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Kikaya V, Katembwe F, Yabili J, Mbwanya M, Dhuse E, Gomez P, Waxman R, Mohan D, Tappis H. Effectiveness of Capacity-Building and Quality Improvement Interventions to Improve Day-of-Birth Care in Kinshasa, Democratic Republic of the Congo. Glob Health Sci Pract 2024; 12:GHSP-D-23-00236. [PMID: 38365280 PMCID: PMC10906559 DOI: 10.9745/ghsp-d-23-00236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/23/2024] [Indexed: 02/18/2024]
Abstract
In sub-Saharan African settings like the Democratic Republic of the Congo, high-quality care during childbirth and the immediate postpartum period is lacking in public facilities, necessitating multipronged interventions to improve care. We used a pre-post design to examine the effectiveness of a low-dose, high-frequency capacity-building and quality improvement (QI) intervention to improve care for women and newborns around the day of birth in 16 health facilities in Kinshasa, Democratic Republic of the Congo. Effectiveness was assessed based on changes in provider skills, key health indicators, and beneficiary satisfaction. To assess changes in the competency of the 188 providers participating in the intervention, we conducted objective structured clinical examinations on care for mothers and newborns on the day of birth, immediate postpartum family planning (PPFP) counseling and method provision, and postabortion care before and after implementation of training and at 6 and 12 months after training. Interrupted time series (ITS) analysis techniques were used to analyze routine health service data for changes in select maternal, newborn, and postpartum outcomes before and after the intervention. To assess changes in clients' perceptions of care, 2 rounds of telephone surveys were administered. Before the intervention, less than 2% of participating providers demonstrated competency in skills. Immediately after training, more than 80% demonstrated competency, and 70% retained competency after 12 months. ITS analyses show the risk of early neonatal death declined significantly by 9% (95% confidence interval [CI]=4%, 13%, P<.001), and likelihood of immediate PPFP uptake increased significantly by 72% (95% CI=53%, 92%, P<.001). Client satisfaction improved by 58% over the life of the project. These findings build on previous studies documenting the effectiveness of clinical capacity-building and QI approaches. If implemented at scale, this approach has the potential to substantively contribute to improving maternal and perinatal health in similar settings.
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Affiliation(s)
| | | | - Jacky Yabili
- Jhpiego, Kinshasa, Democratic Republic of the Congo
| | | | | | | | | | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hannah Tappis
- Jhpiego, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Manalai P, Ansari N, Tappis H, Kim YM, Stekelenburg J, van Roosmalen J, Currie S. Women's experience of childbirth care in health facilities: a qualitative assessment of respectful maternity care in Afghanistan. BMC Pregnancy Childbirth 2024; 24:48. [PMID: 38200450 PMCID: PMC10777596 DOI: 10.1186/s12884-023-06234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Respectful maternity care (RMC) remains a key challenge in Afghanistan, despite progress on improving maternal and newborn health during 2001-2021. A qualitative study was conducted in 2018 to provide evidence on the situation of RMC in health facilities in Afghanistan. The results are useful to inform strategies to provide RMC in Afghanistan in spite of the humanitarian crisis due to Taliban's takeover in 2021. METHODS Focus group discussions were conducted with women (4 groups, 43 women) who had used health facilities for giving birth and with providers (4 groups, 21 providers) who worked in these health facilities. Twenty key informant interviews were conducted with health managers and health policy makers. Motivators for, deterrents from using, awareness about and experiences of maternity care in health facilities were explored. RESULTS Women gave birth in facilities for availability of maternity care and skilled providers, while various verbal and physical forms of mistreatment were identified as deterrents from facility use by women, providers and key informants. Low awareness, lack of resources and excessive workload were identified among the reasons for violation of RMC. CONCLUSION Violation of RMC is unacceptable. Awareness of women and providers about the rights of women to respectful maternity care, training of providers on the subject, monitoring of care to prevent mistreatment, and conditioning any future technical and financial assistance to commitments to RMC is recommended.
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Affiliation(s)
| | | | - Hannah Tappis
- Jhpiego - Johns Hopkins University Affiliate, Baltimore, USA
| | - Young Mi Kim
- Jhpiego - Johns Hopkins University Affiliate, Baltimore, USA
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health Unit, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Sheena Currie
- Jhpiego - Johns Hopkins University Affiliate, Baltimore, USA
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Karp C, Edwards EM, Tappis H. Quality improvement in maternal and reproductive health services. BMC Pregnancy Childbirth 2024; 24:21. [PMID: 38172801 PMCID: PMC10762983 DOI: 10.1186/s12884-023-06207-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
As maternal mortality and morbidity rates stagnate or increase worldwide, there is an urgent need to address health system issues that impede access to high-quality care. Learning from efforts to address the value, safety, and effectiveness of reproductive and maternal health care is essential to advancing quality improvement efforts.
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Affiliation(s)
- Celia Karp
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Erika M Edwards
- College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT, USA.
- Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA.
- Vermont Oxford Network, 33 Kilburn Street, 05401, Burlington, VT, USA.
| | - Hannah Tappis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- JHPIEGO, Baltimore, MD, USA
- Center for Humanitarian Health, Johns Hopkins University, Baltimore, MD, USA
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Alier KK, Tappis H, Ismail S, Doocy S. Impact of COVID-19 program adaptations on costs and cost-effectiveness of community management of acute malnutrition program in South Sudan. Public Health Nutr 2023; 27:e15. [PMID: 38095095 PMCID: PMC10830371 DOI: 10.1017/s1368980023002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE We assessed the impact of the COVID-19 pandemic and the protocol adaptations on cost and cost-effectiveness of community management of acute malnutrition (CMAM) program in South Sudan. DESIGN Retrospective program expenditure-based analysis of non-governmental organisation (NGO) CMAM programs for COVID-19 period (April 2020-December 2021) in respect to pre-COVID period (January 2019-March 2020). SETTING Study was conducted as part of a bigger evaluation study in South Sudan. PARTICIPANTS International and national NGOs operating CMAM programs under the nutrition cluster participated in the study. RESULTS The average cost per child recovered from the programme declined by 20 % during COVID from $133 (range: $34-1174) pre-COVID to $107 (range: $20-333) during COVID. The cost per child recovered was negatively correlated with programme size (pre-COVID r-squared = 0·58; during COIVD r-squared = 0·50). Programmes with higher enrollment were cheaper compared with those with low enrolment. Salaries, ready to use food and community activities accounted for over two-thirds of the cost per recovery during both pre-COVID (69 %) and COVID (79 %) periods. While cost per child recovered decreased during COVID period, it did not negatively impact on the programme outcome. Enrolment increased by an average of 19·8 % and recovery rate by 4·6 % during COVID period. CONCLUSIONS Costs reduced with no apparent negative implication on recovery rates after implementing the COVID CMAM protocol adaptations with a strong negative correlation between cost and programme size. This suggests that investing in capacity, screening and referral at existing CMAM sites to enable expansion of caseload maybe a preferable strategy to increasing the number of CMAM sites in South Sudan.
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Affiliation(s)
- Kemish Kenneth Alier
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Sule Ismail
- US Centers for Disease Control and Prevention, Juba, South Sudan
- Integral Global Consulting, Atlanta, GA
| | - Shannon Doocy
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
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Abbara A, Rayes D, Tappis H, Hamze M, Wais R, Alahmad H, Almhawish N, Rubenstein L, Haar R. "Actually, the psychological wounds are more difficult than physical injuries:" a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict. Confl Health 2023; 17:48. [PMID: 37807074 PMCID: PMC10561459 DOI: 10.1186/s13031-023-00546-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023] Open
Abstract
INTRODUCTION Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them. METHODS We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed. RESULTS A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the 'double tap' nature of attacks as well as opportunities related to coping mechanisms among health workers. CONCLUSION Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.
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Affiliation(s)
- Aula Abbara
- Syrian American Medical Society, Washington, DC, USA.
- Department of Infectious Diseases, Imperial College, London, St Marys Hospital, Praed Street, London, W2 1NY, UK.
- Syria Public Health Network, London, UK.
| | - Diana Rayes
- Syria Public Health Network, London, UK
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Hannah Tappis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Mohamed Hamze
- Syrian American Medical Society, Washington, DC, USA
| | - Reham Wais
- Syrian American Medical Society, Gaziantep, Turkey
| | | | - Naser Almhawish
- Syria Public Health Network, London, UK
- Assistance Coordination Unit, Gaziantep, Turkey
| | | | - Rohini Haar
- School of Public Health, University of California, Berkeley, Berkeley, USA
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Doocy S, Lyles E, Tappis H, Norton A. Effectiveness of humanitarian health interventions: a systematic review of literature published between 2013 and 2021. BMJ Open 2023; 13:e068267. [PMID: 37474188 PMCID: PMC10360420 DOI: 10.1136/bmjopen-2022-068267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/12/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVES To provide a thorough mapping of the current quality and depth of evidence examining the effectiveness of health interventions in humanitarian settings in low and middle-income countries published in peer-reviewed journals since 2013. METHODS We searched MEDLINE, Embase and Global Health for English language peer-reviewed literature published from May 2013 through April 2021 to analyse the strength of evidence on health interventions' effectiveness in humanitarian settings in low and middle-income countries across nine thematic areas. Quality was assessed using standardised criteria and critical appraisal tools based on study design. RESULTS A total of 269 publications were included in this review. The volume of publications increased since the first Elrha Humanitarian Health Evidence Review in 2013, but non-communicable diseases and water, sanitation and hygiene remain the areas with the most limited evidence base on intervention effectiveness in addition to injury and rehabilitation. Economic evaluations continued to constitute a small proportion (5%) of studies. Half of studies had unclear risk of bias, while 28% had low, 11% moderate and 11% high risk of bias. Despite increased diversity in studied interventions, variations across and within topics do not necessarily reflect the health issues of greatest concern or barriers to quality service delivery in humanitarian settings. CONCLUSIONS Despite an increasing evidence base, the challenge of implementing high-quality and well-reported humanitarian health research persists as a critical concern. Improvements in reporting and intervention description are needed as are study designs that allow for attribution, standard indicators and longer term follow-up and outcome measures. There is a clear need to prioritise expansion of cross-cutting topics, namely health service delivery, health systems and cost-effectiveness. PROSPERO REGISTRATION NUMBER CRD42021254408.
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Affiliation(s)
- Shannon Doocy
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emily Lyles
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hannah Tappis
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alexandra Norton
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Tappis H, Lak R, Alhilfi R, Zangana AH, Wadi F, Hipgrave D, Ibrahim S. Quality of maternal and newborn health care at private hospitals in Iraq: a cross-sectional study. BMC Pregnancy Childbirth 2023; 23:331. [PMID: 37161362 PMCID: PMC10170688 DOI: 10.1186/s12884-023-05678-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Approximately 25% of facility births take place in private health facilities. Recent national studies of maternal and newborn health (MNH) service availability and quality have focused solely on the status of public sector facilities, leaving a striking gap in information on the quality of maternal and newborn care services. METHODS A rapid cross-sectional assessment was conducted in November 2022 to assess the quality of MNH services at private hospitals in Iraq. Multi-stage sampling was used to select 15% of the country's 164 private hospitals. Assessment tools included a facility assessment checklist, a structured health worker interview tool, and a structured client exit interview tool. Data collection was conducted using KoboToolbox software on Android tablets, and analysis conducted using SPSS v28. RESULTS All hospitals visited provided MNH services and had skilled personnel present or on-call 24 h/day, 7 days/week. Most births (88%) documented between January and June 2022 were cesarean births. Findings indicate that nearly all hospitals have the human resources, equipment, medicines and supplies necessary for quality antenatal, intrapartum and early essential newborn care, and many are also equipped with special units and resources needed to care for small and sick babies. However, while resources are in place for basic and advanced care, there are gaps in knowledge and practice of high-impact interventions that require few or no resources to perform, including skin-to-skin thermal care and support for early initiation of breastfeeding. Person-centered maternity care scores suggest that private hospitals offer a positive experience of care for all clients, however there is room for improvement in provider-client communication. CONCLUSIONS This assessment highlights the need for deeper dives into factors that underly decisions about how and where to give birth, and both understanding and practice of early essential newborn care and pre-discharge examinations and counseling at private healthcare facilities in Iraq. Engaging private health facility staff in efforts to monitor and improve the quality of maternal and newborn care, with a focus on early essential newborn care and provider-client communication for all clients, will ensure that women and newborns benefit from the best care possible with available resources.
