1
|
Tura AK, Knight M, Girma S, Ahmed R, Yuya M, Bekele D, Hassen TA, Stekelenburg J, van den Akker T. Characteristics and outcomes of pregnant women hospitalized with severe maternal outcomes in eastern Ethiopia: Results from the Ethiopian Obstetric Surveillance System study. Int J Gynaecol Obstet 2024; 164:714-720. [PMID: 37961999 PMCID: PMC10952177 DOI: 10.1002/ijgo.15240] [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: 04/29/2023] [Revised: 10/16/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVE The aim of the present study was to identify facility-based incidence of severe obstetric complications through a newly established obstetric surveillance system in eastern Ethiopia. METHODS Monthly registration of obstetric hemorrhage, eclampsia, uterine rupture, severe anemia and sepsis was introduced in 13 maternity units in eastern Ethiopia. At each hospital, a designated clinician reported details of women admitted during pregnancy, childbirth or within 42 days of termination of pregnancy from April 01, 2021 to March 31, 2022 developing any of these conditions. Detailed data on sociodemographic characteristics, obstetric complications and status at discharge were collected by trained research assistants. RESULTS Among 38 782 maternities during the study period, 2043 (5.3%) women had any of the five conditions. Seventy women died, representing a case fatality rate of 3.4%. The three leading reasons for admission were obstetric hemorrhage (972; 47.6%), severe anemia (727; 35.6%), and eclampsia (438; 21.4%). The majority of the maternal deaths were from obstetric hemorrhage (27/70; 38.6%) followed by eclampsia (17/70; 24.3%). CONCLUSION Obstetric hemorrhage, severe anemia and eclampsia were the leading causes of severe obstetric complications in eastern Ethiopia. Almost one in 29 women admitted with obstetric complications died. Audit of quality of care is indicated to design tailored interventions to improve maternal survival and obstetric complications.
Collapse
Affiliation(s)
- Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical SciencesHaramaya UniversityHararEthiopia
- Department of Obstetrics and GynecologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Marian Knight
- National Perinatal Epidemiology UnitUniversity of OxfordOxfordUK
| | - Sagni Girma
- School of Nursing and Midwifery, College of Health and Medical SciencesHaramaya UniversityHararEthiopia
- Department of Obstetrics and GynecologyLeiden University Medical CenterLeidenThe Netherlands
| | - Redwan Ahmed
- Department of Obstetrics and GynecologyHiwot Fana Specialized University HospitalHararEthiopia
| | - Mohammed Yuya
- Department of Obstetrics and GynecologyLeiden University Medical CenterLeidenThe Netherlands
- School of Public Health, College of Health and Medical Sciences, Haramaya UniversityHararEthiopia
| | - Delayehu Bekele
- Department of Obstetrics and GynecologySt. Paul's Hospital Millennium Medical CollegeAddis AbabaEthiopia
| | - Tahir Ahmed Hassen
- Center for Women's Health ResearchUniversity of NewcastleNewcastleNew South WalesAustralia
| | - Jelle Stekelenburg
- Department of Health Sciences, Global HealthUniversity Medical Center Groningen, University of GroningenThe Netherlands
- Department of Obstetrics and GynecologyLeeuwarden Medical CenterLeeuwardenThe Netherlands
| | - Thomas van den Akker
- National Perinatal Epidemiology UnitUniversity of OxfordOxfordUK
- Department of Obstetrics and GynecologyLeiden University Medical CenterLeidenThe Netherlands
- Athena Institute, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| |
Collapse
|
2
|
Olde Loohuis KM, de Kok BC, Bruner W, Jonker A, Salia E, Tunçalp Ö, Portela A, Mehrtash H, Grobbee DE, Srofeneyoh E, Adu-Bonsaffoh K, Brown Amoakoh H, Amoakoh-Coleman M, Browne JL. Strategies to improve interpersonal communication along the continuum of maternal and newborn care: A scoping review and narrative synthesis. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002449. [PMID: 37819950 PMCID: PMC10566738 DOI: 10.1371/journal.pgph.0002449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/12/2023] [Indexed: 10/13/2023]
Abstract
Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns' families. Eligible studies were published in English between January 1st 2000 and July 1st 2020. In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals (building a relationship, inclusion of women and partners in decision making) could further improve the experience of care for women, their partners and the families of newborns.
