate how recent graduates from a combined work/study midwifery degree programme in Uganda viewed its effects on their wellbeing and work prospects. DESIGN Using an adapted version of the Qualitative Impact Protocol (QuIP), a phenomenological approach was applied to thematic analysis to examine semi-structured interviews and WhatsApp group discussion. SETTING Introduction of enhanced midwifery training (from Diploma to Degree level) combining study with professional practice within a low income country health system facing extreme capacity constraints. PARTICIPANTS 14 members of the first cohort of graduates from the degree programme. FINDINGS The graduates were overwhelmingly positive about improved professional knowledge, clinical skills, confidence, career commitment and prospects. They also had to contend with resentment from colleagues, increased workload and debt. Counselling training, peer support, and experience of managing stress during the training helped them to cope with these challenges. CONCLUSIONS Qualitative feedback from those receiving advanced midwifery training highlights the importance of addressing social as well as technical skills, including leadership capacity and resilience in handling working relationships.
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Affiliation(s)
- James Copestake
- Department of Social and Policy Sciences, University of Bath, Bath BA2 6QP, UK.
| | - Marc Theuss
- Evaluation and Research Unit, Aga Khan Development Network, UK.
| | - Sharon Brownie
- Green Templeton College, Oxford University, 43 Woodstock Road, Oxford OX2 6 HG, UK; School of Medicine Griffith University, University Drive, Gold Coast 4222, Australia
| | - Gabby Davies
- Bath Social and Development Research Ltd., University of Bath, Bath BA2 7AY, United Kingdom.
| | - Eva Burke
- Bath Social and Development Research Ltd., University of Bath, Bath BA2 7AY, United Kingdom
| | - Moses Mukuru
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Upper Mulago Hill Road, P.O Box 7072, Kampala, Uganda.
| | - Hellen Kyakuwaire
- Aga Khan University, School of Nursing and Midwifery, Uganda, Plot 9/11 Colonol Gadaffi Road, Kampala, Uganda.
| | - Grace Edwards
- Aga Khan University, School of Nursing and Midwifery, East Africa, Plot 9/11 Colonol Gadaffi Road, Kampala, Uganda.
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Bogren M, Erlandsson K, Johansson A, Kalid M, Abdi Igal A, Mohamed J, Said F, Pedersen C, Byrskog U, Osman F. Health workforce perspectives of barriers inhibiting the provision of quality care in Nepal and Somalia - A qualitative study. SEXUAL & REPRODUCTIVE HEALTHCARE 2019; 23:100481. [PMID: 31783321 DOI: 10.1016/j.srhc.2019.100481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/15/2019] [Accepted: 11/18/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In this paper settings from Nepal and Somalia are used to focus on the perspectives of healthcare providers within two fragile health systems. The objective of this study was to describe barriers inhibiting quality healthcare in Nepal and Somalia from a health workforce perspective. METHODS Data were collected through 19 semi-structured interviews with healthcare providers working in healthcare facilities. Ten interviews were conducted in Nepal and nine in Somalia. RESULTS Various structural barriers inhibiting the availability, accessibility, and acceptability of the quality care were similar in both countries. Barriers inhibiting the availability of quality care were linked to healthcare providers being overburdened with multiple concurrent jobs. Barriers inhibiting the accessibility to quality healthcare included long distances and the uncertain availability of transportation, and barriers to acceptability of quality healthcare was inhibited by a lack of respect from healthcare providers, characterised by neglect, verbal abuse, and lack of competence. CONCLUSIONS Inequality, poverty, traditional and cultural practices plus the heavy burden placed on healthcare providers are described as the underlying causes of the poor provision of quality care and the consequential shortcomings that emerge from it. In order to improve this situation adequate planning and policies that support the deployment and retention of the healthcare providers and its equitable distribution is required. Another important aspect is provision of training to equip healthcare providers with the ability to provide respectful quality care in order for the population to enjoy good standard of healthcare services.