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Affiliation(s)
- Hannah Tappis
- Department of International Health, Johns Hopkins Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Rebaz Lak
- Kurdistan Higher Council of Medical Specialties, Erbil, Iraq
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Mubanga B, Fwoloshi S, Lwatula L, Siamwanza N, Zyambo K, Sichinga H, Tappis H, Mulenga LB, Moonga A, Ziko L, Simushi F, Massamba HM, Hapunda G, Sichimba F, Mtonga H, Kalubula M. Effects of the ECHO tele-mentoring program on HIV/TB service delivery in health facilities in Zambia: a mixed-methods, retrospective program evaluation. Hum Resour Health 2023; 21:24. [PMID: 36941682 PMCID: PMC10026214 DOI: 10.1186/s12960-023-00806-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/22/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND In the quest to ensure that quality healthcare is provided to all citizens through building healthcare worker capacity and extending reach for expert services, Zambia's Ministry of Health (MoH) in collaboration with its partners PEPFAR through the CDC and HRSA, began to implement the Extension for Community Healthcare Outcomes (ECHO) tele-mentoring program across the country through the Health Workers for the 21st Century (HW21) Project and University Teaching Hospital HIV/AIDS Project (UTH-HAP). This ECHO tele-mentoring approach was deemed pivotal in helping to improve the human immunodeficiency virus (HIV) service delivery capacity of health care workers. METHOD The study used a mixed method, retrospective program evaluation to examine ECHO participants' performance in the management of HIV/AIDS patients in all the 10 provinces of Zambia. CASE PRESENTATION A phenomenological design was applied in order to elicit common experiences of ECHO users through focus group discussions using semi-structured facilitation guides in four provinces (Eastern, Lusaka, Southern and Western) implementing ECHO tele-mentoring approach. These provinces were purposively selected for this study. From which, only participants that had a monthly frequency of ECHO attendance of ten (10) and above were selected. The participants were purposively selected based on the type of cadre as well as facility type so that the final sample consisted of Doctors, Nurses, Midwives, Clinical Officers, Medical Licentiates, Pharmacy and Laboratory Personnel. All sessions were audio recorded and transcribed by the data collectors. A thematic content analysis approach was adopted for analyzing content of the interview's transcripts. RESULTS Enhanced knowledge and skills of participants on HIV/TB improved by 46/70 (65.7%) in all provinces, while 47/70 (67.1%) of the participants reported that ECHO improved their clinical practice. Further, 12/70 (17.1%) of participants in all provinces reported that presenter/presentation characteristics facilitated ECHO implementation and participation. While, 15/70(21.4%) of the participants reported that ownership of the program had contributed to ECHO implementation and participation. Coordination, another enabler accounted for 14/70 (20%). Inclusiveness was reported as a barrier by 16/70 (22.8%) of the participants while 6/70 (8.6%) of them reported attitudes as a barrier (8.6%) to ECHO participation. In addition, 34/70 (48.6%) reported poor connectivity as a barrier to ECHO implementation and participation while 8/70 (11.5%) of the participants reported that the lack of ownership of the ECHO program was a barrier. 22/70 (31.4%) reported that increased workload was also a barrier to the program's implementation. CONCLUSION Consistent with its logical pathway model, healthcare providers' participation in ECHO sessions and onsite mentorship contributed to improved knowledge on HIV/TB among health care providers and patient health outcomes. In addition, barriers to ECHO implementation were intrinsic to the program its self, such as coordination, presenter and presentation characteristics other barriers were extrinsic to the program such as poor connectivity, poor infrastructure in health facilities and negative attitudes towards ECHO. Improving on intrinsic factors and mitigating extrinsic factors may help improve ECHO outcomes and scale-up plans.
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Affiliation(s)
- Brian Mubanga
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia.
| | - Sombo Fwoloshi
- Zambian Ministry of Health, Ndeke House, Haile Selassie Avenue, Lusaka, Zambia
| | - Lastina Lwatula
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | - Nomsa Siamwanza
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | - Khozya Zyambo
- Zambian Ministry of Health, Ndeke House, Haile Selassie Avenue, Lusaka, Zambia
| | - Henry Sichinga
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | - Hannah Tappis
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA
| | - Lloyd B Mulenga
- Zambian Ministry of Health, Ndeke House, Haile Selassie Avenue, Lusaka, Zambia
| | - Aurthur Moonga
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | - Lunga Ziko
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | - Faith Simushi
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | | | - Given Hapunda
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | - Francis Sichimba
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | - Hellen Mtonga
- Jhpiego Zambia Country Office, 8 Ngumbo Road, Longacres, Lusaka, Zambia
| | - Maybin Kalubula
- Zambian Ministry of Health, Ndeke House, Haile Selassie Avenue, Lusaka, Zambia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Jeffers NK, Wilson D, Tappis H, Bertrand D, Veenema T, Glass N. Experiences of pregnant women exposed to Hurricanes Irma and Maria in the US Virgin Islands: a qualitative study. BMC Pregnancy Childbirth 2022; 22:947. [PMID: 36528572 PMCID: PMC9759877 DOI: 10.1186/s12884-022-05232-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/22/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Hurricanes Irma and Maria made landfall in the US Virgin Islands (USVI) in 2017. To date, there is no published literature available on the experiences of pregnant women in the USVI exposed to these hurricanes. Understanding how hurricanes affect pregnant women is key to developing and executing targeted hurricane preparedness and response policies. The purpose of this study was to explore the experiences of pregnancy and birth among women in the USVI exposed to Hurricanes Irma and Maria. METHODS We employed a qualitative descriptive methodology to guide sampling, data collection, and analysis. Semi-structured interviews of 30-60 min in length were conducted with a purposive sample of women (N = 18) in the USVI who were pregnant during or became pregnant within two months after the hurricanes. Interviews were transcribed verbatim and data managed in MAXQDA. Team members developed a codebook, applied codes for content, and reconciled discrepancies. We thematically categorized text according to a socioecological conceptual framework of risk and resilience for maternal-neonatal health following hurricane exposure. RESULTS Women's experiences were organized into two main categories (risk and resilience). We identified the following themes related to risk at 3 socioecological levels including: (1) individual: changes in food access (We had to go without) and stress (I was supposed to be relaxing); (2) household/community: diminished psychosocial support (Everyone was dealing with their own things) and the presence of physical/environmental hazards (I was really scared); and (3) maternity system: compromised care capacity (The hospital was condemned). The themes related to resilience included: (1) individual: personal coping strategies (Being calm); (2) household/community: mutual psychosocial and tangible support (We shared our resources); and (3) the maternity system: continuity of high-quality care (On top of their game). CONCLUSIONS A socioecological approach provides a useful framework to understand how risk and resilience influence the experience of maternal hurricane exposure. As the frequency of the most intense hurricanes is expected to increase, clinicians, governments, and health systems should work collaboratively to implement hurricane preparedness and response plans that address pregnant women's unique needs and promote optimal maternal-infant health.
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Affiliation(s)
- Noelene K. Jeffers
- grid.21107.350000 0001 2171 9311Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Deborah Wilson
- grid.21107.350000 0001 2171 9311Johns Hopkins University School of Nursing, Baltimore, MD USA
| | - Hannah Tappis
- grid.21107.350000 0001 2171 9311Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA ,grid.21107.350000 0001 2171 9311Jhpiego, MD Baltimore, USA
| | - Desiree Bertrand
- grid.410427.40000 0001 2284 9329Augusta University College of Nursing, GA Augusta, USA
| | - Tener Veenema
- grid.21107.350000 0001 2171 9311Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Nancy Glass
- grid.21107.350000 0001 2171 9311Johns Hopkins University School of Nursing, Baltimore, MD USA
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Altare C, Weiss W, Ramadan M, Tappis H, Spiegel PB. Measuring results of humanitarian action: adapting public health indicators to different contexts. Confl Health 2022; 16:54. [PMID: 36242013 PMCID: PMC9569100 DOI: 10.1186/s13031-022-00487-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/28/2022] [Accepted: 10/07/2022] [Indexed: 11/25/2022] Open
Abstract
Humanitarian crises represent a significant public health risk factor for affected populations exacerbating mortality, morbidity, disabilities, and reducing access to and quality of health care. Reliable and timely information on the health status of and services provided to crisis-affected populations is crucial to establish public health priorities, mobilize funds, and monitor the performance of humanitarian action. Numerous efforts have contributed to standardizing and presenting timely public health information in humanitarian settings over the last two decades. While the prominence of process and output (rather than outcome and impact) indicators in monitoring frameworks leads to adequate information on resources and activities, health outcomes are rarely measured due to the challenges of measuring them using gold-standard methods that are difficult to implement in humanitarian settings. We argue that challenges in collecting the gold-standard performance measures should not be a rationale for neglecting outcome measures for critical health and nutrition programs in humanitarian emergencies. Alternative indicators or measurement methods that are robust, practical, and feasible in varying contexts should be used in the interim while acknowledging limitations or interpretation constraints. In this paper, we draw from existing literature, expert judgment, and operational experience to propose an approach to adapt public health indicators for measuring performance of the humanitarian response across varied contexts. Contexts were defined in terms of parameters that capture two of the main constraints affecting the capacity to obtain performance information in humanitarian settings: (i) access to population or health facilities; and (ii) availability of resources for measurement. Consequently, 2 × 2 tables depict four possible scenarios: (A) a situation with accessible populations and with available resources; (B) a situation with available resources but limited access to affected populations; (C) a situation with accessible populations and limited resources; and (D) a situation with both limited access and limited resources. Methods and data sources can vary from large population-based surveys, rapid assessments of populations or health facilities, routine health management information systems, or data from sentinel sites in the community or among facilities. Adapting indicators and methods to specific contexts of humanitarian settings increases the potential for measuring the performance of humanitarian programs beyond inputs and outputs by assessing health outcomes, and consequently improving program impact, reducing morbidity and mortality, and improving the quality of lives amongst persons affected by humanitarian emergencies.
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Affiliation(s)
- Chiara Altare
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - William Weiss
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marwa Ramadan
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Jhpiego, Baltimore, MD, USA
| | - Paul B Spiegel
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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12
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Ramadan M, Tappis H, Brieger W. Primary Healthcare Quality in Conflict and Fragility: a subnational analysis of disparities using Population Health surveys. Confl Health 2022; 16:36. [PMID: 35706012 PMCID: PMC9202222 DOI: 10.1186/s13031-022-00466-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators. Methods A secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level. Results Overall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity. Conclusion Each of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-022-00466-w.
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Affiliation(s)
- Marwa Ramadan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of Community Medicine and Public Health, Alexandria University, Alexandria, Egypt.
| | - Hannah Tappis
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Technical leadership and Innovations Office, Jhpiego, Baltimore, MD, USA
| | - William Brieger
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Dawson A, Tappis H, Tran NT. Self-care interventions for sexual and reproductive health in humanitarian and fragile settings: a scoping review. BMC Health Serv Res 2022; 22:757. [PMID: 35672763 PMCID: PMC9172979 DOI: 10.1186/s12913-022-07916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-care is the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and manage illness and disability with or without a health care provider. In resource-constrained settings with disrupted sexual and reproductive health (SRH) service coverage and access, SRH self-care could play a critical role. Despite SRH conditions being among the leading causes of mortality and morbidity among women of reproductive age in humanitarian and fragile settings, there are currently no reviews of self-care interventions in these contexts to guide policy and practice. METHODS We undertook a scoping review to identify the design, implementation, and outcomes of self-care interventions for SRH in humanitarian and fragile settings. We defined settings of interest as locations with appeals for international humanitarian assistance or identified as fragile and conflict-affected situations by the World Bank. SRH self-care interventions were described according to those aligned with the Minimum Initial Services Package for Reproductive Health in Crises. We searched six databases for records using keywords guided by the PRISMA statement. The findings of each included paper were analysed using an a priori framework to identify information concerning effectiveness, acceptability and feasibility of the self-care intervention, places where self-care interventions were accessed and factors relating to the environment that enabled the delivery and uptake of the interventions. RESULTS We identified 25 publications on SRH self-care implemented in humanitarian and fragile settings including ten publications on maternal and newborn health, nine on HIV/STI interventions, two on contraception, two on safe abortion care, one on gender-based violence, and one on health service provider perspectives on multiple interventions. Overall, the findings show that well-supported self-care interventions have the potential to increase access to quality SRH for crisis-affected communities. However, descriptions of interventions, study settings, and factors impacting implementation offer limited insight into how practical considerations for SRH self-care interventions differ in stable, fragile, and crisis-affected settings. CONCLUSION It is time to invest in self-care implementation research in humanitarian settings to inform policies and practices that are adapted to the needs of crisis-affected communities and tailored to the specific health system challenges encountered in such contexts.
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Affiliation(s)
- Angela Dawson
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
| | - Hannah Tappis
- Jhpiego, 1615 Thames St, Baltimore, MD, USA. .,Johns Hopkins Center for Humanitarian Health, 615 N. Wolfe St, Baltimore, MD, USA.
| | - Nguyen Toan Tran
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia.,Faculty of Medicine, University of Geneva, Rue Michel Servet 1, 1211, Geneva 4, Switzerland
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14
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Russell N, Tappis H, Mwanga JP, Black B, Thapa K, Handzel E, Scudder E, Amsalu R, Reddi J, Palestra F, Moran AC. Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees. Confl Health 2022; 16:23. [PMID: 35526012 PMCID: PMC9077967 DOI: 10.1186/s13031-022-00440-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/03/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th-18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees. CONSULTATION FINDINGS Interviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings. CONCLUSIONS Despite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.
