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Gausman J, Kenu E, Adanu R, Bandoh DAB, Berrueta M, Chakraborty S, Khan N, Langer A, Nigri C, Odikro MA, Pingray V, Ramesh S, Saggurti N, Vázquez P, Williams CR, Jolivet RR. Validating the indicator "maternal death review coverage" to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data. PLoS One 2024; 19:e0303028. [PMID: 38768186 PMCID: PMC11104582 DOI: 10.1371/journal.pone.0303028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility- versus district-level data. METHODS AND FINDINGS We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of a review, the percentage of reviews that met the World Health Organization defined standard for maternal and perinatal death surveillance and response. Results were stratified by sociodemographic characteristics of women and facility location and type. We compared these estimates to that obtained using district-level data. and looked at evidence of the review at the district/provincial level. Study teams reviewed facility records at 34 facilities in Argentina, 51 facilities in Ghana, and 282 facilities in India. In total, we found 17 deaths in Argentina, 14 deaths in Ghana, and 58 deaths in India evidenced at facilities. Overall, >80% of deaths had evidence of a review at facilities. In India, a much lower percentage of deaths occurring at secondary-level facilities (61.1%) had evidence of a review compared to deaths in tertiary-level facilities (92.1%). In all three countries, only about half of deaths in each country had complete reviews: 58.8% (n = 10) in Argentina, 57.2% (n = 8) in Ghana, and 41.1% (n = 24) in India. Dramatic reductions in indicator value were seen in several subnational geographic areas, including Gonda and Meerut in India and Sunyani in Ghana. For example, in Gonda only three of the 18 reviews conducted at facilities met the definitional standard (16.7%), which caused the value of the indicator to decrease from 81.8% to 13.6%. Stratification by women's sociodemographic factors suggested systematic differences in completeness of reviews by women's age, place of residence, and timing of death. CONCLUSIONS Our study assessed the validity of an important indicator for ending preventable deaths: the coverage of reviews of maternal deaths occurring in facilities in three study settings. We found discrepancies in deaths recorded at facilities and those reported to districts from facilities. Further, few maternal death reviews met global quality standards for completeness. The value of the calculated indicator masked inaccuracies in counts of both deaths and reviews and gave no indication of completeness, thus undermining the ultimate utility of the measure in achieving an accurate measure of coverage.
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Affiliation(s)
- Jewel Gausman
- Women and Health Initiative, Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Maternal and Child Nursing Department, School of Nursing, University of Jordan, Amman, Jordan
| | - Ernest Kenu
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | - Richard Adanu
- Department of Population, Family, and Reproductive Health, University of Ghana School of Public Health, Accra, Ghana
| | - Delia A. B. Bandoh
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | - Mabel Berrueta
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | | | | | - Ana Langer
- Women and Health Initiative, Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Carolina Nigri
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | - Magdalene A. Odikro
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | - Verónica Pingray
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | | | | | - Paula Vázquez
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
- Department of Health Science, Kinesiology, and Rehabilitation, Universidad Nacional de La Matanza, Buenos Aires, Argentina
| | - Caitlin R. Williams
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
- Department of Maternal & and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - R. Rima Jolivet
- Women and Health Initiative, Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Willcox ML, Okello IA, Maidwell-Smith A, Tura AK, van den Akker T, Knight M, Dumont A, Muller I. Determinants of behaviors influencing implementation of maternal and perinatal death surveillance and response in low- and middle-income countries: A systematic review of qualitative studies. Int J Gynaecol Obstet 2024; 165:586-600. [PMID: 37727893 DOI: 10.1002/ijgo.15132] [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: 05/05/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Maternal and Perinatal Death Surveillance and Review (MPDSR) can reduce mortality but its implementation is often suboptimal, especially in low- and middle-income countries (LMICs). OBJECTIVES To understand the determinants of behaviors influencing implementation of MPDSR in LMICs (through a systematic review of qualitative studies), in order to plan an intervention to improve its implementation. SEARCH STRATEGY Terms for maternal or perinatal death reviews and qualitative studies. SELECTION CRITERIA Qualitative studies regarding implementation of MPDSR in LMICs. DATA COLLECTION AND ANALYSIS We coded the included studies using the Theoretical Domains Framework and COM-B model of behavior change (Capability, Opportunity, Motivation). We developed guiding principles for interventions to improve implementation of MPDSR. MAIN RESULTS Fifty-nine studies met our inclusion criteria. Capabilities required to conduct MPDSR (knowledge and technical/leadership skills) increase cumulatively from community to health facility and leadership levels. Physical and social opportunities depend on adequate data, human and financial resources, and a blame-free environment. All stakeholders were motivated to avoid negative consequences (blame, litigation, disciplinary action). CONCLUSIONS Implementation of MPDSR could be improved by (1) introducing structural changes to reduce negative consequences, (2) strengthening data collection tools and information systems, (3) mobilizing adequate resources, and (4) building capabilities of all stakeholders.