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Affiliation(s)
- Malin Bogren
- Institute of Health Care and Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Kerstin Erlandsson
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
| | | | | | | | | | - Fatumo Said
- Ministry of Health, Garowe, Puntland, Somalia
| | - Christina Pedersen
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
| | - Ulrika Byrskog
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
| | - Fatumo Osman
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
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Baguiya A, Meda IB, Coulibaly A, Fayama M, Sanon Ouédraogo D, Zan S, Bélemviré S, Ouédraogo HG, Kouanda S. Assessment Of Maternity Staff Training And Knowledge Of Obstetric Care In Burkina Faso: A Repeated Cross-Sectional Study. Int J Womens Health 2019; 11:577-588. [PMID: 31807085 PMCID: PMC6842283 DOI: 10.2147/ijwh.s220018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022] Open
Abstract
Background and aim The quality of maternity care in low-income countries has often been questioned. The objective of this study was to describe the trend of the percentage of staff trained on selected obstetric care topics and their level of knowledge of maternal care over a 5-year period in Burkina Faso. Methods We conducted a secondary analysis of data from two national emergency obstetric and newborn care (EmONC) needs assessments. Staff members’ knowledge scores were determined at the facility level for 2010 and 2014 and were further categorized into low (less than 50%), medium (50 to 74%) or high (at least 75%) levels. We used McNemar’s test with a 5% significance level to compare the distribution of the proportions in 2010 versus 2014. Results Out of 789 facilities surveyed in the 2014 assessment, 736 (93.3%) were eligible for this study. Most of them were primary healthcare centers (87.2%). Overall, 21.6% (n=197) of health workers in 2010 and 39% in 2014 were midwives. The proportions of staff who received training on focused antenatal care (FANC) and on how to perform active management of the third stage of labor (AMSTL) have increased by 15.8% and 14.7%, respectively. A significant proportion of facilities had health workers with a low level of knowledge of FANC (p<0.001), the parameters that indicate the start of labor (p<0.001), the monitoring of labor progress (p<0.001) and AMSTL (p<0.001). There was no significant change in staff knowledge in hospitals over the 5-year period. Conclusion From 2010 to 2014, the proportion of staff trained in obstetric care has increased. Their level of knowledge also improved, except in hospitals. However, further efforts are needed to reach a high level of knowledge.
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Affiliation(s)
- Adama Baguiya
- Research Institute of Health Sciences (IRSS), Ouagadougou, Burkina Faso
| | | | - Abou Coulibaly
- Research Institute of Health Sciences (IRSS), Ouagadougou, Burkina Faso
| | | | | | | | - Seydou Bélemviré
- United Nations Fund for Papulation (UNFPA), Ouagadougou, Burkina Faso
| | | | - Séni Kouanda
- Research Institute of Health Sciences (IRSS), Ouagadougou, Burkina Faso.,African Institute of Public Health, Ouagadougou, Burkina Faso
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Goyet S, Broch-Alvarez V, Becker C. Quality improvement in maternal and newborn healthcare: lessons from programmes supported by the German development organisation in Africa and Asia. BMJ Glob Health 2019; 4:e001562. [PMID: 31565404 PMCID: PMC6747907 DOI: 10.1136/bmjgh-2019-001562] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/02/2019] [Accepted: 07/27/2019] [Indexed: 11/25/2022] Open
Abstract
Improving the quality of maternal and child healthcare (MCH) is a mandatory step on the path to reaching the Sustainable Development Goals and Universal Health Coverage. Quality improvement (QI) in MCH is a strong focus of the bilateral development cooperation provided by Germany to help strengthen the health systems of countries with high maternal and child mortality rates and/or with high unmet needs for family planning. In this article, we report on the findings of an analysis commissioned by a community of practice on MCH, of Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). The objectives were to review the QI interventions implemented through programmes which have received technical assistance from GIZ on behalf of the German Federal Ministry for Economic Cooperation and Development in 14 Asian and African countries, to identify and describe the existing approaches and their results, and finally to draw lessons learnt from their implementation. Our analysis of the information contained in programme documents and reports identified five main methodologies used to improve the quality of care: capacity-building and supervision, governance and regulation, systemic QI at facility level, support to infrastructures, and community support. It is difficult to attribute the observed progresses in maternal and neonatal health to a particular agency, programme or intervention. We acknowledge that systemic implementation research embedded within the programmes would facilitate an understanding of the determinants of successful QI interventions, would better assess their effectiveness, and therefore better guide future bilateral aid programmatic decisions.