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Affiliation(s)
| | - Hannah Tappis
- grid.21107.350000 0001 2171 9311Jhpiego, Baltimore, MD USA
| | - Jean Paul Mwanga
- Hôpital Générale de Mweso, Nord Kivu, Democratic Republic of the Congo
| | - Benjamin Black
- grid.452780.cMédecins Sans Frontières, Amsterdam, The Netherlands
| | - Kusum Thapa
- grid.21107.350000 0001 2171 9311Jhpiego, Baltimore, MD USA
| | - Endang Handzel
- grid.416738.f0000 0001 2163 0069Centre for Disease Control and Prevention, Atlanta, GA USA
| | - Elaine Scudder
- grid.420433.20000 0000 8728 7745International Rescue Committee, New York, NY USA
| | - Ribka Amsalu
- grid.266102.10000 0001 2297 6811University of California San Francisco, San Francisco, CA USA
| | - Jyoti Reddi
- grid.3575.40000000121633745World Health Organization, Geneva, Switzerland
| | - Francesca Palestra
- grid.3575.40000000121633745World Health Organization, Geneva, Switzerland
| | - Allisyn C. Moran
- grid.3575.40000000121633745World Health Organization, Geneva, Switzerland
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15
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Amsalu R, Firoz T, Lange IL, Tappis H. Editorial: Maternal Health in Conflict Settings. Front Glob Womens Health 2022; 3:807257. [PMID: 35368994 PMCID: PMC8964459 DOI: 10.3389/fgwh.2022.807257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/08/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Ribka Amsalu
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, CA, United States,Department of Obstetrics, Gynecology and Reproductive Sciences, Medical Center, University of California, San Francisco, San Francisco, CA, United States,*Correspondence: Ribka Amsalu
| | - Tabassum Firoz
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Isabelle L. Lange
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
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16
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Manalai P, Currie S, Jafari M, Ansari N, Tappis H, Atiqzai F, Kim YM, van Roosmalen J, Stekelenburg J. Quality of pre-service midwifery education in public and private midwifery schools in Afghanistan: a cross sectional survey. BMC Med Educ 2022; 22:39. [PMID: 35034654 PMCID: PMC8761336 DOI: 10.1186/s12909-021-03056-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Midwives are the key skilled birth attendants in Afghanistan. Rapid assessment of public and private midwifery education schools was conducted in 2017 to examine compliance with national educational standards. The aim was to assess midwifery education to inform Afghanistan Nurses and Midwives Council and other stakeholders on priorities for improving quality of midwifery education. METHODS A cross-sectional assessment of midwifery schools was conducted from September 12-December 17, 2017. The Midwifery Education Rapid Assessment Tool was used to assess 29 midwifery programs related to infrastructure, management, teachers, preceptors, clinical practice sites, curriculum and students. A purposive sample of six Institute of Health Sciences schools, seven Community Midwifery Education schools and 16 private midwifery schools was used. Participants were midwifery school staff, students and clinical preceptors. RESULTS Libraries were available in 28/29 (97%) schools, active skills labs in 20/29 (69%), childbirth simulators in 17/29 (59%) and newborn resuscitation models in 28/29 (97%). School managers were midwives in 21/29 (72%) schools. Median numbers of students per teacher and students per preceptor were 8 (range 2-50) and 6 (range 2-20). There were insufficient numbers of teachers practicing midwifery (132/163; 81%), trained in teaching skills (113/163; 69%) and trained in emergency obstetric and newborn care (88/163; 54%). There was an average of 13 students at clinical sites in each shift. Students managed an average of 15 births independently during their training, while 40 births are required. Twenty-four percent (7/29) of schools used the national 2015 curriculum alone or combined with an older one. Ninety-one percent (633/697) of students reported access to clinical sites and skills labs. Students mentioned, however, insufficient clinical practice due to low case-loads in clinical sites, lack of education materials, transport facilities and disrespect from school teachers, preceptors and clinical site providers as challenges. CONCLUSIONS Positive findings included availability of required infrastructure, amenities, approved curricula in 7 of the 29 midwifery schools, appropriate clinical sites and students' commitment to work as midwives upon graduation. Gaps identified were use of different often outdated curricula, inadequate clinical practice, underqualified teachers and preceptors and failure to graduate all students with sufficient skills such as independently having supported 40 births.
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Affiliation(s)
- Partamin Manalai
- Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Sheena Currie
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA
| | - Massoma Jafari
- Afghan Midwives Association, HNO5, Baharistan, 2th District, Kabul, Afghanistan
| | | | - Hannah Tappis
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA
| | | | - Young Mi Kim
- Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen/University of Groningen, PO Box 196, 9700, AD, Groningen, The Netherlands
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Henri Dunantweg 2, 8934, AD, Leeuwarden, The Netherlands
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17
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Ramadan M, Tappis H, Uribe MV, Brieger W. Access to primary healthcare Services in Conflict-Affected Fragile States: a subnational descriptive analysis of educational and wealth disparities in Cameroon, Democratic Republic of Congo, Mali, and Nigeria. Int J Equity Health 2021; 20:253. [PMID: 34895244 PMCID: PMC8665620 DOI: 10.1186/s12939-021-01595-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/17/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Measuring and improving equitable access to care is a necessity to achieve universal health coverage. Pre-pandemic estimates showed that most conflict-affected and fragile situations were off-track to meet the Sustainable Development Goals on health and equity by 2030. Yet, there is a paucity of studies examining health inequalities in these settings. This study addresses the literature gap by applying a conflict intensity lens to the analysis of disparities in access to essential Primary Health Care (PHC) services in four conflict-affected fragile states: Cameroon, Democratic Republic of Congo, Mali and Nigeria. METHODS For each studied country, disparities in geographic and financial access to care were compared across education and wealth strata in areas with differing levels of conflict intensity. The Demographic Health Survey (DHS) and the Uppsala Conflict Data Program were the main sources of information on access to PHC and conflict events, respectively. To define conflict intensity, household clusters were linked to conflict events within a 50-km distance. A cut-off of more than two conflict-related deaths per 100,000 population was used to differentiate medium or high intensity conflict from no or low intensity conflict. We utilized three measures to assess inequalities: an absolute difference, a concentration index, and a multivariate logistic regression coefficient. Each disparity measure was compared based on the intensity of conflict the year the DHS data was collected. RESULTS We found that PHC access varied across subnational regions in the four countries studied; with more prevalent financial than geographic barriers to care. The magnitude of both educational and wealth disparities in access to care was higher with geographic proximity to medium or high intensity conflict. A higher magnitude of wealth rather than educational disparities was also likely to be observed in the four studied contexts. Meanwhile, only Nigeria showed statistically significant interaction between conflict intensity and educational disparities in access to care. CONCLUSION Both educational and wealth disparities in access to PHC services can be exacerbated by geographic proximity to organized violence. This paper provides additional evidence that, despite limitations, household surveys can contribute to healthcare assessment in conflict-affected and fragile settings.
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Affiliation(s)
- Marwa Ramadan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Hannah Tappis
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Technical Leadership and Innovations Office, Jhpiego, Baltimore, MD, USA
| | - Manuela Villar Uribe
- Health Nutrition and Population Global Practice, World Bank Group, Washington, DC, USA
| | - William Brieger
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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18
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Maruf F, Tappis H, Stekelenburg J, van den Akker T. Quality of Maternal Death Documentation in Afghanistan: A Retrospective Health Facility Record Review. Front Glob Womens Health 2021; 2:610578. [PMID: 34816182 PMCID: PMC8593965 DOI: 10.3389/fgwh.2021.610578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 02/17/2021] [Indexed: 11/26/2022] Open
Abstract
Objectives: To assess the quality of health facility documentation related to maternal deaths at health facilities in Afghanistan. Methods: Analysis of a subset of findings from the 2016 National Maternal and Newborn Health Quality of Care Assessment in Afghanistan. At each facility, maternity registers were reviewed to obtain data related to maternity caseload, and number and causes of maternal deaths in the year preceding the survey. Detailed chart reviews were conducted for up to three maternal deaths per facility. Analyses included completeness of charts, quality of documentation, and cause of death using WHO application of International Statistical Classification of Disease to deaths during pregnancy, childbirth and the puerperium. Key findings: Only 129/226 (57%) of facilities had mortality registers available for review on the day of assessment and 41/226 (18%) had charts documenting maternal deaths during the previous year. We reviewed 68 maternal death cases from the 41 facilities. Cause of death was not recorded in nearly half of maternal death cases reviewed. Information regarding mode of birth was missing in over half of the charts, and one third did not capture gestational age at time of death. Hypertensive disorders of pregnancy and obstetric hemorrhage were the most common direct causes of death, followed by maternal sepsis and unanticipated complications of clinical management including anesthesia-related complications. Documented indirect causes of maternal deaths were anemia, cardiac arrest, kidney and hepatic failure. Charts revealed at least eight maternal deaths from indirect causes that were not captured in register books, indicating omission or misclassification of registered deaths. Conclusion: Considerable gaps in quality of recordkeeping exist in Afghanistan, including underreporting, misclassification and incompleteness. This hampers efforts to improve quality of maternal and newborn health data and priority setting.
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Affiliation(s)
- Farzana Maruf
- Global Financing Facility, World Bank Group, Kabul, Afghanistan.,Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Jelle Stekelenburg
- Global Health Unit, Department of Health Sciences, University Medical Centre Groningen/University of Groningen, Groningen, Netherlands.,Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, Netherlands
| | - Thomas van den Akker
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
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Sodeno M, Tappis H, Burnham G, Ververs M. Associations between caesarean births and breastfeeding in the Middle East: a scoping review. East Mediterr Health J 2021; 27:931-940. [PMID: 34569049 DOI: 10.26719/emhj.21.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 02/04/2021] [Indexed: 11/09/2022]
Abstract
Background There is a paucity of published studies on factors influencing feeding practices for infants and young children born via caesarean section. Aims To assess whether the mode of childbirth affects early initiation and exclusive breastfeeding, and to identify factors that positively or negatively influence breastfeeding after caesarean births in selected countries in the Middle East. Methods We conducted a scoping review of publicly available population-based surveys and peer-reviewed literature on the associations between birthing mode and breastfeeding published between 2000 and 2018. The search identified 33 demographic surveys and 16 studies containing information on the mode of childbirth and breastfeeding in selected countries in the Middle East listed in PubMed, Embase, and CINAHL databases. Searches were completed in March 2019. Results Demographic surveys in 6 participating Middle Eastern countries demonstrated increased rates of births by caesarean section. All 3 countries with ≥ 3 datasets available demonstrated that early initiation of breastfeeding was less likely after caesarean section than after vaginal births. Eleven studies analysed differences in breastfeeding outcomes between caesarean section and vaginal births, and all of them identified significant differences between birthing modes. Five studies addressed factors influencing breastfeeding after caesarean births. Conclusion Caesarean births are associated with a higher risk of delayed initiation of breastfeeding as well as early cessation of exclusive breastfeeding.