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Affiliation(s)
- Merlin L Willcox
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Immaculate A Okello
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Alice Maidwell-Smith
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Thomas van den Akker
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | | | - Ingrid Muller
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
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Nonyane R, Du Plessis E, Clase J. Identifying avoidable causes of perinatal deaths in a district hospital in Lesotho. Curationis 2024; 47:e1-e8. [PMID: 38426794 PMCID: PMC10912939 DOI: 10.4102/curationis.v47i1.2497] [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: 05/02/2023] [Revised: 11/10/2023] [Accepted: 12/07/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Certain determinants can be associated with avoidable perinatal deaths, and audits are needed to establish what these determinants are, and what can be done to prevent such deaths. OBJECTIVES The study aimed at identifying and describing determinants associated with avoidable perinatal deaths at a district hospital in Lesotho and strategies to curb their occurrence. METHOD A retrospective descriptive study was conducted using 142 anonymised obstetric records from January 2018 to December 2020. A data collection tool was adopted from the Perinatal Problem Identification Programme. In this tool, avoidable determinants are referred to as 'factors' or 'problems'. RESULTS A concerning number of perinatal deaths were secondary to avoidable patient factors, namely a delay in seeking medical care, inappropriate responses to antepartum haemorrhage, and inadequate responses to poor foetal movements. Medical personnel factors are also worth observing, namely incorrect use of partograph, insufficient notes to comment on avoidable factors and 'other' medical personnel problems. Ranking highest among administrative problems were the unavailability of intensive care unit beds and ventilators and inadequate resuscitation equipment. Administrative problems accounted for more perinatal deaths than the patient-related factors and medical personnel factors. CONCLUSION There is an urgent need for periodic audits, health education for patients, staff competency and the necessary equipment to resuscitate neonates.Contribution: Avoidable determinants associated with perinatal deaths in a district hospital in Lesotho could be identified. This information provides an understanding of what can be done to limit avoidable perinatal deaths.
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Affiliation(s)
- Rose Nonyane
- NuMIQ / School of Nursing Science, Faculty of Health Sciences, North-West University, Potchefstroom.
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Odhus CO, Kapanga RR, Oele E. Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002756. [PMID: 38236832 PMCID: PMC10796071 DOI: 10.1371/journal.pgph.0002756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/06/2023] [Indexed: 01/22/2024]
Abstract
The quality of health care remains generally poor across primary health care settings, especially in low- and middle-income countries where tertiary care tends to take up much of the limited resources despite primary health care being the first (and often the only) point of contact with the health system for nearly 80 per cent of people in these countries. Evidence is needed on barriers and enablers of quality improvement initiatives. This systematic review sought to answer the question: What are the enablers of and barriers to quality improvement in primary health care in low- and middle-income countries? It adopted an integrative review approach with narrative evidence synthesis, which combined qualitative and mixed methods research studies systematically. Using a customized geographic search filter for LMICs developed by the Cochrane Collaboration, Scopus, Academic Search Ultimate, MEDLINE, CINAHL, PSYCHINFO, EMBASE, ProQuest Dissertations and Overton.io (a new database for LMIC literature) were searched in January and February 2023, as were selected websites and journals. 7,077 reports were retrieved. After removing duplicates, reviewers independently screened titles, abstracts and full texts, performed quality appraisal and data extraction, followed by analysis and synthesis. 50 reports from 47 studies were included, covering 52 LMIC settings. Six themes related to barriers and enablers of quality improvement were identified and organized using the model for understanding success in quality (MUSIQ) and the consolidated framework for implementation research (CFIR). These were: microsystem of quality improvement, intervention attributes, implementing organization and team, health systems support and capacity, external environment and structural factors, and execution. Decision makers, practitioners, funders, implementers, and other stakeholders can use the evidence from this systematic review to minimize barriers and amplify enablers to better the chances that quality improvement initiatives will be successful in resource-limited settings. PROSPERO registration: CRD42023395166.