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Affiliation(s)
| | - Valerie Broch-Alvarez
- Health and social protection, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Kathmandu, Nepal
| | - Cornelia Becker
- Maternal and Newborn Care, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia
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Kaur J, Franzen SRP, Newton-Lewis T, Murphy G. Readiness of public health facilities to provide quality maternal and newborn care across the state of Bihar, India: a cross-sectional study of district hospitals and primary health centres. BMJ Open 2019; 9:e028370. [PMID: 31362965 PMCID: PMC6678016 DOI: 10.1136/bmjopen-2018-028370] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Poor access to quality healthcare is one of the most important reasons of high maternal and neonatal mortality in India, particularly in poorer states like Bihar. India has implemented initiatives to promote institutional maternal deliveries. It is important to ensure that health facilities are adequately equipped and staffed to provide quality care for mothers and newborns. METHODS We conducted a cross-sectional study of 190 primary health centres (PHCs) and 36 district hospitals (DHs) across all districts in Bihar to assess the readiness of facilities to provide quality maternal and neonatal care. Infrastructure, equipment and supplies and staffing were assessed using the WHO service availability and readiness assessment and Indian public health standard guidelines. Additionally, we used household survey data to assess the quality of care reported by mothers delivering at study facilities. RESULTS PHCs and DHs were found to have 61% and 67% of the mandated structural components to provide maternal and neonatal care, on average, respectively. DHs were, on average, slightly better equipped in terms of infrastructure, equipment and supplies by comparison to PHCs. DHs were found to be inadequately prepared to provide neonatal care. Lack of recommended handwashing stations and bins at both DHs and PHCs suggested low levels of hygiene. Only half of the essential drugs were available in both DHs and PHCs. While no association was revealed between structural capacity and patient-reported quality of care, adequacy of staffing was positively associated with the quality of care in DHs. CONCLUSION Examining all DHs and a representative sample of PHCs in Bihar, this study revealed the gaps in structural components that need to be filled to provide quality care to mothers and newborns. Access to quality care is essential if progress in reducing maternal and neonatal mortality is to be achieved in this high-burden state.
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Affiliation(s)
| | - Samuel Richard Piers Franzen
- Oxford Policy Management, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | - Georgina Murphy
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
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Gautham M, Bruxvoort K, Iles R, Subharwal M, Gupta S, Jain M, Goodman C. Investigating the nature of competition facing private healthcare facilities: the case of maternity care in Uttar Pradesh, India. Health Policy Plan 2019; 34:450-460. [PMID: 31302699 PMCID: PMC6735944 DOI: 10.1093/heapol/czz056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2019] [Indexed: 12/02/2022] Open
Abstract
The private healthcare sector in low- and middle-income countries is increasingly seen as of public health importance, with widespread interest in improving private provider engagement. However, there is relatively little literature providing an in-depth understanding of the operation of private providers. We conducted a mixed methods analysis of the nature of competition faced by private delivery providers in Uttar Pradesh, India, where maternal mortality remains very high. We mapped health facilities in five contrasting districts, surveyed private facilities providing deliveries and conducted in-depth interviews with facility staff, allied providers (e.g. ambulance drivers, pathology laboratories) and other key informants. Over 3800 private facilities were mapped, of which 8% reported providing deliveries, mostly clustered in cities and larger towns. 89% of delivery facilities provided C-sections, but over half were not registered. Facilities were generally small, and the majority were independently owned, mostly by medical doctors and, to a lesser extent, AYUSH (non-biomedical) providers and others without formal qualifications. Recent growth in facility numbers had led to intense competition, particularly among mid-level facilities where customers were more price sensitive. In all facilities, nearly all payment was out-of-pocket, with very low-insurance coverage. Non-price competition was a key feature of the market and included location (preferably on highways or close to government facilities), medical infrastructure, hotel features, staff qualifications and reputation, and marketing. There was heavy reliance on visiting consultants such as obstetricians, surgeons and anaesthetists, and payment of hefty commission payments to agents who brought clients to the facility, for both new patients and those transferring from public facilities. Building on these insights, strategies for private sector engagement could include a foundation of universal facility registration, adaptation of accreditation schemes to lower-level facilities, improved third-party payment mechanisms and strategic purchasing, and enhanced patient information on facility availability, costs and quality.