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Affiliation(s)
- Miho Sodeno
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, United States of America
| | - Hannah Tappis
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, United States of America
| | - Gilbert Burnham
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, United States of America
| | - Mija Ververs
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, United States of America
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20
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Maruf F, Tappis H, Lu E, Yaqubi GS, Stekelenburg J, van den Akker T. Health facility capacity to provide postabortion care in Afghanistan: a cross-sectional study. Reprod Health 2021; 18:160. [PMID: 34321023 PMCID: PMC8317397 DOI: 10.1186/s12978-021-01204-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Afghanistan has one of the highest burdens of maternal mortality in the world, estimated at 638 deaths per 100,000 live births in 2017. Infections, obstetric hemorrhage, and unsafe abortion are the three leading causes of maternal death. Contraceptive prevalence rate has fluctuated between 10 and 20% since 2006. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment evaluated facility readiness to provide quality routine and emergency obstetric and newborn care, including postabortion care services. Methods Accessible public health facilities with at least five births per day (n = 77), a nationally representative sample of public health facilities with fewer than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Assessment components examining postabortion care included a facility inventory and record review tool to verify drug, supply, equipment, and facility record availability, and an interview tool to collect information on skilled birth attendants’ knowledge and perceptions. Results Most facilities had supplies, equipment, and drugs to manage postabortion care, including family planning counseling and services provision. At public facilities, 36% of skilled birth attendants asked to name essential actions to address abortion complications mentioned manual vacuum aspiration (23% at private facilities); fewer than one-quarter mentioned counseling. When asked what information should be given to postabortion clients, 73% described family planning counseling need (70% at private facilities). Nearly all high-volume public health facilities with an average of five or more births per day and less than 5% of low volume public health facilities with an average of 0–4 deliveries per day reported removal of retained products of conception in the past 3 months. Among the 77 high volume facilities assessed, 58 (75%) reported using misoprostol for removal of retained products of conception, 59 (77%) reported using manual vacuum aspiration, and 67 (87%) reported using dilation and curettage. Conclusions This study provides evidence that there is room for improvement in postabortion care services provision in Afghanistan health facilities including post abortion family planning. Access to high-quality postabortion care needs additional investments to improve providers’ knowledge and practice, availability of supplies and equipment. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01204-w. Afghanistan has one of the highest burdens of maternal mortality in the world. Infections, bleeding around childbirth, and unsafe abortion are the three leading causes of mortality in the country. The uptake of contraceptives is low, and only one-fifth of married women use contraceptives. A National Maternal and Newborn Health Quality of Care Assessment was conducted in 2016 at a selected number of public and private health facilities (n = 226; n = 20) to evaluate health facilities’ capacity to provide postabortion care, and skilled birth attendants’ knowledge and perceptions with regard to such care. Postabortion care is an essential package of services to make women survive complications of miscarriage and abortion and reduce unplanned pregnancies by providing postabortion family planning counseling and services, community empowerment, and mobilization. The result of this study showed that most facilities had supplies, equipment, and drugs to give postabortion care, including family planning services provision. However, there are gaps in birth attendants’ knowledge and their capacity to deliver high-quality postabortion care services at public and private facilities. This study provides evidence that there is room for improvement in postabortion care services provision at health facilities in Afghanistan. Access to high-quality postabortion care needs additional investments to improve providers’ knowledge and practice, and availability of supplies.
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Affiliation(s)
- Farzana Maruf
- Jhpiego Afghanistan, Kabul, Afghanistan. .,Global Financing Facility, World Bank Group, Kabul, Afghanistan. .,Athena Institute, Vrije Universitate, Amsterdam, The Netherlands.
| | | | | | | | - Jelle Stekelenburg
- University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands.,Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Thomas van den Akker
- Athena Institute, Vrije Universitate, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
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Lydon MM, Maruf F, Tappis H. Facility-level determinants of quality routine intrapartum care in Afghanistan. BMC Pregnancy Childbirth 2021; 21:438. [PMID: 34162347 PMCID: PMC8223289 DOI: 10.1186/s12884-021-03916-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 05/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan. METHODS We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores. RESULTS Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care. CONCLUSIONS Quality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.
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Affiliation(s)
| | - Farzana Maruf
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Global Financing Facility, World Bank Group, Kabul, Afghanistan
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22
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Currie S, Natiq L, Anwari Z, Tappis H. Assessing respectful maternity care in a fragile, conflict-affected context: Observations from a 2016 national assessment in Afghanistan. Health Care Women Int 2021; 45:169-189. [PMID: 34126037 DOI: 10.1080/07399332.2021.1932890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 05/17/2021] [Indexed: 12/17/2022]
Abstract
Evidence on experiences and perceptions of care in pregnancy and childbirth in conflict-affected settings is limited. We interviewed 561 maternity care providers and observed 413 antenatal care consultations, 671 births, and 393 postnatal care consultations at public health facilities across Afghanistan. We found that healthcare providers work under stressed conditions with insufficient support, and most women receive mixed quality care. Understanding socio-cultural and contextual factors underpinning acceptance of mistreatment in childbirth, related to conflict, insecurity, gender and power dynamics, is critical for improving the quality of maternity care in Afghanistan and similar fragile and conflict affected settings.
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Affiliation(s)
- Sheena Currie
- Jhpiego, Technical Leadership Office, Baltimore, Maryland, USA
| | - Laila Natiq
- Jhpiego, Technical Leadership Office, Baltimore, Maryland, USA
- Independent Researcher, Alexandria, Virginia, USA
| | | | - Hannah Tappis
- Jhpiego, Technical Leadership Office, Baltimore, Maryland, USA
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23
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Tran NT, Tappis H, Moon P, Christofield M, Dawson A. Sexual and reproductive health self-care in humanitarian and fragile settings: where should we start? Confl Health 2021; 15:22. [PMID: 33827633 PMCID: PMC8024937 DOI: 10.1186/s13031-021-00358-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/22/2021] [Indexed: 11/28/2022] Open
Abstract
Recent crises have accelerated global interest in self-care interventions. This debate paper aims to raise the issue of sexual and reproductive health (SRH) self-care and invites members of the global community operating in crisis-affected settings to look at potential avenues in mainstreaming SRH self-care interventions. We start by exploring self-care interventions that could align with well-established humanitarian standards, such as the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in Crises, point to the potential of digital health support for SRH self-care in crisis-affected settings, and discuss related policy, programmatic, and research considerations. These considerations underscore the importance of self-care as part of the care continuum and within a whole-system approach. Equally critical is the need for self-care in crisis-affected settings to complement other live-saving SRH interventions-it does not eliminate the need for provider-led services in health facilities. Further research on SRH self-care interventions focusing distinctively on humanitarian and fragile settings is needed to inform context-specific policies and practice guidance.
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Affiliation(s)
- Nguyen Toan Tran
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia.
- Faculty of Medicine, University of Geneva, Rue Michel Servet 1, 1211, Geneva 4, Switzerland.
| | - Hannah Tappis
- Johns Hopkins Center for Humanitarian Health, 615 N. Wolfe St, Baltimore, MD, USA
| | - Pierre Moon
- Population Services International, 1120 19th St. NW, Suite 600, Washington, DC, 20036, USA
| | - Megan Christofield
- Self-Care Trailblazer Group, 1120 19th St. NW, Suite 600, Washington, DC, 20036, USA
| | - Angela Dawson
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
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Elnakib S, Elaraby S, Othman F, BaSaleem H, Abdulghani AlShawafi NA, Saleh Al-Gawfi IA, Shafique F, Al-Kubati E, Rafique N, Tappis H. Providing care under extreme adversity: The impact of the Yemen conflict on the personal and professional lives of health workers. Soc Sci Med 2021; 272:113751. [PMID: 33588206 PMCID: PMC7938221 DOI: 10.1016/j.socscimed.2021.113751] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/24/2020] [Accepted: 02/03/2021] [Indexed: 11/28/2022]
Abstract
The war in Yemen, described as the world's 'worst humanitarian crisis,' has seen numerous attacks against health care. While global attention to attacks on health workers has increased significantly over the past decade, gaps in research on the lived experiences of frontline staff persist. This study draws on perspectives of frontline health workers in Yemen to understand the impact of the ongoing conflict on their personal and professional lives. Forty-three facility-based health worker interviews, and 6 focus group discussions with community-based health workers and midwives were conducted in Sana'a, Aden and Taiz governorates at the peak of the Yemen conflict. Data were analysed using content analysis methods. Findings highlight the extent and range of violence confronting health workers in Yemen as well as the coping strategies they use to attenuate the impact of acute and chronic stressors resulting from conflict. We find that the complex security situation - characterized by multiple parties to the conflict, politicization of humanitarian aid and constraints in humanitarian access - was coupled with everyday stressors that prevented health workers from carrying out their work. Participants reported sporadic attacks by armed civilians, tensions with patients, and harassment at checkpoints. Working conditions were dire, and participants reported chronic suspension of salaries as well as serious shortages of essential supplies and medicines. Themes specific to coping centered around fatalism and religious motivation, resourcefulness and innovation, and sense of duty and patriotism. Our findings demonstrate that health workers experience substantial stress and face various pressures while delivering lifesaving services in Yemen. While they exhibit considerable resilience and coping, they have needs that remain largely unaddressed. Accordingly, the humanitarian community should direct more attention to responding to the mental health and psychosocial needs of health workers, while actively working to ameliorate the conditions in which they work.
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Affiliation(s)
- Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sarah Elaraby
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Alexandria University, Alexandria, Egypt
| | | | | | | | | | | | | | | | - Hannah Tappis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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25
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Tappis H, Ramadan M, Vargas J, Kahi V, Hering H, Schulte-Hillen C, Spiegel P. Neonatal mortality burden and trends in UNHCR refugee camps, 2006-2017: a retrospective analysis. BMC Public Health 2021; 21:390. [PMID: 33618684 PMCID: PMC7898433 DOI: 10.1186/s12889-021-10343-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 01/26/2021] [Indexed: 12/16/2022] Open
Abstract
Background More than 100 million people were forcibly displaced over the last decade, including millions of refugees displaced across international borders. Although refugee health and well-being has gained increasing attention from researchers in recent years, few studies have examined refugee birth outcomes or newborn health on a regional or global scale. This study uses routine health information system data to examine neonatal mortality burden and trends in refugee camps between 2006 and 2017. Methods Refugee population and mortality data were exported from the United Nations High Commissioner for Refugees (UNHCR) Health Information System (HIS) database. Tableau was used to export the data. Stata was used for data cleaning and statistical analysis. Neonatal mortality burdens and trends in refugee camps were analyzed and compared to national and subnational neonatal mortality rates captured by household surveys. Findings One hundred fifty refugee camps in 21 countries were included in this study, with an average population of 1,725,433 between 2006 and 2017. A total of 663,892 live births and 3382 neonatal deaths were captured during this period. Annual country-level refugee camp neonatal mortality rates (NMR) ranged from 12 to 56 neonatal deaths per 1000 live births. In most countries and years where national population-based surveys are available, refugee camp NMR as reported in the UNHCR HIS was lower than that of the immediate host community. Conclusion The UNHCR HIS provides insights into the neonatal mortality burden among refugees in camp settings and issues to consider in design and use of routine health information systems to monitor neonatal health in sub-national populations. Increased visibility of neonatal deaths and stillbirths among displaced populations can drive advocacy and inform decisions needed to strengthen health systems. Efforts to count every stillbirth and neonatal death are critical, as well as improvements to reporting systems and mechanisms for data review within broader efforts to improve the quality of neonatal care practices within and outside of health facilities. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10343-5.
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Affiliation(s)
- Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21201, USA.
| | - Marwa Ramadan
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21201, USA
| | - Josep Vargas
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Vincent Kahi
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Heiko Hering
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | | | - Paul Spiegel
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21201, USA
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26
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Singh NS, Ataullahjan A, Ndiaye K, Das JK, Wise PH, Altare C, Ahmed Z, Sami S, Akik C, Tappis H, Mirzazada S, Garcés-Palacio IC, Ghattas H, Langer A, Waldman RJ, Spiegel P, Bhutta ZA, Blanchet K. Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies? Lancet 2021; 397:533-542. [PMID: 33503459 DOI: 10.1016/s0140-6736(21)00132-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 10/05/2020] [Accepted: 10/05/2020] [Indexed: 10/22/2022]
Abstract
Armed conflict disproportionately affects the morbidity, mortality, and wellbeing of women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child, and adolescent health and nutrition interventions in ten conflict-affected settings in Afghanistan, Colombia, Democratic Republic of the Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen. We found that despite large variations in contexts and decision making processes, antenatal care, basic emergency obstetric and newborn care, comprehensive emergency obstetric and newborn care, immunisation, treatment of common childhood illnesses, infant and young child feeding, and malnutrition treatment and screening were prioritised in these ten conflict settings. Many lifesaving women's and children's health (WCH) services, including the majority of reproductive, newborn, and adolescent health services, are not reported as being delivered in the ten conflict settings, and interventions to address stillbirths are absent. International donors remain the primary drivers of influencing the what, where, and how of implementing WCH interventions. Interpretation of WCH outcomes in conflict settings are particularly context-dependent given the myriad of complex factors that constitute conflict and their interactions. Moreover, the comprehensiveness and quality of data remain limited in conflict settings. The dynamic nature of modern conflict and the expanding role of non-state armed groups in large geographic areas pose new challenges to delivering WCH services. However, the humanitarian system is creative and pluralistic and has developed some novel solutions to bring lifesaving WCH services closer to populations using new modes of delivery. These solutions, when rigorously evaluated, can represent concrete response to current implementation challenges to modern armed conflicts.
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Affiliation(s)
- Neha S Singh
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Khadidiatou Ndiaye
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Jai K Das
- Centre of Excellence in Women and Child Health and Institute of Global Health and Development, The Aga Khan University, Karachi, Pakistan
| | - Paul H Wise
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Chiara Altare
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Zahra Ahmed
- Somali Disaster Resilience Institute, Mogadishu, Somalia
| | - Samira Sami
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, GA, USA
| | - Chaza Akik
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Hannah Tappis
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Hala Ghattas
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ana Langer
- Women and Health Initiative, Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ronald J Waldman
- Global Health Department, Milken Institute School of Public Health, George Washington University, Washington, DC, USA; Doctors of the World, New York, NY, USA
| | - Paul Spiegel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Centre of Excellence in Women and Child Health and Institute of Global Health and Development, The Aga Khan University, Karachi, Pakistan
| | - Karl Blanchet
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, London, UK; The Geneva Centre of Humanitarian Studies, University of Geneva, Graduate Institute, Geneva 1211, Switzerland.