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Affiliation(s)
- Camlus Otieno Odhus
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | | | - Elizabeth Oele
- County Department of Health, County Government of Kisumu, Kisumu, Kenya
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Maliqi B, Cocoman O, Dohlsten M, Dussey S, Hinton R, Mannah MT, Muzigaba M, Rammal T, Sabiiti J, Yaqub N, Banerjee A. Strengthening the policy, implementation, and accountability environment for quality care: experiences from quality of care network countries. FRONTIERS IN HEALTH SERVICES 2024; 3:1292510. [PMID: 38292915 PMCID: PMC10825031 DOI: 10.3389/frhs.2023.1292510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024]
Abstract
Despite global commitment to universal health coverage with quality, poor quality of care (QOC) continues to impact health outcomes for mothers and newborns, especially in low-and-middle income countries. Although there is much experience from small-scale projects, without a long-term perspective it is unclear how to implement quality of care effectively and consistently for impact. In 2017, ten countries together with the WHO and a coalition of partners established the Network for Improving Quality of Care for Maternal, Newborn and Child Health (the Network). The Network agreed to pursue four strategic objectives-Leadership, Action, Learning and Accountability (LALA) for QOC. This paper describes, analyses and reflects on what has worked and some of the challenges faced in implementation of the LALA framework. The implementation of the LALA framework has served as a catalyst to develop an enabling environment for QOC in the Network countries through strengthening the policy, implementation, accountability and community engagement for quality care. Developing an enabling health system environment takes time, but it is possible and shows results. The implementation shows that health systems continue to face persistent challenges such as capacities to quickly scale up changes across subnational levels, limited workforce capability to implement quality improvement consistently and gaps in quality of relevant data. The implementation has also highlighted the need to develop new mechanisms for community engagement and learning systems that inform scaling up of good QOC practices across programmes and levels of care. Moving forward, the Network countries will build on the experiences and lessons learned and continue to strengthen the implementation of LALA strategic objectives for impact. We hope the Network experience will encourage other countries and partners to adopt the Network implementation model to enable delivery of quality care for everyone, everywhere, and actively collaborate and contribute to the QOC global learning network.
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Affiliation(s)
- Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Olive Cocoman
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Martin Dohlsten
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Selina Dussey
- Quality Management Unit, Ministry of Health, Accra, Ghana
| | | | - Margaret T. Mannah
- National Quality Management Programme, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Moise Muzigaba
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Tala Rammal
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Jesca Sabiiti
- Department of Reproductive and Child Health, Ministry of Health, Kampala, Uganda
| | - Nuhu Yaqub
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Anshu Banerjee
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
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Arendse N, Goolam Nabi Z, van Niekerk A. A qualitative exploration of forensic pathology service staff perceptions of the implementation barriers and facilitators of manual- and electronic injury mortality surveillance system methods in South Africa. BMC Public Health 2023; 23:2354. [PMID: 38017400 PMCID: PMC10685614 DOI: 10.1186/s12889-023-17337-5] [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: 08/15/2023] [Accepted: 11/25/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Injury mortality surveillance systems are critical to monitor changes in a population's injury outcomes so that relevant injury prevention responses may be adopted. This is particularly the case in South Africa, where the injury burden is nearly twice the global rate. Regular evaluations of surveillance systems are pivotal to strengthening surveillance capacity, performance, and cost effectiveness. The National Injury Mortality Surveillance System (NIMSS) is an injury mortality surveillance system that is currently focused in Mpumalanga and utilises manual and electronic web-based systems for data collection. This study explored Forensic Pathology Service (FPS) staff perceptions of the implementation barriers and facilitators of manual- and electronic injury mortality surveillance system methods. METHODS A qualitative study was employed using purposive sampling. Forty-seven participants, aged 29 to 59 years comprising 31 males and 16 females were recruited across 21 FPS facilities that serve the province. The formative evaluation occurred over the November 2019 to November 2022 period. Twelve focus group discussions were thematically analysed to determine emerging themes and patterns related to the use of the system using the WHO surveillance system guidelines as a framework. RESULTS The key themes concerning the barriers and facilitators were located along WHO attributes of simplicity, acceptability, timeliness, flexibility, data quality and stability. Distinctions between the manual and e-surveillance systems were drawn upon across the attributes highlighting their experience with the system, user preference, and its contextual relevance. With Mpumalanga predominantly rural, internet connectivity was a common issue, with most participants consequently showing a preference for the manual system, even though the electronic system's automated internal validation process was of benefit. The data quality however remained similar for both methods. With program stability and flexibility, the manual system proved more beneficial as the dataset was reported to be easily transferrable across computer devices. CONCLUSION Obtaining FPS perceptions of their experiences with the system methodologies are pertinent for the enhancement of injury surveillance systems so to improve prospective engagements with the systems. This will facilitate timely and accurate injury mortality information which is vital to inform public policy, and injury control and prevention responses.
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Affiliation(s)
- N Arendse
- Institute for Social and Health Sciences, University of South Africa (Unisa), Johannesburg, Gauteng, South Africa.