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Affiliation(s)
- Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
| | - Katia Bruxvoort
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA, USA
| | - Richard Iles
- School of Economic Sciences, Washington State University, Pullman, WA, USA
| | - Manish Subharwal
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Sanjay Gupta
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Manish Jain
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Catherine Goodman
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
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Alyahya MS, Khader YS, Batieha A, Asad M. The quality of maternal-fetal and newborn care services in Jordan: a qualitative focus group study. BMC Health Serv Res 2019; 19:425. [PMID: 31242940 PMCID: PMC6595569 DOI: 10.1186/s12913-019-4232-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 06/07/2019] [Indexed: 01/06/2023] Open
Abstract
Background The antenatal, intrapartum, and postnatal periods are considered high-risk periods for the health of mothers and their newborns. Although the current utilization rate of some maternal and child care services in Jordan is encouraging, detailed information about the quality of these services is limited. Therefore, this study aimed to explore the quality of maternal-fetal and newborn antenatal care (ANC), delivery, and postnatal care (PNC) services in Jordan. Methods We conducted 12 focus group discussions (FGDs) with pregnant and postpartum women who attended maternal-child care services in three major hospitals in Jordan. All FGDs were recorded and transcribed verbatim. An inductive thematic analysis approach was used to identify themes and subthemes. Results The content analysis of the FGDs revealed a consensus among the discussants regarding the importance of ANC and PNC services for the health of mothers and their newborns. However, the participating women viewed ANC to be much more important than PNC. With regards to the choice between public and private antenatal care services, some of the discussants were disposed towards the private sector. Reasons for this included longer consultation time, a higher quality of services, better interpersonal and communication skills of healthcare providers, better treatment, more advanced equipment and devices, availability of female obstetricians, and more flexible appointment times. These women only perceived public hospital services to be necessary in cases of pregnancy-related complications and labor, as the costs of private sector services in such cases are too high. The findings also revealed that mothers usually only seek PNC services to check up on their newborn’s health and not their own. Conclusion Visiting private ANC clinics throughout pregnancy while giving birth in public facilities leads to the discontinuity and fragmentation in maternal-fetal and child healthcare services. To address this fragmentation, healthcare systems are proposed to establish interprofessional teamwork that requires different healthcare providers with complementary skills and practices in both public and private settings to work co-operatively and collectively. Investment in new technologies and interventions which enhance coordination and collaboration between public and private healthcare settings is necessary for the provision of non-traditional maternal healthcare. Electronic supplementary material The online version of this article (10.1186/s12913-019-4232-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohammad S Alyahya
- Department of Health Management and Policy, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box: 3030, Irbid, 22110, Jordan.