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27
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Kim C, Tappis H, Natiq L, Fried B, Lich KH, Delamater PL, Weinberger M, Trogdon JG. Travel time, availability of emergency obstetric care, and perceived quality of care associated with maternal healthcare utilisation in Afghanistan: A multilevel analysis. Glob Public Health 2021; 17:569-586. [PMID: 33460359 DOI: 10.1080/17441692.2021.1873400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Limited understanding of factors such as travel time, availability of emergency obstetric care (EmOC), and satisfaction/perceived quality of care on the utilisation of maternal health services exists in fragile and conflict-affect settings. We examined these key factors on three utilisation outcomes: at least one skilled antenatal care (ANC) visit, in-facility delivery, and bypassing the nearest public facility for childbirth in Afghanistan from 2010 to 2015. We used three-level multilevel mixed effects logistic regression models to assess the relationships between women's and their nearest public facilities' characteristics and outcomes. The nearest facility score for satisfaction/perceived quality was associated with having at least one skilled ANC visit (AOR: 2.02, 95% CI: 1.21, 3.36). Women whose nearest facility provided EmOC had a higher odds of in-facility childbirth compared to women whose nearest facility did not (AOR: 1.24, 95% CI: 1.04, 1.48). Nearest hospital travel time (AOR: 0.95, 95% CI: 0.93, 0.98) and nearest facility satisfaction/perceived quality (AOR: 0.34, 95% CI: 0.14, 0.82) were associated with lower odds of women bypassing their nearest facility. Afghanistan has made progress in expanding access to maternal healthcare services during the ongoing conflict. Addressing key barriers is essential to ensure that women have access to life-saving services.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hannah Tappis
- Technical Leadership and Innovations Department, Jhpiego, Baltimore, MD, USA
| | - Laila Natiq
- Silk Route Training and Research Organization, Kabul, Afghanistan
| | - Bruce Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paul L Delamater
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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28
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Kim C, Tappis H, McDaniel P, Soroush MS, Fried B, Weinberger M, Trogdon JG, Kristen Hassmiller Lich, Delamater PL. National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility. Health Place 2020; 66:102452. [PMID: 33011490 DOI: 10.1016/j.healthplace.2020.102452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/30/2022]
Abstract
In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015 at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2 h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2 h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2 h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Hannah Tappis
- Technical Leadership and Innovations Department, Jhpiego, Baltimore, MD, USA.
| | - Philip McDaniel
- Davis Library, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Bruce Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul L Delamater
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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29
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Ansari N, Maruf F, Manalai P, Currie S, Soroush MS, Amin SS, Higgins-Steele A, Kim YM, Stekelenburg J, van Roosmalen J, Tappis H. Quality of care in prevention, detection and management of postpartum hemorrhage in hospitals in Afghanistan: an observational assessment. BMC Health Serv Res 2020; 20:484. [PMID: 32487154 PMCID: PMC7265625 DOI: 10.1186/s12913-020-05342-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 05/20/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hemorrhage is the leading cause of maternal mortality worldwide and accounts for 56% of maternal deaths in Afghanistan. Postpartum hemorrhage (PPH) is commonly caused by uterine atony, genital tract trauma, retained placenta, and coagulation disorders. The purpose of this study is to examine the quality of prevention, detection and management of PPH in both public and private hospitals in Afghanistan in 2016, and compare the quality of care in district hospitals with care in provincial, regional, and specialty hospitals. METHODS This study uses a subset of data from the 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment. It covers a census of all accessible public hospitals, including 40 district hospitals, 27 provincial hospitals, five regional hospitals, and five specialty hospitals, as well as 10 purposively selected private hospitals. RESULTS All public and private hospitals reported 24 h/7 days a week service provision. Oxytocin was available in 90.0% of district hospitals, 89.2% of provincial, regional and specialty hospitals and all 10 private hospitals; misoprostol was available in 52.5% of district hospitals, 56.8% of provincial, regional and specialty hospitals and in all 10 private hospitals. For prevention of PPH, 73.3% women in district hospitals, 71.2% women at provincial, regional and specialty hospitals and 72.7% women at private hospital received uterotonics. Placenta and membranes were checked for completeness in almost half of women in all hospitals. Manual removal of placenta was performed in 97.8% women with retained placenta. Monitoring blood loss during the immediate postpartum period was performed in 48.4% of women in district hospitals, 36.9% of women in provincial, regional and specialty hospitals, and 43.3% in private hospitals. The most commonly observed cause of PPH was retained placenta followed by genital tract trauma and uterine atony. CONCLUSION Gaps in performance of skilled birth attendants are substantial across public and private hospitals. Improving and retaining skills of health workers through on-site, continuous capacity development approaches and encouraging a culture of audit, learning and quality improvement may address clinical gaps and improve quality of PPH prevention, detection and management.
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Affiliation(s)
- Nasratullah Ansari
- Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
| | - Farzana Maruf
- Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
- Global Financing Facility, World Bank Group, Kabul, Afghanistan
| | - Partamin Manalai
- Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
- Jhpiego, Kabul, Afghanistan
| | | | - Mohammad Samim Soroush
- Reproductive, Maternal, Newborn, Child and Adolescent Health Department, Ministry of Public Health, Masood Square, Kabul, Afghanistan
| | | | | | | | - Jelle Stekelenburg
- University Medical Centre Groningen, Department of Health Sciences, Global Health, University of Groningen, Groningen, the Netherlands
- Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
| | - Jos van Roosmalen
- Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
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30
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Tran NT, Tappis H, Spilotros N, Krause S, Knaster S. Not a luxury: a call to maintain sexual and reproductive health in humanitarian and fragile settings during the COVID-19 pandemic. Lancet Glob Health 2020; 8:e760-e761. [PMID: 32330429 PMCID: PMC7173831 DOI: 10.1016/s2214-109x(20)30190-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Nguyen Toan Tran
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, NSW 2007, Australia; Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Hannah Tappis
- Johns Hopkins Center for Humanitarian Health, Baltimore, MD, USA
| | | | | | - Sarah Knaster
- Inter-Agency Working Group on Reproductive Health in Crises, New York, NY, USA
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31
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Tappis H, Elaraby S, Elnakib S, AlShawafi NAA, BaSaleem H, Al-Gawfi IAS, Othman F, Shafique F, Al-Kubati E, Rafique N, Spiegel P. Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study. Confl Health 2020; 14:30. [PMID: 32514295 PMCID: PMC7254736 DOI: 10.1186/s13031-020-00269-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 03/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care. METHODS This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018. RESULTS Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services. CONCLUSIONS Challenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.
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Affiliation(s)
- Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | - Sarah Elaraby
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | - Shatha Elnakib
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | | | | | | | | | | | | | | | - Paul Spiegel
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
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Sami S, Mayai A, Sheehy G, Lightman N, Boerma T, Wild H, Tappis H, Ochan W, Wanyama J, Spiegel P. Maternal and child health service delivery in conflict-affected settings: a case study example from Upper Nile and Unity states, South Sudan. Confl Health 2020; 14:34. [PMID: 32514299 PMCID: PMC7254670 DOI: 10.1186/s13031-020-00272-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 04/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decades of war left the Republic of South Sudan with a fragile health system that has remained deprived of resources since the country's independence. We describe the coverage of interventions for women's and children's health in Upper Nile and Unity states, and explore factors that affected service provision during a protracted conflict. METHODS We conducted a case study using a desk review of publicly available literature since 2013 and a secondary analysis of intervention coverage and conflict-related events from 2010 to 2017. During June through September 2018, we conducted 26 qualitative interviews with technical leads and 9 focus groups among health workers working in women and children's health in Juba, Malakal, and Bentiu. RESULTS Coverage for antenatal care, institutional delivery, and childhood vaccines were low prior to the escalation of conflict in 2013, and the limited data indicate that coverage remained low through 2017. Key factors that determined the delivery of services for women and children in our study sites were government leadership, coordination of development and humanitarian efforts, and human resource capacity. Participants felt that national and local health officials had a limited role in the delivery of services, and financial tracking data showed that funding stagnated or declined for humanitarian health and development programming during 2013-2014. Although health services were concentrated in camp settings, the availability of healthcare providers was negatively impacted by the protracted nature of the conflict and insecurity in the region. CONCLUSIONS Health care for women and children should be prioritized during acute and protracted periods of conflict by strengthening surveillance systems, coordinating short and long term activities among humanitarian and development organizations, and building the capacity of national and local government officials to ensure sustainability.
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Affiliation(s)
- Samira Sami
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Augustino Mayai
- University of Juba, and The Sudd Institute, Juba, South Sudan
| | - Grace Sheehy
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Nicole Lightman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Ties Boerma
- Centre for Global Public Health, University of Manitoba, and Countdown to 2030 for Women’s, Children’s and Adolescents’ Health, Winnipeg, Canada
| | - Hannah Wild
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305 USA
| | - Hannah Tappis
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Wilfred Ochan
- United Nations Population Fund South Sudan, Juba, South Sudan
| | - James Wanyama
- United Nations Population Fund South Sudan, Juba, South Sudan
| | - Paul Spiegel
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Altare C, Malembaka EB, Tosha M, Hook C, Ba H, Bikoro SM, Scognamiglio T, Tappis H, Pfaffmann J, Balaluka GB, Boerma T, Spiegel P. Health services for women, children and adolescents in conflict affected settings: experience from North and South Kivu, Democratic Republic of Congo. Confl Health 2020; 14:31. [PMID: 32514296 PMCID: PMC7254646 DOI: 10.1186/s13031-020-00265-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/02/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Insecurity has characterized the Eastern regions of the Democratic Republic of Congo for decades. Providing health services to sustain women's and children's health during protracted conflict is challenging. This mixed-methods case study aimed to describe how reproductive, maternal, newborn, child, adolescent health and nutrition (RMNCAH+N) services have been offered in North and South Kivu since 2000 and how successful they were. METHODS We conducted a case study using a desk review of publicly available literature, secondary analysis of survey and health information system data, and primary qualitative interviews. The qualitative component provides insights on factors shaping RMNCAH+N design and implementation. We conducted 49 interviews with government officials, humanitarian agency staff and facility-based healthcare providers, and focus group discussions with community health workers in four health zones (Minova, Walungu, Ruanguba, Mweso). We applied framework analysis to investigate key themes across informants.The quantitative component used secondary data from nationwide surveys and the national health facility information system to estimate coverage of RMNCAH+N interventions at provincial and sub-provincial level. The association between insecurity on service provision was examined with random effects generalized least square models using health facility data from South Kivu. RESULTS Coverage of selected preventive RMNCAH+N interventions seems high in North and South Kivu, often higher than the national level. Health facility data show a small negative association of insecurity and preventive service coverage within provinces. However, health outcomes are poorer in conflict-affected territories than in stable ones. The main challenges to service provisions identified by study respondents are the availability and retention of skilled personnel, the lack of basic materials and equipment as well as the insufficient financial resources to ensure health workers' regular payment, medicaments' availability and facilities' running costs. Insecurity exacerbates pre-existing challenges, but do not seem to represent the main barrier to service provision in North and South Kivu. CONCLUSIONS Provision of preventive schedulable RMNCAH+N services has continued during intermittent conflict in North and South Kivu. The prolonged effort by non-governmental organizations and UN agencies to respond to humanitarian needs was likely key in maintaining intervention coverage despite conflict. Health actors and communities appear to have adapted to changing levels and nature of insecurity and developed strategies to ensure preventive services are provided and accessed. However, emergency non-schedulable RMNCAH+N interventions do not appear to be readily accessible. Achieving the Sustainable Development Goals will require increased access to life-saving interventions, especially for newborn and pregnant women.