- Masculinity and Health Research Unit, South African Medical Research Council-Unisa, Cape Town, South Africa.
| | - Z Goolam Nabi
- Institute for Social and Health Sciences, University of South Africa (Unisa), Johannesburg, Gauteng, South Africa
- Masculinity and Health Research Unit, South African Medical Research Council-Unisa, Cape Town, South Africa
| | - A van Niekerk
- Institute for Social and Health Sciences, University of South Africa (Unisa), Johannesburg, Gauteng, South Africa
- Masculinity and Health Research Unit, South African Medical Research Council-Unisa, Cape Town, South Africa
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Namagembe I, Beyeza-Kashesya J, Rujumba J, K.Kaye D, Mukuru M, Kiwanuka N, Moffett A, Nakimuli A, Byamugisha J. Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda. OPEN RESEARCH AFRICA 2023; 5:31. [PMID: 37346758 PMCID: PMC10280031 DOI: 10.12688/openresafrica.13438.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 06/23/2023]
Abstract
Background: Preventable maternal and newborn deaths remain a global concern, particularly in low- and- middle-income countries (LMICs) Timely maternal death surveillance and response (MDSR) is a recommended strategy to account for such deaths through identifying contextual factors that contributed to the deaths to inform recommendations to implement in order to reduce future deaths. Implementation of MDSR is still suboptimal due to barriers such as inadequate skills and leadership to support MDSR. With the leadership of WHO and UNFPA, there is momentum to roll out MDSR, however, the barriers and enablers for implementation have received limited attention. These have implications for successful implementation. The aim of this study was: To assess barriers and facilitators to implementation of MDSR at a busy urban National Referral Hospital as perceived by health workers, administrators, and other partners in Reproductive Health. Methods: Qualitative study using in-depth interviews (24), 4 focus-group discussions with health workers, 15 key-informant interviews with health sector managers and implementing partners in Reproductive-Health. We conducted thematic analysis drawing on the Theory of Planned Behaviour (TPB). Results: The major barriers to implementation of MDSR were: inadequate knowledge and skills; fear of blame / litigation; failure to implement recommendations; burn out because of workload and inadequate leadership- to support health workers. Major facilitators were involving all health workers in the MDSR process, eliminate blame, strengthen leadership, implement recommendations from MDSR and functionalize lower health facilities (especially Health Centre -IVs). Conclusions: The barriers of MDSR include knowledge and skills gaps, fear of blame and litigation, and other health system factors such as erratic emergency supplies, and leadership/governance challenges. Recommendation: Efforts to strengthen MDSR for impact should use health system responsiveness approach to address the barriers identified, constructive participation of health workers to harness the facilitators and addressing the required legal framework.
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Affiliation(s)
- Imelda Namagembe
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University and Mulago Specialized Women Neonatal Hospital, Kampala, Uganda, +256, Uganda, Makerere University and MSWNH, Kampala, Uganda, +256, Uganda
| | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University and Mulago Specialized Women Neonatal Hospital, Kampala, Uganda, +256, Uganda, Makerere University /MSWNH, Kampala, Uganda, +256, Uganda
| | - Joseph Rujumba
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University, Kampala, Uganda, +256, Uganda
| | - Dan K.Kaye
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University, Kampala, Uganda, +256, Uganda
| | - Moses Mukuru
- Department of Health Policy Planning and Management, School of Public Health, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Ashley Moffett
- Department of Pathology and Centre for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom, University of Cambridge, Cambridge, United Kingdom, +44, UK
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Mak- CHS, Kampala, Uganda, +256, Uganda
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Kinney MV, George AS, Rhoda NR, Pattinson RC, Bergh AM. From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa. GLOBAL HEALTH: SCIENCE AND PRACTICE 2023; 11:GHSP-D-22-00213. [PMID: 37116922 PMCID: PMC10141437 DOI: 10.9745/ghsp-d-22-00213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/07/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa. METHODS Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation. RESULTS Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice. CONCLUSION This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust.
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Affiliation(s)
- Mary V. Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Asha S. George
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Natasha R. Rhoda
- Mowbray Maternity Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Robert C. Pattinson
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council and Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Anne-Marie Bergh
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council and Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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van Boekholt TA, Moturi E, Hölscher H, Schulte-Hillen C, Tappis H, Burton A. Review of maternal death audits in refugee camps in UNHCR East and Horn of Africa and Great Lakes Region, 2017-2019. Int J Gynaecol Obstet 2023; 160:483-491. [PMID: 36217727 PMCID: PMC10092615 DOI: 10.1002/ijgo.14504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/25/2022] [Accepted: 10/02/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To review the quality of maternal death audits and identify factors contributing to refugee maternal deaths in the East and Horn of Africa. METHODS Maternal death audits submitted to The UN Refugee Agency (UNHCR) from 2017 to 2019 in 43 refugee camps in eight countries were analyzed for completeness, obstetric history, cause of death, and contributing factors. RESULTS A total of 191 refugee maternal death audits were retrieved. The mean age of the deceased was 28 years (range, 15-45 years), and 13% were adolescents and 17% were of advanced maternal age. Most patients (55%) were grand multigravida (≥5 pregnancies). The majority (86%) attended antenatal care visits, with 51% attending four or more visits. Among women who delivered (n = 140), 91% were facility-based deliveries. Most (68%) deaths occurred postpartum. Obstetric hemorrhage (49%) was the leading direct cause of death (with 77 cases of postpartum hemorrhage), followed by hypertensive disorder (19%) and infection (15%). Delays in care were identified in 185 (97%) cases. Delays in receiving care were more prevalent (81%) than in seeking (61%) and reaching (26%) care. CONCLUSION Factors contributing to delays in receiving care highlight the capacity gaps in provision of emergency obstetric care, including management of postpartum hemorrhage, requiring urgent additional investments. Audit findings also show the need for attention and action towards family planning, contraception, and adolescent sexual and reproductive health services.