| | - Yousef S Khader
- Department of Public Health and Community Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Anwar Batieha
- Department of Public Health and Community Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Majed Asad
- Jordan Ministry of Health, Directorate of non-communicable diseases, Amman, Jordan
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Tancred T, Bates I. Improving blood transfusion services. Best Pract Res Clin Obstet Gynaecol 2019; 61:130-142. [PMID: 31285175 DOI: 10.1016/j.bpobgyn.2019.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/19/2022]
Abstract
Postpartum haemorrhage contributes to 25% of maternal deaths worldwide, rising to 40% in sub-Saharan Africa. Treatment of postpartum haemorrhage-particularly for women with anaemia -requires timely, quality blood transfusions. There are a number of barriers to the provision of transfusion services, especially in low- and middle-income settings where the need is the greatest. These include unavailability of blood, unsafe blood, poor uptake of labour and delivery care, difficulties getting blood to transfusing facilities and poor documentation of patient information. Examples of innovative and practical solutions to overcome these barriers are highlighted.
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Affiliation(s)
- Tara Tancred
- International Public Health, Liverpool School of Tropical Medicine, UK.
| | - Imelda Bates
- International Public Health, Liverpool School of Tropical Medicine, UK
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Bhattacharyya S, Srivastava A, Saxena M, Gogoi M, Dwivedi P, Giessler K. Do women's perspectives of quality of care during childbirth match with those of providers? A qualitative study in Uttar Pradesh, India. Glob Health Action 2019; 11:1527971. [PMID: 30295161 PMCID: PMC6179056 DOI: 10.1080/16549716.2018.1527971] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background: Persistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions. Objective: This study aimed to examine pregnant women’s expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider’s perceptions of the same, as well as the barriers that limit their ability to provide high-quality care. Methods: A qualitative descriptive analysis was conducted on data from two studies – focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women’s experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016–17) to understand provision of person-centred care. Provider perspectives were matched with themes of women’s perspectives on quality of childbirth care in facilities. Results: Major themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries. Conclusions: This study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers’ perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes.
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Affiliation(s)
| | - Aradhana Srivastava
- a Research Department , Public Health Foundation of India , NCR Delhi , India
| | - Malvika Saxena
- a Research Department , Public Health Foundation of India , NCR Delhi , India
| | - Mousumi Gogoi
- a Research Department , Public Health Foundation of India , NCR Delhi , India
| | - Pravesh Dwivedi
- a Research Department , Public Health Foundation of India , NCR Delhi , India
| | - Katie Giessler
- b Global Health Sciences , University of California , San Francisco , CA , USA
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Munabi-Babigumira S, Glenton C, Willcox M, Nabudere H. Ugandan health workers' and mothers' views and experiences of the quality of maternity care and the use of informal solutions: A qualitative study. PLoS One 2019; 14:e0213511. [PMID: 30856217 PMCID: PMC6411106 DOI: 10.1371/journal.pone.0213511] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 02/22/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Although the coverage of maternity services in some low and middle-income countries (LMIC) has greatly improved, the quality of maternity care remains poor, and maternal mortality rates are high. In this study, we describe the meaning and determinants of maternity care quality from the perspective of health workers and mothers in Uganda, the informal solutions used by health workers to manage their daily challenges, and we suggest ways in which maternal care quality can be improved. METHODS We conducted a qualitative study in the Mpigi and Rukungiri districts of Uganda. Twenty-eight health workers based at selected health centres participated in structured interviews. Thirty-six mothers, half of whom had delivered at health facilities, participated in focus group discussions. Data were analysed thematically, and informed by the WHO framework on quality of care for maternal and newborn health and by Lipsky's street level bureaucracy concept. RESULTS According to health workers, knowledge of clinical standards and processes, timeliness, and women's choice during labour, as well as resources, physical infrastructure; collaboration with mothers, professionals and community health workers; were important aspects of good quality care. Mothers' perceptions of good quality care were largely similar to health workers' views, though mothers were more concerned about health workers' interaction skills. Structural challenges sometimes led health workers to develop informal solutions such as asking mothers to purchase their own supplies with variable implications on the quality of care. While several of these informal solutions were useful in addressing bottlenecks in the health system, they sometimes placed additional burdens and personal costs on health workers, created mistrust, inequity in care and negative experiences among mothers who could not afford the extra costs. CONCLUSIONS Health system structural factors; including technical, interpersonal, resource and infrastructural factors; impede the provision and experience of good quality maternity care at health centres in Uganda. Improving the quality of care will require strategies that address these core problems in the health system structure. Such structural reforms will require political support to commit resources, skilful management and leadership that seek to change organisational behaviour and build trust through good quality, woman-centred maternity care.