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Affiliation(s)
- Chiara Altare
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Espoir Bwenge Malembaka
- Ecole Régionale de Santé Publique, ERSP, Faculty of Medicine, Université catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Maphie Tosha
- Foundation RamaLevina, Bukavu, Democratic Republic of Congo
| | - Christopher Hook
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Hamady Ba
- United Nations Children’s Fund, Bukavu, Democratic Republic of Congo
| | | | - Thea Scognamiglio
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Hannah Tappis
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Ghislain Bisimwa Balaluka
- Ecole Régionale de Santé Publique, ERSP, Faculty of Medicine, Université catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Ties Boerma
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
| | - Paul Spiegel
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Ataullahjan A, Gaffey MF, Sami S, Singh NS, Tappis H, Black RE, Blanchet K, Boerma T, Langer A, Spiegel PB, Waldman RJ, Wise PH, Bhutta ZA. Investigating the delivery of health and nutrition interventions for women and children in conflict settings: a collection of case studies from the BRANCH Consortium. Confl Health 2020; 14:29. [PMID: 32514294 PMCID: PMC7254714 DOI: 10.1186/s13031-020-00276-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
Globally, the number of people affected by conflict is the highest in history, and continues to steadily increase. There is currently a pressing need to better understand how to deliver critical health interventions to women and children affected by conflict. The compendium of articles presented in this Conflict and Health Collection brings together a range of case studies recently undertaken by the BRANCH Consortium (Bridging Research & Action in Conflict Settings for the Health of Women and Children). These case studies describe how humanitarian actors navigate and negotiate the multiple obstacles and forces that challenge the delivery of health and nutrition interventions for women, children and adolescents in conflict-affected settings, and to ultimately provide some insight into how service delivery can be improved.
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Affiliation(s)
| | - Michelle F. Gaffey
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Samira Sami
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Neha S. Singh
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Robert E. Black
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Karl Blanchet
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Ana Langer
- Women and Health Initiative, Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, USA
| | - Paul B. Spiegel
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Ronald J. Waldman
- Milken Institute School of Public Health, George Washington University, Washington DC, USA
| | - Paul H. Wise
- The Center for Policy, Outcomes and Prevention, Stanford University, Palo Alto, CA USA
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
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Ansari N, Tappis H, Manalai P, Anwari Z, Kim YM, van Roosmalen JJM, Stekelenburg J. Readiness of emergency obstetric and newborn care in public health facilities in Afghanistan between 2010 and 2016. Int J Gynaecol Obstet 2019; 148:361-368. [PMID: 31811740 DOI: 10.1002/ijgo.13076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 10/05/2019] [Accepted: 12/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess changes in readiness to provide emergency obstetric and newborn care (EmONC) in health facilities in Afghanistan between 2010 and 2016. METHODS A secondary analysis was performed of a subset of data from cross-sectional health facility assessments conducted in December 2009 to February 2010 and May 2016 to January 2017. Interviews with health providers, facility inventory, and record review were conducted in both assessments. Descriptive statistics and χ2 tests were used to compare readiness of EmONC at 59 public health facilities expected to provide comprehensive EmONC. RESULTS The proportion of facilities reporting provision of uterotonic drugs, anticonvulsants, parenteral antibiotics, newborn resuscitation, and cesarean delivery did not change significantly between 2010 and 2016. Provision of assisted vaginal deliveries increased from 78% in 2010 to 98% in 2016 (P<0.001). Fewer health facilities had amoxicillin (61% in 2016 vs 90% in 2010; P<0.001) and gentamicin (74% in 2016 vs 95% in 2010; P<0.002). The number of facilities with at least one midwife on duty 24 hours a day/7 days a week significantly declined (88% in 2016 vs 98% in 2010; P=0.028). CONCLUSION Despite a few positive changes, readiness of EmONC services in Afghanistan in 2016 had declined from 2010 levels.
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Affiliation(s)
- Nasratullah Ansari
- Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | | | | | - Zelaikha Anwari
- Reproductive, Maternal, Newborn, Child and Adolescent Health Department, Ministry of Public Health, Kabul, Afghanistan
| | | | - Jos J M van Roosmalen
- Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
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Nelson AR, Cooper CM, Kamara S, Taylor ND, Zikeh T, Kanneh-Kesselly C, Fields R, Hossain I, Oseni L, Getahun BS, Fiedler A, Schuster A, Tappis H. Operationalizing Integrated Immunization and Family Planning Services in Rural Liberia: Lessons Learned From Evaluating Service Quality and Utilization. Glob Health Sci Pract 2019; 7:418-434. [PMID: 31558598 PMCID: PMC6816810 DOI: 10.9745/ghsp-d-19-00012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 07/16/2019] [Indexed: 11/15/2022]
Abstract
Providers, managers, and clients valued the integrated service delivery model. Trends indicated slightly higher family planning uptake in intervention facilities, but that difference was not statistically significant. Intrafacility referrals by postpartum women did not negatively affect immunization utilization rates. Background: Integration of family planning and immunization services provides an opportunity to meet women's need for postpartum family planning and infants' vaccination needs through client-centered care, while reducing financial and opportunity costs for families. The United States Agency for International Development's Maternal and Child Survival Program (MCSP) supported the Liberia Ministry of Health to scale up integrated family planning and immunization services as part of a broader service delivery and health systems recovery program after the Ebola epidemic. Methods: We conducted a mixed-methods program evaluation in 22 health facilities in Grand Bassa and Lofa counties. Family planning uptake and immunization dropout rates at project sites were compared to rates at 18 matched health facilities in the same counties. We conducted 34 focus group discussions with community members and 43 key informant interviews with health care providers and managers to explore quality of care and contextual factors affecting provision and use of integrated services including postpartum family planning. Results: From November 2016 to July 2017, 1,066 women accepted referrals from immunization to family planning counseling (10% of all vaccinator-caregiver interactions); the majority of women who were referred (75%) accepted a family planning method the same day. Trends indicated slightly higher family planning uptake in intervention over nonintervention facilities, but differences were not statistically significant. Pentavalent vaccine dropout rates did not increase in intervention compared to nonintervention facilities indicating no negative impact on utilization of immunization services. Clients and providers expressed that the integrated services reduced costs and time for the clients, educated mothers about postpartum family planning, and ensured infants were completing their vaccinations. Providers expressed the need for increased human resources to meet the elevated demand for family planning counseling services and additional focus on community-level social and behavior change activities. Both groups emphasized that social stigma and norms about postpartum sexual abstinence prevented many women from seeking postpartum family planning services. Conclusion: Although scaling up integrated family planning-immunization services may be programmatically feasible and acceptable to clients and providers, the intervention's success and ability to understand and quantify impact are driven by the effect of contextual factors and fidelity to the intervention approach. Contextual factors need to be understood before implementation, measured during implementation, and addressed throughout implementation to maximize the approach's impact on service utilization and health outcomes.
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Atiqzai F, Manalai P, Amin SS, Edmond KM, Naziri M, Soroush MS, Sultana S, Yousufi K, van den Akker T, Stekelenburg J, Tappis H. Quality of essential newborn care and neonatal resuscitation at health facilities in Afghanistan: a cross-sectional assessment. BMJ Open 2019; 9:e030496. [PMID: 31473621 PMCID: PMC6720229 DOI: 10.1136/bmjopen-2019-030496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess readiness and quality of essential newborn care and neonatal resuscitation practices in public health facilities in Afghanistan. DESIGN Cross-sectional assessment. SETTING 226 public health facilities in Afghanistan, including 77 public health facilities with at least five births per day (high-volume facilities) and 149 of 1736 public health facilities with fewer than five births per day (low-volume facilities). PARTICIPANTS Managers of 226 public health facilities, 734 skilled birth attendants (SBAs) working at these facilities, and 643 women and their newborns observed during childbirth at 77 high-volume health facilities. OUTCOME MEASURES Availability of knowledgeable SBAs, availability of supplies and compliance with global guidelines for essential newborn care and neonatal resuscitation practices. RESULTS At high-volume facilities, 569/636 (87.9%) of babies were dried immediately after birth, 313/636 (49.2%) were placed in skin-to-skin contact with their mother and 581/636 (89.7%) had their umbilical cord cut with a sterile blade or scissors. A total of 87 newborn resuscitation attempts were observed. Twenty-four of the 87 (27.5%) began to breath or cry after simply clearing the airway or on stimulation. In the remaining 63 (72.5%) cases, a healthcare worker began resuscitation with a bag and mask; however, only 54 (62%) used a correct size of mask and three babies died as their resuscitation with bag and mask was unsuccessful. CONCLUSIONS The study indicates room for improvement of the quality of neonatal resuscitation practices at public health facilities in Afghanistan, requiring only strengthening of the current best practices in newborn care. Certain basic and effective aspects of essential newborn care that can be improved on with little additional resources were also missing, such as skin-to-skin contact of the babies with their mother. Improvement of compliance with the standard newborn care practices must be ensured to reduce preventable newborn mortality and morbidity in Afghanistan.
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Affiliation(s)
| | | | - Sher Shah Amin
- Office of Health and Nutrition, USAID Afghanistan, Kabul, Afghanistan
| | | | | | - Mohammad Samim Soroush
- Reproductive, Maternal, Newborn and Child Health Department, Ministry of Public Health, Kabul, Afghanistan
| | | | | | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen, Groningen, The Netherlands
- Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Hannah Tappis
- Technical Leadership Office, Jhpiego, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Rogers E, Tappis H, Doocy S, Martínez K, Villeminot N, Suk A, Kumar D, Pietzsch S, Puett C. Costs and cost-effectiveness of three point-of-use water treatment technologies added to community-based treatment of severe acute malnutrition in Sindh Province, Pakistan. Glob Health Action 2019; 12:1568827. [PMID: 30888265 PMCID: PMC6427553 DOI: 10.1080/16549716.2019.1568827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Severe acute malnutrition (SAM) is a major global public health concern. Despite the cost-effectiveness of treatment, ministries of health are often unable to commit the required funds which limits service coverage. Objective: A randomised controlled trial was conducted in Sindh Province, Pakistan, to assess whether adding a point of use water treatment to the treatment of SAM without complications improved its cost-effectiveness. Three treatment strategies – chlorine disinfection (Aquatabs); flocculent disinfection (Procter and Gamble Purifier of Water [P&G PoW]) and Ceramic Filters – were compared to a standard SAM treatment protocol. Methods: An institutional perspective was adopted for costing, considering the direct and indirect costs incurred by the provider. Combining the cost of SAM treatment and water treatment, an average cost per child was calculated for the combined interventions for each arm. The costs of water treatment alone and the incremental cost-effectiveness of each water treatment intervention were also assessed. Results: The incremental cost-effectiveness ratio for Aquatabs was 24 US dollars (USD), making it the most cost-effective strategy. The P&G PoW arm was the next least expensive strategy, costing an additional 149 USD per additional child recovered, though it was also the least effective of the three intervention strategies. The Ceramic Filters intervention was the most costly strategy and achieved a recovery rate lower than the Aquatabs arm and marginally higher than the P&G PoW arm. Conclusions: This study found that the addition of a chlorine or flocculent disinfection point-of-use drinking water treatment intervention to the treatment of SAM without complications reduced the cost per child recovered compared to standard SAM treatment. To inform the feasibility of future implementation, further research is required to understand the costs of government implementation and the associated costs to the community and beneficiary household of receiving such an intervention in comparison with the existing SAM treatment protocol.
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Affiliation(s)
| | - Hannah Tappis
- b Department of International Health , Johns Hopkins Bloomberg School of Public Health, Department of International Health , Baltimore , MD , USA
| | - Shannon Doocy
- b Department of International Health , Johns Hopkins Bloomberg School of Public Health, Department of International Health , Baltimore , MD , USA
| | - Karen Martínez
- c Operations department , Action Against Hunger USA , New York , NY , USA
| | - Nicolas Villeminot
- c Operations department , Action Against Hunger USA , New York , NY , USA
| | - Ann Suk
- d Programme department , Action Against Hunger Pakistan , Islamabad , Pakistan
| | - Deepak Kumar
- d Programme department , Action Against Hunger Pakistan , Islamabad , Pakistan
| | - Silke Pietzsch
- c Operations department , Action Against Hunger USA , New York , NY , USA
| | - Chloe Puett
- c Operations department , Action Against Hunger USA , New York , NY , USA
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Boerma T, Tappis H, Saad-Haddad G, Das J, Melesse DY, DeJong J, Spiegel P, Black R, Victora C, Bhutta ZA, Barros AJD. Armed conflicts and national trends in reproductive, maternal, newborn and child health in sub-Saharan Africa: what can national health surveys tell us? BMJ Glob Health 2019; 4:e001300. [PMID: 31297253 PMCID: PMC6590971 DOI: 10.1136/bmjgh-2018-001300] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/28/2019] [Accepted: 02/25/2019] [Indexed: 01/22/2023] Open
Abstract
Armed conflicts are widespread in sub-Saharan Africa and considered to be an important factor in slowing down national progress in reproductive, maternal, newborn and child health (RMNCH). The measurement of the impact of conflicts on national levels and trends in RMNCH is difficult. National surveys conducted before and sometimes during and after conflicts are a major source of information on the national and local effects of conflicts on RMNCH. We examined data from national surveys in 13 countries in sub-Saharan Africa with major conflicts during 1990–2016 to assess the levels and trends in RMNCH intervention coverage, nutritional status and mortality in children under 5 years in comparison with subregional trends. The surveys provide substantive evidence of a negative association between levels and trends in national indicators of RMNCH service coverage, child growth and under-5 mortality with armed conflict, with some notable exceptions. National surveys are an important source of data to assess the longer term national consequences of conflicts for RMNCH in most countries, despite limitations due to sampling and timing of the surveys.