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Affiliation(s)
- Tessa A van Boekholt
- UNHCR Regional Bureau of East and Horn of Africa and Great Lakes, Nairobi, Kenya
| | - Edna Moturi
- UNHCR Regional Bureau of East and Horn of Africa and Great Lakes, Nairobi, Kenya
| | | | | | - Hannah Tappis
- John Hopkins Center for Humanitarian Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ann Burton
- UNHCR Public Health Section, Geneva, Switzerland
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Willcox ML, Okello IA, Maidwell-Smith A, Tura AK, van den Akker T, Knight M. Maternal and perinatal death surveillance and response: a systematic review of qualitative studies. Bull World Health Organ 2023; 101:62-75G. [PMID: 36593778 PMCID: PMC9795385 DOI: 10.2471/blt.22.288703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 01/04/2023] Open
Abstract
Objective To understand the experiences and perceptions of people implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries, and the mechanisms by which this process can achieve its intended outcomes. Methods In June 2022, we systematically searched seven databases for qualitative studies of stakeholders implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries. Two reviewers independently screened articles and assessed their quality. We used thematic synthesis to derive descriptive themes and a realist approach to understand the context-mechanism-outcome configurations. Findings Fifty-nine studies met the inclusion criteria. Good outcomes (improved quality of care or reduced mortality) were underpinned by a functional action cycle. Mechanisms for effective death surveillance and response included learning, vigilance and implementation of recommendations which motivated further engagement. The key context to enable effective death surveillance and response was a blame-free learning environment with good leadership. Inadequate outcomes (lack of improvement in care and mortality and discontinuation of death surveillance and response) resulted from a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which led to demotivation and disengagement. Some harmful outcomes were reported, such as inappropriate referrals and worsened staff shortages, which resulted from a fear of negative consequences, including blame, disciplinary action or litigation. Conclusion Conditions needed for effective maternal and/or perinatal death surveillance and response include: separation of the process from litigation and disciplinary procedures; comprehensive guidelines and training; adequate resources to implement recommendations; and supportive supervision to enable safe learning.
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Affiliation(s)
- Merlin L Willcox
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Immaculate A Okello
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Alice Maidwell-Smith
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Abera K Tura
- School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, England
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11
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Abouchadi S, Godin I, Zhang WH, De Brouwere V. Eight-year experience of maternal death surveillance in Morocco: qualitative study of stakeholders’ views at a subnational level. BMC Public Health 2022; 22:2111. [DOI: 10.1186/s12889-022-14556-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 11/05/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background
Since 2009, Morocco has been implementing the Maternal Death Surveillance System (MDSS). The results obtained indicate significant regional variations in terms of implementation stage, completeness of maternal death reporting, and information use for action. The objective of this research is to better understand the contextual factors involved in the implementation process and use of MDSS, with a focus on the facilitators and barriers, as experienced by stakeholders in health regions.
Methods
Evaluation research was conducted in 2017 based on a descriptive qualitative study using semi-structured in-depth interviews, in four out of the twelve health regions of Morocco. A total of thirty-one in-depth interviews were held with members of regional committees of maternal death reviews (RC-MDR) and other key informant staff. Interviews focused on participants’ views and their experiences with the MDSS since the introduction in 2009. We conducted thematic analysis relied on inductive and deductive approaches. Applying the Consolidated Framework for Implementation Research guided data analysis and reporting findings.
Findings
Engaging leadership at all health system levels, regular training of district and regional MDSS coordinators and supportive supervision at a national level were the most important MDSS implementation facilitators. Reported barriers were essentially related to the review system: Irregular review meetings, blame culture, high turn-over of RC-MDR members, lack of analytical capacity to inform the review process and formulate recommendations, finally limited accountability for recommendation follow-up. While financial incentives boosted MDSS adoption, they were nonetheless a substantial barrier to its sustainability.