Collapse
Affiliation(s)
- Klaartje M. Olde Loohuis
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bregje C. de Kok
- Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
| | - Winter Bruner
- Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center, Memphis, TN, United States of America
| | - Annemoon Jonker
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emmanuella Salia
- Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center, Memphis, TN, United States of America
| | - Özge Tunçalp
- Department of Sexual and Reproductive Health and Research Including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Hedieh Mehrtash
- Department of Sexual and Reproductive Health and Research Including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Diederick E. Grobbee
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emmanuel Srofeneyoh
- Department of Obstetrics and Gynecology, Greater Regional Hospital, Accra, Ghana
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana
| | - Hannah Brown Amoakoh
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Accra, Accra, Ghana
| | - Mary Amoakoh-Coleman
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Accra, Accra, Ghana
| | - Joyce L. Browne
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
3
|
Sørensen JB, Housseine N, Maaløe N, Bygbjerg IC, Pinkowski Tersbøl B, Konradsen F, Sequeira Dmello B, van Den Akker T, van Roosmalen J, Mookherji S, Siaity E, Osaki H, Khamis RS, Kujabi ML, John TW, Wolf Meyrowitsch D, Mbekenga C, Skovdal M, L Kidanto H. Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study. Glob Health Action 2022; 15:2034136. [PMID: 35311627 PMCID: PMC8942528 DOI: 10.1080/16549716.2022.2034136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study’s programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants’ motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.
Collapse
Affiliation(s)
- Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Housseine
- Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Konradsen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Sequeira Dmello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania.,Comprehensive Community Based Rehabilitation in Tanzania Tanzania
| | - Thomas van Den Akker
- Athena Institute is the department, Athena Institute, VU University, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jos van Roosmalen
- Athena Institute is the department, Athena Institute, VU University, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sangeeta Mookherji
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington DC, US
| | - Eunice Siaity
- Medical college, Aga Khan University, School of Nursing and Midwifery East Africa, Dar Es Salaam Campus Tanzania
| | - Haika Osaki
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Rashid Saleh Khamis
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Monica Lauridsen Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Wiswa John
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Columba Mbekenga
- Medical college, Aga Khan University, School of Nursing and Midwifery East Africa, Dar Es Salaam Campus Tanzania
| | - Morten Skovdal
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hussein L Kidanto
- Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| |
Collapse
|
4
|
Maaløe N, Housseine N, Sørensen JB, Obel J, Sequeira DMello B, Kujabi ML, Osaki H, John TW, Khamis RS, Muniro ZSS, Nkungu DJ, Pinkowski Tersbøl B, Konradsen F, Mookherji S, Mbekenga C, Meguid T, van Roosmalen J, Bygbjerg IC, van den Akker T, Jensen AK, Skovdal M, L. Kidanto H, Wolf Meyrowitsch D. Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study). Glob Health Action 2022; 15:2034135. [PMID: 35410590 PMCID: PMC9009913 DOI: 10.1080/16549716.2022.2034135] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 01/21/2022] [Indexed: 11/04/2022] Open
Abstract
While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.