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Affiliation(s)
- Susan Munabi-Babigumira
- Global Health Unit, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Claire Glenton
- Global Health Unit, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
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Muller N, Emmrich PMF, Rajemison EN, De Neve JW, Bärnighausen T, Knauss S, Emmrich JV. A Mobile Health Wallet for Pregnancy-Related Health Care in Madagascar: Mixed-Methods Study on Opportunities and Challenges. JMIR Mhealth Uhealth 2019; 7:e11420. [PMID: 30457972 PMCID: PMC6423468 DOI: 10.2196/11420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/22/2018] [Accepted: 10/22/2018] [Indexed: 11/14/2022] Open
Abstract
Background Mobile savings and payment systems have been widely adopted to store money and pay for a variety of services, including health care. However, the possible implications of these technologies on financing and payment for maternal health care services—which commonly require large 1-time out-of-pocket payments—have not yet been systematically assessed in low-resource settings. Objective The aim of this study was to determine the structural, contextual, and experiential characteristics of a mobile phone–based savings and payment platform, the Mobile Health Wallet (MHW), for skilled health care during pregnancy among women in Madagascar. Methods We used a 2-stage cluster random sampling scheme to select a representative sample of women utilizing either routine antenatal (ANC) or routine postnatal care (PNC) in public sector health facilities in 2 of 8 urban and peri-urban districts of Antananarivo, Madagascar (Atsimondrano and Renivohitra districts). In a quantitative structured survey among 412 randomly selected women attending ANC or PNC, we identified saving habits, mobile phone use, media consumptions, and perception of an MHW with both savings and payment functions. To confirm and explain the quantitative results, we used qualitative data from 6 semistructured focus group discussions (24 participants in total) in the same population. Results 59.3% (243/410, 95% CI 54.5-64.1) saved toward the expected costs of delivery and, out of those, 64.4% (159/247, 95% CI 58.6-70.2) used household cash savings for this purpose. A total of 80.3% (331/412, 95% CI 76.5-84.1) had access to a personal or family phone and 35.7% (147/412, 95% CI 31.1-40.3) previously used Mobile Money services. Access to skilled health care during pregnancy was primarily limited because of financial obstacles such as saving difficulties or unpredictability of costs. Another key barrier was the lack of information about health benefits or availability of services. The general concept of an MHW for saving toward and payment of pregnancy-related care, including the restriction of payments, was perceived as beneficial and practicable by the majority of participants. In the discussions, several themes pointed to opportunities for ensuring the success of an MHW through design features: (1) intuitive technical ease of use, (2) clear communication and information about benefits and restrictions, and (3) availability of personal customer support. Conclusions Financial obstacles are a major cause of limited access to skilled maternal health care in Madagascar. An MHW for skilled health care during pregnancy was perceived as a useful and desirable tool to reduce financial barriers among women in urban Madagascar. The design of this tool and the communication strategy will likely be the key to success. Particularly important dimensions of design include technical user friendliness and accessible and personal customer service.