Conclusions
The MDSS is a complex process that requires taking numerous steps, including the commitment of multiple stakeholders with varying roles as well as information sharing across health system levels. Contextual factors that influence MDSS implementation at the sub-national level are to be considered. Horizontal and vertical communication about MDSS goals and feedback is crucial to strengthen stakeholders’ commitment, hence improving quality and use of MDSS. Furthermore, health regions should place emphasis on making high-quality recommendations in partnerships between the regional management teams, RC-MDR members and external stakeholders.
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12
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Cetin K, Worku D, Demtse A, Melberg A, Miljeteig I. "Death audit is a fight" - provider perspectives on the ethics of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system in Ethiopia. BMC Health Serv Res 2022; 22:1214. [PMID: 36175949 PMCID: PMC9524002 DOI: 10.1186/s12913-022-08568-0] [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: 03/09/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal and neonatal health are regarded as important indicators of health in most countries. Death auditing through, for example, the Maternal and Perinatal Death Surveillance and Response (MPDSR) is viewed as key to preventing maternal and newborn mortality. However, little is known about the implications of implementing perinatal auditing for healthcare professionals in low-income contexts. This study aimed to explore the ethical and practical consequences clinicians experience concerning MPDSR reporting practices in Ethiopia. METHODS: Qualitative semi-structured in-depth individual interviews were conducted with 16 healthcare workers across professions at selected facilities in Ethiopia. The interview questions were related to clinicians' experiences with, and perceptions of, death auditing. Their strategies for coping with newborn losses and the related reporting practices were also explored. The material was analyzed following systematic text condensation, and the NVivo11 software was used for organizing and coding the data material. RESULTS Participants experienced fear of punishment and blame in relation to the perinatal death auditing process. They found that auditing did not contribute to reducing perinatal deaths and that their motivation to stick to the obligation was negatively affected by this. Performing audits without available resources to provide optimal care or support in the current system was perceived as unfair. Some hid information or misreported information in order to avoid accusations of misconduct when they felt they were not to blame for the baby's death. Coping strategies such as engaging in exceedingly larger work efforts, overtreating patients, or avoiding complicated medical cases were described. CONCLUSIONS Experiencing perinatal death and death reporting constitutes a double burden for the involved healthcare workers. The preventability of perinatal death is perceived as context-dependent, and both clinicians and the healthcare system would benefit from a safe and blame-free reporting environment. To support these healthcare workers in a challenging clinical reality, guidelines and action plans that are specific to the Ethiopian context are needed.
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Affiliation(s)
- Kaya Cetin
- Bergen Center for Ethics and Priority Setting, University of Bergen, Bergen, Norway.
| | - Dawit Worku
- Addis Center for Ethics and Priority Setting, Addis Ababa University, Addis Ababa, Ethiopia
| | - Asrat Demtse
- Addis Center for Ethics and Priority Setting, Addis Ababa University, Addis Ababa, Ethiopia
| | - Andrea Melberg
- Bergen Center for Ethics and Priority Setting, University of Bergen, Bergen, Norway
| | - Ingrid Miljeteig
- Bergen Center for Ethics and Priority Setting, University of Bergen, Bergen, Norway
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13
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Kinney M, Bergh AM, Rhoda N, Pattinson R, George A. Exploring the sustainability of perinatal audit in four district hospitals in the Western Cape, South Africa: a multiple case study approach. BMJ Glob Health 2022; 7:bmjgh-2022-009242. [PMID: 35738843 PMCID: PMC9226866 DOI: 10.1136/bmjgh-2022-009242] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/29/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Maternal and perinatal death surveillance and response (MPDSR) is an intervention process that uses a continuous cycle of identification, notification and review of deaths to determine avoidable causes followed by actions to improve health services and prevent future deaths. This study set out to understand how and why a perinatal audit programme, a form of MPDSR, has sustained practice in South Africa from the perspectives of those engaged in implementation. Methods A multiple case study design was carried out in four rural subdistricts of the Western Cape with over 10 years of implementing the programme. Data were collected from October 2019 to March 2020 through non-participant observation of seven meetings and key informant interviews with 41 purposively selected health providers and managers. Thematic analysis was conducted inductively and deductively adapting the extended normalisation process theory to examine the capability, contribution, potential and capacity of the users to implement MPDSR. Results The perinatal audit programme has sustained practice due to integration of activities into routine tasks (capability), clear value-add (contribution), individual and collective commitment (potential), and an enabling environment to implement (capacity). The complex interplay of actors, their relationships and context revealed the underlying individual-level and organisational-level factors that support sustainability, such as trust, credibility, facilitation and hierarchies. Local adaption and the broad social and structural resources were required for sustainability. Conclusion This study applied theory to explore factors that promote sustained practice of perinatal audit from the perspectives of the users. Efforts to promote and sustain MPDSR will benefit from overall good health governance, specific skill development, embedded activities, and valuing social processes related to implementation. More research using health policy and system approaches, including use of implementation theory, will further advance our understanding on how to support sustained MPDSR practice in other settings.