Collapse
Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Natasha Housseine
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Josephine Obel
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Sequeira DMello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
- Comprehensive Community Based Rehabilitation in Tanzania, Dar Es Salaam, Tanzania
| | - Monica Lauridsen Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Haika Osaki
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Thomas Wiswa John
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Rashid Saleh Khamis
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | | | | | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Konradsen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sangeeta Mookherji
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Columba Mbekenga
- School of Nursing and Midwifery East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | | | - Jos van Roosmalen
- Athena Institute, VU University, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Thomas van den Akker
- Athena Institute, VU University, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Andreas Kryger Jensen
- Section for Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Morten Skovdal
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hussein L. Kidanto
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
5
|
Mwansisya T, Mbekenga C, Isangula K, Mwasha L, Mbelwa S, Lyimo M, Kisaka L, Mathias V, Pallangyo E, Edwards G, Mantel M, Konteh S, Rutachunzibwa T, Mrema S, Kidanto H, Temmerman M. The impact of training on self-reported performance in reproductive, maternal, and newborn health service delivery among healthcare workers in Tanzania: a baseline- and endline-survey. Reprod Health 2022; 19:143. [PMID: 35725562 PMCID: PMC9210613 DOI: 10.1186/s12978-022-01452-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 06/01/2022] [Indexed: 11/21/2022] Open
Abstract
Background Delivery of quality reproductive health services has been documented to depend on the availability of healthcare workers who are adequately supported with appropriate training. However, unmet training needs among healthcare workers in reproductive, maternal, and newborn health (RMNH) in low-income countries remain disproportionately high. This study investigated the effectiveness of training with onsite clinical mentorship towards self-reported performance in RMNH among healthcare workers in Mwanza Region, Tanzania. Methods The study used a quasi-experimental design with pre-and post-intervention evaluation strategy. The baseline was compared with two endline groups: those with intervention (training and onsite mentorship) and those without. The differences among the three groups in the sociodemographic characteristics were analyzed by using chi-square test for categorical variables, independent-sample t-test for continuous variables and Mann–Whitney U test for ordinal or skewed continuous data. The independent sample t-test was used to determine the effect of the intervention by comparing the computed self-reported performance on RMNH services between the intervention and control groups. The paired-samples t-test was used to measure the differences between before and after intervention groups. Significance was set at a 95% confidence interval with p ≤ 0.05. Results The study included a sample of 216 participants with before and after intervention groups comprising of 95 (44.0%) and 121 (56.0%) in the control group. The comparison between before and after intervention groups revealed a statistically significant difference (p ≤ 0.05) in all the dimensions of the self-reported performance scores. However, the comparison between intervention groups and controls indicated a statistical significant difference on intra-operative care (t = 3.10, df = 216, p = 0.002), leadership skills (t = 1.85, df = 216, p = 0.050),
Comprehensive emergency obstetric and newborn care (CEMONC) (t = 34.35, df = 216, p ≤ 0.001), and overall self-reported performance in RMNH (t = 3.15, df = 216, p = 0.002). Conclusions This study revealed that the training and onsite clinical mentorship to have significant positive changes in self-reported performance in a wide range of RMNH services especially on intra-operative care, leadership skills and CEMONC. However, further studies with rigorous designs are warranted to evaluate the long-term effect of such training programs on RMNH outcomes. Reproductive maternal and newborn health (RMNH) in low- and middle-income countries continue to face critical challenges. Training healthcare workers especially using a combined approach (training followed by immediate clinical mentorship) in RMNH have been documented as an essential strategy to reduce maternal and neonatal mortality in low-and middle-income countries closer to those in high-income countries. This study investigated the effectiveness of a Continuous Professional Development (CPD) trainings on performance among healthcare workers in Mwanza Region. The study included a sample of 216 participants with before and after intervention groups comprising of 95 participants and control group comprising of 121 participants. The findings revealed that in comparison between before and after intervention groups all dimensions of the self-reported TNA questionnaire had a statistically significant difference. However, the comparison between intervention and controls groups indicated a statistical significant difference on leadership skills, intra-operative care,
Comprehensive emergency obstetric and newborn care (CEMONC) and overall RMNH self-reported performance. In conclusion, the findings demonstrated that healthcare workers’ self-identified and prioritized training needs that are supported with clinical mentorship results in significant positive changes in performance across a wide range of RMNH tasks. Therefore, conducting TNA that is followed by training and mentorship according to the identified needs among healthcare workers plays a significant role in improving performance on RMNH services among healthcare workers.
