Emergency obstetric care in a rural district of Burundi: What are the surgical needs?

Addressing the need for an appropriate skilled delivery care workforce in Burundi to support Maternal and Newborn Health Service Delivery Redesign (MNH-Redesign): a sequential study protocol

Background Despite Burundi having formed a network of 112 health facilities that provide emergency obstetric and neonatal care (EmONC), the country continues to struggle with high rates of maternal and newborn deaths. There is a dearth of empirical evidence on the capacity and performance of EmONC health facilities and on the real needs to inform proper planning and policy. Our study aims to generate evidence on the capacity and performance of EmONC health facilities in Burundi and examine how the country might develop an appropriate skilled delivery care workforce to improve maternal and newborn survival. Methods We will use a sequential design where each study phase serially inputs into the subsequent phase. Three main study phases will be carried out: i) an initial policy document review to explore global norms and local policy intentions for EmONC staffing and ii) a cross-sectional survey of all EmONC health facilities to determine what percent of facilities are functional including geographic and population coverage gaps, identify staffing gaps assessed against norms, and identify other needs for health facility strengthening. Finally, we will conduct surveys in selected schools and ministries to examine training and staffing costs to inform staffing options that might best promote service delivery with adequate budget impacts to increase efficiency. Throughout the study, we will engage stakeholders to provide input into what are reasonable staffing norms as well as feasible staffing alternatives within Burundi's budget capacity. Analytical models will be used to develop staffing proposals over a realistic policy timeline. Conclusion Evidence-based health planning improves cost-effectiveness and reduces wastage within scarce and resource-constrained contexts. This study will be the first large-scale research in Burundi that builds on stakeholder support to generate evidence on the capacity of designated EmONC health facilities including human resources diagnosis and develop staffing skill-mix tradeoffs for policy discussion.

Addressing the need for an appropriate skilled delivery care workforce in Burundi to support Maternal and Newborn Health Service Delivery Redesign (MNH-Redesign): a sequential study protocol

Background Despite Burundi having formed a network of 112 health facilities that provide emergency obstetric and neonatal care (EmONC), the country continues to struggle with high rates of maternal and newborn deaths. There is a dearth of empirical evidence on the capacity and performance of EmONC health facilities and on the real needs to inform proper planning and policy. Our study aims to generate evidence on the capacity and performance of EmONC health facilities in Burundi and examine how the country might develop an appropriate skilled delivery care workforce to improve maternal and newborn survival. Methods We will use a sequential design where each study phase serially inputs into the subsequent phase. Three main study phases will be carried out: i) an initial policy document review to explore global norms and local policy intentions for EmONC staffing and ii) a cross-sectional survey of all EmONC health facilities to determine what percent of facilities are functional including geographic and population coverage gaps, identify staffing gaps assessed against norms, and identify other needs for health facility strengthening. Finally, we will conduct surveys in schools and different ministries to examine training and staffing costs to inform staffing options that might best promote service delivery with adequate budget impacts to increase efficiency. Throughout the study, we will engage stakeholders to provide input into what is reasonable staffing norms as well as feasible staffing alternatives within Burundi's budget capacity. Analytical models will be used to develop staffing proposals over a realistic policy timeline. Conclusion Evidence-based health planning improves cost-effectiveness and reduces wastage within scarce and resource-constrained contexts. This study will be the first large-scale research in Burundi that builds on stakeholder support to generate evidence on the capacity of designated EmONC health facilities including human resources diagnosis and develop staffing skill-mix tradeoffs for policy discussion.

Trends in socio-economic, sex and geographic disparities in childhood underweight in Mauritania: evidence from Multiple Indicator Cluster Surveys (2007-2015)

Background

Underweight is one of the largest contributors to child morbidity and mortality and is considered to be the largest contributor to the global burden of diseases in low-and middle-income countries. In Mauritania, where one-fifth of children are underweight, there is a dearth of evidence on socio-economic, sex and geographic disparities in childhood underweight. As a result, this study aimed at investigating the socio-economic, sex and geographic disparities in childhood underweight in Mauritania.

Methods

Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the Mauritania Multiple Indicator Cluster Surveys (MICSs) conducted between 2007 and 2015 were analysed. Childhood underweight was disaggregated by five equity stratifiers: education, wealth, residence, region and sex. In addition, absolute and relative inequality measures, namely difference (D), population attributable risk (PAR), ratio (R) and population attributable fraction (PAF) were calculated to understand inequalities from wider perspectives. Corresponding 95% confidence intervals (CIs) were computed to measure statistical significance.

Results

Substantial absolute and relative socio-economic, sex and geographic disparities in underweight were observed from 2007 to 2015. Children from the poorest households (PAR=−12.66 [95% CI −14.15 to −11.16]), those whose mothers were uneducated (PAF=−9.11 [95% CI −13.41 to −4.81]), those whose mothers were rural residents (R=1.52 [95% CI 1.37 to 1.68]), residents of HodhCharghy (PAF=−66.51 [95% CI −79.25 to −53.76]) and males (D=4.30 [95% CI 2.09 to 6.52]) experienced a higher burden of underweight. Education-related disparities decreased from 2007 to 2015. The urban–rural gap in underweight similarly decreased over time with the different measures showing slightly different reductions. Wealth-driven disparities decreased marginally from 2011 to 2015. The sex-based and regional disparities increased, at least on average, over the 8-y intersurvey period.

Conclusions

The burden of underweight was significantly higher among children from disadvantaged subpopulations, those with uneducated and poorest/poor mothers, those living in rural areas and those living in HodhCharghy. Special nutrition intervention and efforts focused on these deprived subpopulations are required to reduce childhood morbidity and mortality associated with underweight and help achieve the Sustainable Development Goals.

Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years

OBJECTIVE

To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload.

DESIGN

Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB).

SETTING

Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres.

PARTICIPANTS

The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers.

PRIMARY OUTCOME MEASURE

Volume and nature of surgical workload of different anaesthesia providers.

RESULTS

Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%.

CONCLUSION

Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.