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Affiliation(s)
- Mary Kinney
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa
| | - Anne-Marie Bergh
- Maternal and Infant Health Care Strategies Research Unit, Medical Research Council of South Africa, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Natasha Rhoda
- Department of Neonatology, Mowbray Maternity Hospital, Cape Town, South Africa.,Department of Paediatrics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Robert Pattinson
- Maternal and Infant Health Care Strategies Research Unit, Medical Research Council of South Africa, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Asha George
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa
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14
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Kashililika CJ, Moshi FV. Implementation of maternal and perinatal death surveillance and response system among health facilities in Morogoro Region: a descriptive cross-sectional study. BMC Health Serv Res 2021; 21:1242. [PMID: 34789245 PMCID: PMC8596850 DOI: 10.1186/s12913-021-07268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND When used effectively, the Maternal and Perinatal Death Surveillance and Response (MPDSR) system can bring into reality a revolutionary victory in the fight against maternal and perinatal mortality from avoidable causes. This study aimed at determining the status of implementation of the system among health facilities in the Morogoro Region. METHOD This study was conducted among 38 health facilities from three districts of the Morogoro region, Tanzania, from April 27, 2020, to May 29, 2020. Quantitative data were collected through document review for MPDSR implementation status. The outcome was determined by using a unique scoring sheet with a total of 30 points. Facilities that scored less than 11 points were considered to be in the pre-implementation phase, those scored 11 to 17 were considered in the implementation phase, and those scored 18 to 30 were considered to be in the institutionalization phase. RESULTS The majority 20(53 %) of health facilities were in the pre-implementation phase, only 15(40 %) of assessed health facilities were in the implementation phase, and few 3(8 %) of health facilities were in institutionalization phase. There was a strong evidence that MPDSR implementation was more advanced in urban compared to rural health facilities (Fisher's test = 6.158, p = 0.049), hospitals compared to health centers (Fisher's test =14.609, p <0.001) and private and faith-based organization than public facilities (Fisher's test, 15.897 = p = 0.002). CONCLUSIONS The study revealed that health facilities in Morogoro Region have not adequately implemented the MPDSR system. The majority of health facilities in rural settings and owned by the government showed poor MPDSR implementation and hence called for immediate action to rectify the situation. Strengthen MPDSR implementation, health facilities should be encouraged to adhere to the available MPDSR guidelines in the process of death reviews. Transparent systems should also be established to ensure thorough tracking and follow-up of recommendations evolving from MPDSR reviews. Health facilities should also consider integrating MPDSR to other quality improvement teams to maximize its efficiency.
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Affiliation(s)
- Christina Jacob Kashililika
- Department of Clinical Nursing School of Nursing and Public Health, The University of Dodoma, P.O. Box 259, Dodoma, Tanzania
| | - Fabiola Vincent Moshi
- Department of Nursing Management and Education, School of Nursing and Public Health, The University of Dodoma, P.O BOX 259, Dodoma, Tanzania
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15
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Kinney MV, Day LT, Palestra F, Biswas A, Jackson D, Roos N, de Jonge A, Doherty P, Manu AA, Moran AC, George AS. Overcoming blame culture: key strategies to catalyse maternal and perinatal death surveillance and response. BJOG 2021; 129:839-844. [PMID: 34709701 PMCID: PMC9298870 DOI: 10.1111/1471-0528.16989] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/29/2022]
Affiliation(s)
- M V Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - L T Day
- Maternal Newborn Health Group, Maternal Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, UK.,Maternal Newborn Health Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - F Palestra
- World Health Organization, Geneva, Switzerland
| | | | - D Jackson
- School of Public Health, University of the Western Cape, Bellville, South Africa.,Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - N Roos
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Stockholm, Sweden
| | - A de Jonge
- Midwifery Science, AVAG (Academy Midwifery Amsterdam and Groningen), Amsterdam Public Health Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,University Medical Center Groningen, Groningen, The Netherlands
| | - P Doherty
- Options Consultancy Services Ltd, St Magnus House, London, UK
| | - A A Manu
- Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - A C Moran
- Department of Maternal, Newborn, Child, Adolescent Health & Ageing, World Health Organization, Geneva, Switzerland
| | - A S George
- School of Public Health, University of the Western Cape, Bellville, South Africa
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16