Collapse
Affiliation(s)
- Tumbwene Mwansisya
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania.
| | - Columba Mbekenga
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Kahabi Isangula
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Loveluck Mwasha
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Stewart Mbelwa
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Mary Lyimo
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Lucy Kisaka
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Victor Mathias
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Eunice Pallangyo
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Grace Edwards
- School of Nursing and Midwifery, The Aga Khan University, Kampala, Uganda
| | - Michaela Mantel
- Centre of Excellence in Women and Child Health, The Aga Khan University, Nairobi, Kenya
| | | | | | | | - Hussein Kidanto
- Department of Obstetrics and Gynecology, Aga Khan University, Dar es Salaam, Tanzania
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, The Aga Khan University, Nairobi, Kenya
| |
Collapse
|
6
|
Maaløe N, van Roosmalen J, Dmello B, Kwast B, van den Akker T, Housseine N, Kujabi M, Meguid T, Kidanto H. WHO next-generation partograph: revolutionary steps towards individualised labour care? BJOG 2021; 129:682-684. [PMID: 34520112 DOI: 10.1111/1471-0528.16914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Affiliation(s)
- N Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - J van Roosmalen
- Athena Institute, VU University, Amsterdam, the Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - B Dmello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es salaam, United Republic of Tanzania.,Medical College East Africa, Aga Khan University, Dar es Salaam, United Republic of Tanzania
| | - B Kwast
- International Consultant Maternal Health and Safe Motherhood, Leusden, the Netherlands
| | - T van den Akker
- Athena Institute, VU University, Amsterdam, the Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - N Housseine
- Medical College East Africa, Aga Khan University, Dar es Salaam, United Republic of Tanzania
| | - M Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - T Meguid
- Kivunge Hospital, Zanzibar, United Republic of Tanzania
| | - H Kidanto
- Medical College East Africa, Aga Khan University, Dar es Salaam, United Republic of Tanzania
| |
Collapse
|
7
|
Sequeira Dmello B, Sellah Z, Magembe G, Housseine N, Maaløe N, van den Akker T, Meyrowitsch DW, Mushi T, Masweko M, Jidayi D, van Roosmalen J, Kidanto HL. Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019. BMJ Glob Health 2021; 6:bmjgh-2020-004022. [PMID: 33479018 PMCID: PMC7825259 DOI: 10.1136/bmjgh-2020-004022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/24/2020] [Accepted: 12/26/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction Rapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city’s facility births. Methods Multiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed. Results Significant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%). Conclusions This collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.
Collapse
Affiliation(s)
- Brenda Sequeira Dmello
- Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania .,Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark.,Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania
| | - Ziada Sellah
- Director, Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dodoma, United Republic of Tanzania
| | - Grace Magembe
- Director, Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dodoma, United Republic of Tanzania
| | - Natasha Housseine
- Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania
| | - Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark.,Department of Obstetrics and Gynaecology, Hvidovre Hospital, Hvidovre, Denmark
| | - Thomas van den Akker
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Dan W Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark
| | - Timothy Mushi
- Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Mangalu Masweko
- Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Dorcas Jidayi
- Maternal and Newborn Health, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Jos van Roosmalen
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Hussein L Kidanto
- Medical College, Aga Khan University, Dar es Salaam, United Republic of Tanzania
| |
Collapse
|
8
|
Maaløe N, Ørtved AMR, Sørensen JB, Sequeira Dmello B, van den Akker T, Kujabi ML, Kidanto H, Meguid T, Bygbjerg IC, van Roosmalen J, Meyrowitsch DW, Housseine N. The injustice of unfit clinical practice guidelines in low-resource realities. LANCET GLOBAL HEALTH 2021; 9:e875-e879. [PMID: 33765437 PMCID: PMC7984859 DOI: 10.1016/s2214-109x(21)00059-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 12/18/2022]
Abstract
To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle-income countries through co-creation with end-users, and we encourage global sharing of these experiences.