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Affiliation(s)
- Ties Boerma
- Center for Global Public Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hannah Tappis
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ghada Saad-Haddad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Jai Das
- Faculty of Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Dessalegn Y Melesse
- Community Health Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jocelyn DeJong
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Paul Spiegel
- International Health, Bloomberg School of Public Health, Johns Hopkins Unversity, Baltimore, Maryland, USA
| | - Robert Black
- International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cesar Victora
- Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Aluisio J D Barros
- International Center for Equity in Health, Universidade Federal de Pelotas, Pelotas, Brazil
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Asiedu A, Nelson AR, Gomez PP, Tappis H, Effah F, Allen C. "It builds your confidence… you've done well": Healthcare workers' experiences of participating in a low-dose, high-frequency training to improve newborn survival on the day of birth in Ghana. Gates Open Res 2019; 3:1470. [PMID: 31410394 DOI: 10.12688/gatesopenres.12936.1/doi] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2019] [Indexed: 05/29/2023] Open
Abstract
Background: The majority of newborn deaths occur during the first week of life, and 25‒45% occur within the first 24 hours. A low-dose, high-frequency (LDHF) training approach was introduced in 40 hospitals in Ghana to improve newborn survival. The aim of this qualitative study was to explore healthcare workers' experiences with the LDHF approach to in-service training. Methods: A total of 20 in-depth interviews and nine focus group discussions were conducted in 2016 in three regions of Ghana with healthcare workers who participated in implementation of the LDHF training approach. In-depth interviews were conducted with 20 master mentors and peer practice coordinators; 51 practicing doctors, midwives and nurses participated in focus group discussions. Data were analyzed using a thematic analysis approach. Results: Healthcare workers reflected on the differences between the LDHF approach and past learning experiences, highlighting how the skills-based team training approach, coupled with high-frequency practice and mobile mentoring, built their competency and confidence. As participants shared their experiences, they highlighted relationships established between Master Mentors and healthcare workers, and motivation stemming from pride in contributing to reductions in maternal and newborn deaths as critical factors in improving quality of care at participating health facilities. Conclusion: This nested qualitative study documents experiences of healthcare workers and mentors involved in implementation of a multi-faceted intervention that effectively improved maternal and newborn care at health facilities in Ghana. The way the intervention was implemented created an environment conducive to learning within the hospital setting, thus providing an opportunity for professional growth and quality improvement for all staff working in the maternity ward.
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Asiedu A, Nelson AR, Gomez PP, Tappis H, Effah F, Allen C. "It builds your confidence… you've done well": Healthcare workers' experiences of participating in a low-dose, high-frequency training to improve newborn survival on the day of birth in Ghana. Gates Open Res 2019; 3:1470. [PMID: 31410394 PMCID: PMC6667826 DOI: 10.12688/gatesopenres.12936.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2019] [Indexed: 12/04/2022] Open
Abstract
Background: The majority of newborn deaths occur during the first week of life, and 25‒45% occur within the first 24 hours. A low-dose, high-frequency (LDHF) training approach was introduced in 40 hospitals in Ghana to improve newborn survival. The aim of this qualitative study was to explore healthcare workers’ experiences with the LDHF approach to in-service training. Methods: A total of 20 in-depth interviews and nine focus group discussions were conducted in 2016 in three regions of Ghana with healthcare workers who participated in implementation of the LDHF training approach. In-depth interviews were conducted with 20 master mentors and peer practice coordinators; 51 practicing doctors, midwives and nurses participated in focus group discussions. Data were analyzed using a thematic analysis approach. Results: Healthcare workers reflected on the differences between the LDHF approach and past learning experiences, highlighting how the skills-based team training approach, coupled with high-frequency practice and mobile mentoring, built their competency and confidence. As participants shared their experiences, they highlighted relationships established between Master Mentors and healthcare workers, and motivation stemming from pride in contributing to reductions in maternal and newborn deaths as critical factors in improving quality of care at participating health facilities. Conclusion: This nested qualitative study documents experiences of healthcare workers and mentors involved in implementation of a multi-faceted intervention that effectively improved maternal and newborn care at health facilities in Ghana. The way the intervention was implemented created an environment conducive to learning within the hospital setting, thus providing an opportunity for professional growth and quality improvement for all staff working in the maternity ward.
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Pfitzer A, Maly C, Tappis H, Kabue M, Mackenzie D, Healy S, Srivastava V, Ndirangu G. Characteristics of successful integrated family planning and maternal and child health services: Findings from a mixed-method, descriptive evaluation. F1000Res 2019; 8:229. [PMID: 32047599 PMCID: PMC6993833 DOI: 10.12688/f1000research.17208.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Most postpartum women in low- and middle-income countries want to delay or avoid future pregnancies but are not using modern contraception. One promising strategy for increasing the use of postpartum family planning (PPFP) is integration with maternal, newborn and child health (MNCH) services. However, there is limited evidence on effective service integration strategies. We examine facilitators of and barriers to effective PPFP integration in MNCH services in Kenya and India. Methods: We conducted a cross-sectional, mixed-method study in two counties in Kenya and two states in India. Data collection included surveying 215 MNCH clients and surveying or interviewing 82 health care providers and managers in 15 health facilities across the four sites. We analyzed data from each country separately. First, we analyzed quantitative data to assess the extent to which PPFP was integrated within MNCH services at each facility. Then we analyzed qualitative data and synthesized findings from both data sources to identify characteristics of well and poorly integrated facilities. Results: PPFP integration success varied by service delivery area, health facility, and country. Issues influencing the extent of integration included availability of physical space for PPFP services, health workforce composition and capacity, family planning commodities availability, duration and nature of support provided. Conclusions: Although integration level varied between health facilities, factors enabling and hindering PPFP integration were similar in India and Kenya. Better measures are needed to verify whether services are integrated as prescribed by national policies.
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Affiliation(s)
- Anne Pfitzer
- Maternal and Child Survival Program, Jhpiego, Washington, DC, 20036, USA
| | | | | | | | - Devon Mackenzie
- Maternal and Child Survival Program, Jhpiego, Washington, DC, 20036, USA
| | - Sadie Healy
- Molloy Consultants, Cincinnati, OH, 45208, USA
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Ansari N, Manalai P, Maruf F, Currie S, Stekelenburg J, van Roosmalen J, Kim YM, Tappis H. Quality of care in early detection and management of pre-eclampsia/eclampsia in health facilities in Afghanistan. BMC Pregnancy Childbirth 2019; 19:36. [PMID: 30658606 PMCID: PMC6339332 DOI: 10.1186/s12884-018-2143-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/11/2018] [Indexed: 01/11/2023] Open
Abstract
Background Afghanistan faces a high burden of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E), are among the most common causes of maternal and neonatal complications. Hypertensive disorders of pregnancy can lead to fatal complications for both the mother and fetus. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment assessed quality of early detection and management of PE/E in health facilities and skilled birth attendants’ (SBAs) perceptions of their working environment. Methods All accessible public health facilities with an average of at least five births per day (n = 77), a nationally representative sample of public health facilities with less than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Methods included a facility inventory and record review, interviews with SBAs, and direct clinical observation of antenatal care (ANC), intrapartum care and immediate postnatal care (PNC), as well as severe PE/E case management. Results Most facilities had supplies and medicines for early detection and management of PE/E. At public health facilities, 357 of 414 (86.2%) clients observed during ANC consultations had their blood pressure checked and 159 (38.4%) were asked if they had experienced symptoms of PE/E. Only 553 of 734 (72.6%) SBAs interviewed were able to correctly identify severe pre-eclampsia described in a case scenario. Of 29 PE/E cases observed, 17 women (59%) received the correct loading dose of magnesium sulfate (MgSO4) and 12 women (41%) received the correct maintenance dose of MgSO4. At private health facilities, 39 of 45 ANC clients had their blood pressure checked and 9 of 45 (20%) were asked about symptoms of PE/E. Fifty-four of 64(84.4%) SBAs in private facilities correctly identified severe pre-eclampsia described in a case scenario. Conclusion Notable gaps in SBAs’ knowledge and clinical practices in detection and management of PE/E in various health facilities increase the risk of maternal and perinatal mortality. Continuing education of health care providers and increased investment in focused quality improvement initiatives will be critical to improve the quality of health care services in Afghanistan.
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Affiliation(s)
- Nasratullah Ansari
- Jhpiego, 1615 Thames Street, Baltimore, MD, USA. .,Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, De Boelelaan 1105, 1081, HV, Amsterdam, the Netherlands.
| | | | | | | | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.,Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
| | - Jos van Roosmalen
- Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, De Boelelaan 1105, 1081, HV, Amsterdam, the Netherlands
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Abstract
Purpose The influx of Syrian refugees into Jordan and Lebanon over the last 5 years presents an immense burden to national health systems. This study was undertaken to assess utilization of maternal health services among Syrian refugees in both countries. Description A cross-sectional survey of Syrian refugees living in urban and rural (non-camp) settings was conducted using a two-stage cluster survey design with probability proportional to size sampling in 2014-2015. Eighty-six percent of surveyed households in Lebanon and 88% of surveyed households in Jordan included women with a live birth in the last year. Information from women in this sub-set of households was analyzed to understand antenatal and intrapartum health service utilization. Assessment A majority of respondents reported seeking antenatal care, 82% and 89% in Jordan and Lebanon, respectively. Women had an average of at least six antenatal care visits. Nearly all births (98% in Jordan and 94% in Lebanon) took place in a health facility. Cesarean rates were similar in both countries; approximately one-third of all births were cesarean deliveries. A substantial proportion of women incurred costs for intrapartum care; 33% of Syrian women in Jordan and 94% of Syrian women in Lebanon reported paying out of pocket for their deliveries. The proportion of women incurring costs for intrapartum care was higher in Jordan both countries for women with cesarean deliveries compared to those with vaginal deliveries; however, this difference was not statistically significant in either country (Jordan p-value = 0.203; Lebanon p-value = 0.099). Conclusion Syrian refugees living in Jordan and Lebanon had similar levels of utilization of maternal health services, despite different health systems and humanitarian assistance provisions. As expected, a substantial proportion of households incurred out-of-pocket costs for essential maternal and newborn health services, making cost a major factor in care-seeking decisions and locations. As health financing policies shift to account for the continued burden of refugee hosting on the health system, sustained attention to the availability and quality of essential maternal and newborn health services is needed to protect both refugee and host populations women's rights to health and health care during pregnancy, childbirth, and the postpartum period.
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Affiliation(s)
- Hannah Tappis
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Emily Lyles
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Ann Burton
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | | | | | - Shannon Doocy
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
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Cooper CM, Ogutu A, Matiri E, Tappis H, Mackenzie D, Pfitzer A, Galloway R. Maximizing Opportunities: Family Planning and Maternal, Infant, and Young Child Nutrition Integration in Bondo Sub-County, Kenya. Matern Child Health J 2018; 21:1880-1889. [PMID: 28766091 PMCID: PMC5605598 DOI: 10.1007/s10995-017-2341-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Purpose This article shares learning from an innovative demonstration program integrating maternal, infant, and young child nutrition (MIYCN) and family planning (FP) services in western Kenya, providing recommendations for future work to expand MIYCN and FP integration. Description Six health facilities reorganized to integrate MIYCN and FP services and community health volunteers (CHVs) promoted MIYCN and FP in adjacent communities in Bondo Sub-County over a 1-year period. At the facility level, each provider was directed to provide both sets of services in a single room during FP, antenatal care, postnatal care, or child consultation visits (a "one stop shop" approach). At community level, CHVs were to conduct household visits equipped with new integrated materials and incorporate MIYCN and FP within community activities. Assessment Although the "one stop shop" approach, where one provider offers all integrated services in one room, was initially proposed for all facilities, this worked most effectively in the dispensary and health centers. The sub-county hospital adapted the approach such that integrated services were offered by more than one provider during a visit, with clients linked from one provider to another through same-day intra-facility referrals. CHVs were generally able to incorporate MIYCN and FP content within household visits and community activities; however some knowledge gaps were noted after initial training, necessitating additional refresher training. Conclusion This demonstration experience revealed that future replication efforts should enable sub-county team leadership, assess facility readiness, streamline data collection, build local buy-in, and prioritize dispensaries and health centers with high client loads.