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Affiliation(s)
- Nadine Muller
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Department of Infectious Diseases and Pulmonary Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Elsa Niritiana Rajemison
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States.,Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Samuel Knauss
- Department of Experimental Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Julius Valentin Emmrich
- Department of Experimental Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Mukamurigo J, Dencker A, Nyirazinyoye L, Ntaganira J, Berg M. Quality of intrapartum care for healthy women with spontaneous onset of labour in Rwanda: A health facility-based, cross-sectional study. SEXUAL & REPRODUCTIVE HEALTHCARE 2019; 19:78-83. [DOI: 10.1016/j.srhc.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 01/02/2019] [Accepted: 01/14/2019] [Indexed: 12/23/2022]
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Tholandi M, Sethi R, Pedrana A, Qomariyah SN, Amelia D, Kaslam P, Sudirman S, Apriatni MS, Rahmanto A, Emerson M, Ahmed S. The effect of Expanding Maternal and Neonatal Survival interventions on improving the coverage of labor monitoring and complication prevention practices in hospitals in Indonesia: A difference‐in‐difference analysis. Int J Gynaecol Obstet 2019; 144 Suppl 1:21-29. [PMID: 30815869 DOI: 10.1002/ijgo.12732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | | | - Alisa Pedrana
- Disease Elimination Program Burnet Institute Melbourne Victoria Australia
| | | | | | | | | | | | | | - Mark Emerson
- Bloomberg School of Public Health Johns Hopkins University Baltimore MD USA
| | - Saifuddin Ahmed
- Bloomberg School of Public Health Johns Hopkins University Baltimore MD USA
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Ansari N, Manalai P, Maruf F, Currie S, Stekelenburg J, van Roosmalen J, Kim YM, Tappis H. Quality of care in early detection and management of pre-eclampsia/eclampsia in health facilities in Afghanistan. BMC Pregnancy Childbirth 2019; 19:36. [PMID: 30658606 PMCID: PMC6339332 DOI: 10.1186/s12884-018-2143-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/11/2018] [Indexed: 01/11/2023] Open
Abstract
Background Afghanistan faces a high burden of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E), are among the most common causes of maternal and neonatal complications. Hypertensive disorders of pregnancy can lead to fatal complications for both the mother and fetus. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment assessed quality of early detection and management of PE/E in health facilities and skilled birth attendants’ (SBAs) perceptions of their working environment. Methods All accessible public health facilities with an average of at least five births per day (n = 77), a nationally representative sample of public health facilities with less than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Methods included a facility inventory and record review, interviews with SBAs, and direct clinical observation of antenatal care (ANC), intrapartum care and immediate postnatal care (PNC), as well as severe PE/E case management. Results Most facilities had supplies and medicines for early detection and management of PE/E. At public health facilities, 357 of 414 (86.2%) clients observed during ANC consultations had their blood pressure checked and 159 (38.4%) were asked if they had experienced symptoms of PE/E. Only 553 of 734 (72.6%) SBAs interviewed were able to correctly identify severe pre-eclampsia described in a case scenario. Of 29 PE/E cases observed, 17 women (59%) received the correct loading dose of magnesium sulfate (MgSO4) and 12 women (41%) received the correct maintenance dose of MgSO4. At private health facilities, 39 of 45 ANC clients had their blood pressure checked and 9 of 45 (20%) were asked about symptoms of PE/E. Fifty-four of 64(84.4%) SBAs in private facilities correctly identified severe pre-eclampsia described in a case scenario. Conclusion Notable gaps in SBAs’ knowledge and clinical practices in detection and management of PE/E in various health facilities increase the risk of maternal and perinatal mortality. Continuing education of health care providers and increased investment in focused quality improvement initiatives will be critical to improve the quality of health care services in Afghanistan.
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Affiliation(s)
- Nasratullah Ansari
- Jhpiego, 1615 Thames Street, Baltimore, MD, USA. .,Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, De Boelelaan 1105, 1081, HV, Amsterdam, the Netherlands.
| | | | | | | | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.,Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
| | - Jos van Roosmalen
- Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, De Boelelaan 1105, 1081, HV, Amsterdam, the Netherlands
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