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Hug L, You D, Blencowe H, Mishra A, Wang Z, Fix MJ, Wakefield J, Moran AC, Gaigbe-Togbe V, Suzuki E, Blau DM, Cousens S, Creanga A, Croft T, Hill K, Joseph KS, Maswime S, McClure EM, Pattinson R, Pedersen J, Smith LK, Zeitlin J, Alkema L. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. Lancet 2021; 398:772-785. [PMID: 34454675 PMCID: PMC8417352 DOI: 10.1016/s0140-6736(21)01112-0] [Citation(s) in RCA: 165] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Stillbirths are a major public health issue and a sensitive marker of the quality of care around pregnancy and birth. The UN Global Strategy for Women's, Children's and Adolescents' Health (2016-30) and the Every Newborn Action Plan (led by UNICEF and WHO) call for an end to preventable stillbirths. A first step to prevent stillbirths is obtaining standardised measurement of stillbirth rates across countries. We estimated stillbirth rates and their trends for 195 countries from 2000 to 2019 and assessed progress over time. METHODS For a systematic assessment, we created a dataset of 2833 country-year datapoints from 171 countries relevant to stillbirth rates, including data from registration and health information systems, household-based surveys, and population-based studies. After data quality assessment and exclusions, we used 1531 datapoints to estimate country-specific stillbirth rates for 195 countries from 2000 to 2019 using a Bayesian hierarchical temporal sparse regression model, according to a definition of stillbirth of at least 28 weeks' gestational age. Our model combined covariates with a temporal smoothing process such that estimates were informed by data for country-periods with high quality data, while being based on covariates for country-periods with little or no data on stillbirth rates. Bias and additional uncertainty associated with observations based on alternative stillbirth definitions and source types, and observations that were subject to non-sampling errors, were included in the model. We compared the estimated stillbirth rates and trends to previously reported mortality estimates in children younger than 5 years. FINDINGS Globally in 2019, an estimated 2·0 million babies (90% uncertainty interval [UI] 1·9-2·2) were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13·9 stillbirths (90% UI 13·5-15·4) per 1000 total births. Stillbirth rates in 2019 varied widely across regions, from 22·8 stillbirths (19·8-27·7) per 1000 total births in west and central Africa to 2·9 (2·7-3·0) in western Europe. After west and central Africa, eastern and southern Africa and south Asia had the second and third highest stillbirth rates in 2019. The global annual rate of reduction in stillbirth rate was estimated at 2·3% (90% UI 1·7-2·7) from 2000 to 2019, which was lower than the 2·9% (2·5-3·2) annual rate of reduction in neonatal mortality rate (for neonates aged <28 days) and the 4·3% (3·8-4·7) annual rate of reduction in mortality rate among children aged 1-59 months during the same period. Based on the lower bound of the 90% UIs, 114 countries had an estimated decrease in stillbirth rate since 2000, with four countries having a decrease of at least 50·0%, 28 having a decrease of 25·0-49·9%, 50 having a decrease of 10·0-24·9%, and 32 having a decrease of less than 10·0%. For the remaining 81 countries, we found no decrease in stillbirth rate since 2000. Of these countries, 34 were in sub-Saharan Africa, 16 were in east Asia and the Pacific, and 15 were in Latin America and the Caribbean. INTERPRETATION Progress in reducing the rate of stillbirths has been slow compared with decreases in the mortality rate of children younger than 5 years. Accelerated improvements are most needed in the regions and countries with high stillbirth rates, particularly in sub-Saharan Africa. Future prevention of stillbirths needs increased efforts to raise public awareness, improve data collection, assess progress, and understand public health priorities locally, all of which require investment. FUNDING Bill & Melinda Gates Foundation and the UK Foreign, Commonwealth and Development Office.
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Affiliation(s)
- Lucia Hug
- Division of Data, Analytics, Planning and Monitoring, UNICEF, New York, NY, USA.
| | - Danzhen You
- Division of Data, Analytics, Planning and Monitoring, UNICEF, New York, NY, USA
| | - Hannah Blencowe
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Anu Mishra
- Division of Data, Analytics, Planning and Monitoring, UNICEF, New York, NY, USA
| | - Zhengfan Wang
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | | | | | - Allisyn C Moran
- Department of Maternal, Newborn, Child and Adolescent Health, WHO, Geneva, Switzerland
| | | | - Emi Suzuki
- Development Data Group, World Bank, Washington, DC, USA
| | - Dianna M Blau
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Simon Cousens
- Maternal, Adolescent, Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Trevor Croft
- The Demographic and Health Surveys Program, ICF, Rockville, MD, USA
| | | | - K S Joseph
- University of British Columbia, Vancouver, BC, Canada; Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada
| | | | | | - Robert Pattinson
- SAMRC/UP Maternal and Infant Health Care Strategies Unit, Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa
| | | | - Lucy K Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jennifer Zeitlin
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Leontine Alkema
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
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