Collapse
Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark.
| | - Anna Marie Rønne Ørtved
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Sequeira Dmello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Comprehensive Community-Based Rehabilitation in Tanzania, Dar es salaam, Tanzania; Medical College of East Africa, Aga Khan University, Dar es Salaam, Tanzania
| | - Thomas van den Akker
- Athena Institute, Faculty of Science, VU University, Amsterdam, Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Monica Lauridsen Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Department of Obstetrics and Gynaecology, Edna Adan Hospital, Hargeisa, Somalia
| | - Hussein Kidanto
- Medical College of East Africa, Aga Khan University, Dar es Salaam, Tanzania
| | | | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jos van Roosmalen
- Athena Institute, Faculty of Science, VU University, Amsterdam, Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Housseine
- Medical College of East Africa, Aga Khan University, Dar es Salaam, Tanzania
| |
Collapse
|
9
|
Tura AK, Aboul-Ela Y, Fage SG, Ahmed SS, Scherjon S, van Roosmalen J, Stekelenburg J, Zwart J, van den Akker T. Introduction of Criterion-Based Audit of Postpartum Hemorrhage in a University Hospital in Eastern Ethiopia: Implementation and Considerations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E9281. [PMID: 33322495 PMCID: PMC7764538 DOI: 10.3390/ijerph17249281] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 01/10/2023]
Abstract
With postpartum hemorrhage (PPH) continuing to be the leading cause of maternal mortality in most low-resource settings, an audit of the quality of care in health facilities is essential. The purpose of this study was to identify areas of substandard care and establish recommendations for the management of PPH in Hiwot Fana Specialized University Hospital, eastern Ethiopia. Using standard criteria (n = 8) adapted to the local hospital setting, we audited 45 women with PPH admitted from August 2018 to March 2019. Four criteria were agreed as being low: IV line-setup (32 women, 71.1%), accurate postpartum vital sign monitoring (23 women, 51.1%), performing typing and cross-matching (22 women, 48.9%), and fluid intake/output chart maintenance (6 women, 13.3%). In only 3 out of 45 women (6.7%), all eight standard criteria were met. Deficiencies in the case of note documentation and clinical monitoring, non-availability of medical resources and blood for transfusion, as well as delays in clinical management were identified. The audit created awareness, resulting in self-reflection of current practice and promoted a sense of responsibility to improve care among hospital staff. Locally appropriate recommendations and an intervention plan based on available resources were formulated.
Collapse
Affiliation(s)
- Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, P.O. Box 235 Harar, Ethiopia;
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands;
| | - Yasmin Aboul-Ela
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
| | - Sagni Girma Fage
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, P.O. Box 235 Harar, Ethiopia;
| | - Semir Sultan Ahmed
- Department of Obstetrics and Gynaecology, Hiwot Fana Specialized University Hospital, P.O. Box 235 Harar, Ethiopia;
| | - Sicco Scherjon
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands;
| | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
- Athena Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen, 9700 AD Groningen, The Netherlands;
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, 8934 AD Leeuwarden, The Netherlands
| | - Joost Zwart
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, 7416 SE Deventer, The Netherlands;
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
- Athena Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| |
Collapse
|
10
|
Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review. BMC Pregnancy Childbirth 2020; 20:682. [PMID: 33176732 PMCID: PMC7656726 DOI: 10.1186/s12884-020-03339-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/15/2020] [Indexed: 01/23/2023] Open
Abstract
Background sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women. Methods Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility. Results Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral. Conclusions Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals. Trial registration Systematic review registration: PROSPERO registration CRD42018114261. Supplementary information Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.