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Affiliation(s)
- Chelsea M Cooper
- Maternal and Child Survival Program, Washington DC, USA. .,Jhpiego, Baltimore, USA.
| | | | - Everlyn Matiri
- Maternal and Child Survival Program, Nairobi, Kenya.,PATH, Nairobi, Kenya
| | - Hannah Tappis
- Maternal and Child Survival Program, Washington DC, USA.,Jhpiego, Baltimore, USA
| | - Devon Mackenzie
- Maternal and Child Survival Program, Washington DC, USA.,Jhpiego, Baltimore, USA
| | - Anne Pfitzer
- Maternal and Child Survival Program, Washington DC, USA.,Jhpiego, Baltimore, USA
| | - Rae Galloway
- Maternal and Child Survival Program, Washington DC, USA.,PATH, Washington DC, USA
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Gomez PP, Nelson AR, Asiedu A, Addo E, Agbodza D, Allen C, Appiagyei M, Bannerman C, Darko P, Duodu J, Effah F, Tappis H. Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial. BMC Pregnancy Childbirth 2018; 18:72. [PMID: 29566659 PMCID: PMC5863807 DOI: 10.1186/s12884-018-1705-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Newborn deaths comprise nearly half of under-5 deaths in Ghana, despite the fact that skilled birth attendants (SBAs) are present at 68% of births, which implies that evidence-based care during labor, birth and the immediate postnatal period may be deficient. We assessed the effect of a low-dose, high-frequency (LDHF) training approach on long-term evidence-based skill retention among SBAs and impact on adverse birth outcomes. METHODS From 2014 to 2017, we conducted a cluster-randomized trial in 40 hospitals in Ghana. Eligible hospitals were stratified by region and randomly assigned to one of four implementation waves. We assessed the relative risks (RRs) of institutional intrapartum stillbirths and 24-h newborn mortality in months 1-6 and 7-12 of implementation as compared to the historical control period, and in post-intervention facilities compared to pre-intervention facilities during the same period. All SBAs providing labor and delivery care were invited to enroll; their knowledge and skills were assessed pre- and post-training, and 1 year later. RESULTS Adjusting for region and health facility type, the RR of 24-h newborn mortality in the 40 enrolled hospitals was 0·41 (95% CI 0·32-0·51; p < 0.001) in months 1-6 and 0·30 (95% CI 0·21-0·43; p < 0·001) in months 7-12 compared to baseline. The adjusted RR of intrapartum stillbirth was 0·64 (95% CI 0·53-0·77; p < 0·001) in months 1-6 and 0·48 (95% CI 0·36-0·63; p < 0·001) in months 7-12 compared to baseline. Four hundred three SBAs consented and enrolled. After 1 year, 200 SBAs assessed had 28% (95% CI 25-32; p < 0·001) and 31% (95% CI 27-36; p < 0·001) higher scores than baseline on low-dose 1 and 2 content skills, respectively. CONCLUSIONS This training approach results in a sustained decrease in facility-based newborn mortality and intrapartum stillbirths, and retained knowledge and skills among SBAs after a year. We recommend use of this approach for future maternal and newborn health in-service training and programs. TRIAL REGISTRATION Retrospectively registered on 25 September 2017 at Clinical Trials, identifier NCT03290924 .
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Affiliation(s)
| | - Allyson R. Nelson
- Jhpiego/Liberia, UN Drive, OPP Rock Compound, Mamba Point, Monrovia, Liberia
| | - Amos Asiedu
- Jhpiego Ghana, 14 Ollenu Street, East Legon, Accra, Ghana
| | - Etta Addo
- Jhpiego Ghana, 14 Ollenu Street, East Legon, Accra, Ghana
| | - Dora Agbodza
- Jhpiego Ghana, 14 Ollenu Street, East Legon, Accra, Ghana
| | - Chantelle Allen
- Jhpiego/Baltimore, 1615 Thames Street, Baltimore, MD 21232 USA
| | | | | | - Patience Darko
- Jhpiego Ghana, 14 Ollenu Street, East Legon, Accra, Ghana
| | - Julia Duodu
- Jhpiego Ghana, 14 Ollenu Street, East Legon, Accra, Ghana
| | - Fred Effah
- Jhpiego Ghana, 14 Ollenu Street, East Legon, Accra, Ghana
| | - Hannah Tappis
- Jhpiego/Baltimore, 1615 Thames Street, Baltimore, MD 21232 USA
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Bartlett L, LeFevre A, Zimmerman L, Saeedzai SA, Turkmani S, Zabih W, Tappis H, Becker S, Winch P, Koblinsky M, Rahmanzai AJ. Progress and inequities in maternal mortality in Afghanistan (RAMOS-II): a retrospective observational study. Lancet Glob Health 2017; 5:e545-e555. [PMID: 28395847 DOI: 10.1016/s2214-109x(17)30139-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/21/2017] [Accepted: 03/15/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. METHODS We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12-49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. FINDINGS Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553-873 in Ragh vs 166, 63-270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3-2·1 in Ragh vs 0·2, 0·1-0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6-122·3 in Ragh vs 24·8, 20·5-29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11 366 women in Ragh. An estimated 85% of women in Kabul and 47% in Ragh incurred delivery costs (mean US$66·20, IQR $61·30 in Kabul and $9·89, $11·87 in Ragh). Maternal complications were the third leading cause of death in women of reproductive age in Kabul, and the leading cause in Ragh, and were mainly due to hypertensive diseases of pregnancy. The maternal mortality rate decreased significantly between 2002 and 2011 in both Kabul (by 71%) and Ragh (by 84%), plus all other maternal mortality indicators in Ragh. INTERPRETATION Remarkable maternal and other mortality reductions have occurred in Afghanistan, but the disparity between urban and rural sites is alarming, with all maternal mortality indicators significantly higher in Ragh than in Kabul. Customised service delivery is needed to ensure parity for different geographic and security settings. FUNDING United States Agency for International Development (USAID).
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Affiliation(s)
- Linda Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Amnesty LeFevre
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linnea Zimmerman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sayed Ataullah Saeedzai
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Ministry of Public Health, Kabul, Afghanistan
| | - Sabera Turkmani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Weeda Zabih
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Center For Research and Learning, Toronto, ON, Canada
| | - Hannah Tappis
- Technical Leadership Office, Jhpiego, Baltimore, MD, USA
| | - Stan Becker
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peter Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marge Koblinsky
- US Agency for International Development, Washington, DC, USA
| | - Ahmed Javed Rahmanzai
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Emerging Leaders Consulting Services, Kabul, Afghanistan
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Foster AM, Evans DP, Garcia M, Knaster S, Krause S, McGinn T, Rich S, Shah M, Tappis H, Wheeler E. The 2018 Inter-agency field manual on reproductive health in humanitarian settings: revising the global standards. Reprod Health Matters 2017; 25:18-24. [PMID: 29231788 DOI: 10.1080/09688080.2017.1403277] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Since the 1990s, the Inter-agency field manual on reproductive health in humanitarian settings (IAFM) has provided authoritative guidance on reproductive health service provision during different phases of complex humanitarian emergencies. In 2018, the Inter-Agency Working Group on Reproductive Health in Crises will release a new edition of this global resource. In this article, we describe the collaborative and inter-sectoral revision process and highlight major changes in the 2018 IAFM. Key revisions to the manual include repositioning unintended pregnancy prevention within and explicitly incorporating safe abortion care into the Minimum Initial Service Package (MISP) chapter, which outlines a set of priority activities to be implemented at the outset of a humanitarian crisis; stronger guidance on the transition from the MISP to comprehensive sexual and reproductive health services; and the addition of a logistics chapter. In addition, the IAFM now places greater and more consistent emphasis on human rights principles and obligations, gender-based violence, and the linkages between maternal and newborn health, and incorporates a diverse range of field examples. We conclude this article with an outline of plans for releasing the 2018 IAFM and facilitating uptake by those working in refugee, crisis, conflict, and emergency settings.
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Affiliation(s)
- Angel M Foster
- a Associate Professor, Faculty of Health Sciences , University of Ottawa , ON , Canada
| | - Dabney P Evans
- b Assistant Professor, Hubert Department of Global Health & Director, Center for Humanitarian Emergencies, Rollins School of Public Health , Emory University , Atlanta , GA , USA
| | - Melissa Garcia
- c Technical Advisor , International Consortium for Emergency Contraception hosted by Management Sciences for Health , New York , NY , USA
| | - Sarah Knaster
- d Coordinator for the Inter-Agency Working Group on Reproductive Health in Crises , Women's Refugee Commission , New York , NY , USA
| | - Sandra Krause
- e Director, Sexual and Reproductive Health Program , Women's Refugee Commission , New York , NY , USA
| | - Therese McGinn
- f Professor, Heilbrunn Department of Population and Family Health, Mailman School of Public Health , Columbia University , New York , NY , USA
| | - Sarah Rich
- g Senior Advisor, Sexual and Reproductive Health , Women's Refugee Commission , New York , NY , USA
| | - Meera Shah
- h Global Advocacy Adviser , Center for Reproductive Rights , New York , NY , USA
| | - Hannah Tappis
- i Senior Monitoring, Evaluation and Research Advisor , Jhpiego , Baltimore , MD , USA
| | - Erin Wheeler
- j Technical Advisor for Contraception and Abortion Care , International Rescue Committee , New York , NY , USA
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Doocy S, Tappis H, Lyles E, Witiw J, Aken V. Emergency Food Assistance in Northern Syria: An Evaluation of Transfer Programs in Idleb Governorate. Food Nutr Bull 2017; 38:240-259. [PMID: 28359211 DOI: 10.1177/0379572117700755] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The war in Syria has left millions struggling to survive amidst violent conflict, pervasive unemployment, and food insecurity. Although international assistance funding is also at an all-time high, it is insufficient to meet the needs of conflict-affected populations, and there is increasing pressure on humanitarian stakeholders to find more efficient, effective ways to provide assistance. OBJECTIVE To evaluate 3 different assistance programs (in-kind food commodities, food vouchers, and unrestricted vouchers) in Idleb Governorate of Syria from December 2014 and March 2015. METHODS The evaluation used repeated survey data from beneficiary households to determine whether assistance was successful in maintaining food security at the household level. Shopkeeper surveys and program monitoring data were used to assess the impact on markets at the district/governorate levels and compare the cost-efficiency and cost-effectiveness of transfer modalities. RESULTS Both in-kind food assistance and voucher programs showed positive effects on household food security and economic measures in Idleb; however, no intervention was successful in improving all outcomes measured. Food transfers were more likely to improve food access and food security than vouchers and unrestricted vouchers. Voucher programs were found to be more cost-efficient than in-kind food assistance, and more cost-effective for increasing household food consumption. CONCLUSION Continuation of multiple types of transfer programs, including both in-kind assistance and vouchers, will allow humanitarian actors to remain responsive to evolving access and security considerations, local needs, and market dynamics.
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Affiliation(s)
- Shannon Doocy
- 1 Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hannah Tappis
- 1 Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily Lyles
- 1 Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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50
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Nidzvetska S, Rodriguez-Llanes JM, Aujoulat I, Gil Cuesta J, Tappis H, van Loenhout JAF, Guha-Sapir D. Maternal and Child Health of Internally Displaced Persons in Ukraine: A Qualitative Study. Int J Environ Res Public Health 2017; 14:ijerph14010054. [PMID: 28075363 PMCID: PMC5295305 DOI: 10.3390/ijerph14010054] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 11/20/2022]
Abstract
Due to the conflict that started in spring 2014 in Eastern Ukraine, a total of 1.75 million internally displaced persons (IDPs) fled the area and have been registered in government-controlled areas of the country. This paper explores perceived health, barriers to access to healthcare, caring practices, food security, and overall financial situation of mothers and young children displaced by the conflict in Ukraine. This is a qualitative study, which collected data through semi-structured in-depth interviews with nine IDP mothers via Skype and Viber with a convenience sample of participants selected through snowball technique. Contrary to the expectations, the perceived physical health of mothers and their children was found not to be affected by conflict and displacement, while psychological distress was often reported. A weak healthcare system, Ukraine’s proneness to informal payments, and heavy bureaucracy to register as an IDP were reported in our study. A precarious social safety net to IDP mothers in Ukraine, poor dietary diversity, and a generalized rupture of vaccine stocks, with halted or delayed vaccinations in children were identified. Increasing social allowances and their timely delivery to IDP mothers might be the most efficient policy measure to improve health and nutrition security. Reestablishment and sustainability of vaccine stocks in Ukraine is urgent to avoid the risks of a public health crisis. Offering psychological support for IDP mothers is recommended.
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Affiliation(s)
- Svitlana Nidzvetska
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels 1200, Belgium.
| | - Jose M Rodriguez-Llanes
- Food Security Unit, Sustainable Resources Directorate, European Commission Joint Research Centre, I-21027 Ispra, Italy.
| | - Isabelle Aujoulat
- Institute of Health and Society, Université catholique de Louvain, Brussels 1200, Belgium.
| | - Julita Gil Cuesta
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels 1200, Belgium.
| | - Hannah Tappis
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
| | - Joris A F van Loenhout
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels 1200, Belgium.
| | - Debarati Guha-Sapir
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels 1200, Belgium.
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