Collapse
|
11
|
Haddad SM, Souza RT, Cecatti JG, Barreix M, Tamrat T, Footitt C, Mehl GL, Syah IF, Shankar AH, Tunçalp Ö. Building a Digital Tool for the Adoption of the World Health Organization's Antenatal Care Recommendations: Methodological Intersection of Evidence, Clinical Logic, and Digital Technology. J Med Internet Res 2020; 22:e16355. [PMID: 33001032 PMCID: PMC7983224 DOI: 10.2196/16355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 06/26/2020] [Accepted: 07/26/2020] [Indexed: 11/14/2022] Open
Abstract
Background One of the key mandates of the World Health Organization (WHO) is to develop guidelines, defined as “a document containing recommendations for clinical practice or public health policy.” Guidelines represent the global standard for information sources shaping clinical practice and public health policies. Despite the rigorous development process and the value of guidelines for setting standards, implementing such standards within local contexts and at the point of care is a well-documented challenge. Digital technologies enable agile information management and may facilitate the adaptation of guidelines to diverse settings of health services delivery. Objective The objective of this paper is to detail the systematic and iterative process involved in transforming the WHO Antenatal Care (ANC) guidelines into a digital decision-support and patient-record application for routine use in primary health care settings, known as the WHO digital ANC module. Methods The WHO convened a team of clinical and digital health experts to develop the WHO digital ANC module as a tool to assist health care professionals in the implementation of WHO evidence-based recommendations for pregnant women. The WHO digital ANC module’s creation included the following steps: defining a minimum viable product (MVP), developing clinical workflows and algorithms, algorithm testing, developing a data dictionary, and the creation of a user interface or application development. The overall process of development took approximately 1 year to reach a stable prototype and to finalize the underlying content requirements of the data dictionary and decision support algorithms. Results The first output is a reference software reflecting the generic WHO ANC guideline content, known as the WHO digital ANC module. Within it, all actionable ANC recommendations have related data fields and algorithms to confirm whether the associated task was performed. WHO recommendations that are not carried out by the health care worker are saved as pending tasks on a woman’s health record, and those that are adequately fulfilled trigger messages with positive reinforcement. The second output consists of the structured documentation of the different components which contributed to the development of the WHO digital ANC module, such as the data dictionary and clinical decision support workflows. Conclusions This is a novel approach to facilitate the adoption and adaptation of recommendations through digital systems at the health service delivery level. It is expected that the WHO digital ANC module will support the implementation of evidence-based practices and provide information for monitoring and surveillance; however, further evidence is needed to understand how the WHO digital ANC module impacts the implementation of WHO recommendations. Further, the module’s implementation will inform the WHO’s ongoing efforts to create a pathway to adaptive and integrated (Smart) Guidelines in Digital Systems to improve health system quality, coverage, and accountability.
Collapse
Affiliation(s)
- Samira M Haddad
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.,Center for Research in Reproductive Health of Campinas (CEMICAMP), Campinas, Brazil
| | - Renato T Souza
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.,Center for Research in Reproductive Health of Campinas (CEMICAMP), Campinas, Brazil
| | - Jose Guilherme Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.,Center for Research in Reproductive Health of Campinas (CEMICAMP), Campinas, Brazil
| | - Maria Barreix
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Tigest Tamrat
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Garrett L Mehl
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Anuraj H Shankar
- Summit Institute of Development, Mataram, Indonesia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Eijkman-Oxford Clinical Research Unit, Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Özge Tunçalp
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| |
Collapse
|
12
|
Dmello BS, Housseine N, van den Akker T, van Roosmalen J, Maaløe N. Impact of COVID-19 on maternal and child health. LANCET GLOBAL HEALTH 2020; 8:e1259. [PMID: 32758433 PMCID: PMC7398673 DOI: 10.1016/s2214-109x(20)30328-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Brenda Sequeira Dmello
- Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam 23310, Tanzania; Medical College, East Africa, Aga Khan University, Dar es Salaam, Tanzania; Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Natasha Housseine
- Medical College, East Africa, Aga Khan University, Dar es Salaam, Tanzania
| | - Thomas van den Akker
- Athena Institute, VU University, Amsterdam, Netherlands; Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos van Roosmalen
- Athena Institute, VU University, Amsterdam, Netherlands; Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, Netherlands
| | - Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Department of Obstetrics and Gynecology, Hvidovre University Hospital, Hvidovre, Denmark
| |
Collapse
|