Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-30 (of 33 Records) |
Query Trace: Serbanescu F[original query] |
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Identifying the priority infection prevention and control gaps contributing to neonatal healthcare-associated infections in low-and middle-income countries: results from a modified Delphi process
Yee D , Osuka H , Weiss J , Kriengkauykiat J , Kolwaite A , Johnson J , Hopman J , Coffin S , Ram P , Serbanescu F , Park B . J Glob Health Rep 12/28/2021 5 BACKGROUND: In low- and middle-income countries (LMIC), neonatal healthcare-associated infections (HAI) are associated with increased morbidity, mortality, hospital stay, and costs. When resources are limited, addressing HAI through infection prevention and control (IPC) requires prioritizing interventions to maximize impact. However, little is known about the gaps in LMIC that contribute most to HAI. METHODS: A literature review was conducted to identify the leading IPC gaps contributing to neonatal HAIs in intensive care units and specialty care wards in LMIC. Additionally, a panel of 21 global experts in neonatology and IPC participated in an in-person modified Delphi process to achieve consensus on the relative importance of these gaps as contributors to HAI. RESULTS: Thirteen IPC gaps were identified and summarized into four main categories: facility policies such as prioritizing a patient safety culture and maintaining facility capacity, general healthcare worker behaviors such as hand hygiene and proper device insertion and maintenance, specialty healthcare worker behaviors such as cleaning and reprocessing of medical equipment, and infrastructural considerations such as adequate medical equipment and hand hygiene supplies. CONCLUSIONS: Through a modified Delphi process, we identified the leading IPC gaps contributing to neonatal HAIs; this information can assist policymakers, public health officials, researchers, and clinicians to prioritize areas for further study or intervention. |
Maternal death surveillance and response system reports from 32 low-middle income countries, 2011-2020: What can we learn from the reports?
Whiting-Collins L , Serbanescu F , Moller AB , Binzen S , Monet JP , Cresswell JA , Brun M . PLOS Glob Public Health 2024 4 (3) e0002153 Maternal Death Surveillance and Response (MDSR) systems generate information that may aid efforts to end preventable maternal deaths. Many countries report MDSR data, but comparability over time and across settings has not been studied. We reviewed MDSR reports from low-and-middle income countries (LMICs) to examine core content and identify how surveillance data and data dissemination could be improved to guide recommendations and actions. We conducted deductive content analysis of 56 MDSR reports from 32 LMICs. A codebook was developed assessing how reports captured: 1) MDSR system implementation, 2) monitoring of maternal death notifications and reviews, and 3) response formulation and implementation. Reports published before 2014 focused on maternal death reviews only. In September 2013, the World Health Organization and partners published the global MDSR guidance, which advised that country reports should also include identification, notification and response activities. Of the 56 reports, 33 (59%) described their data as incomplete, meaning that not all maternal deaths were captured. While 45 (80%) reports presented the total number of maternal deaths that had been notified (officially reported), only 16 (29%) calculated notification rates. Deaths were reported at both community and facility levels in 31 (55%) reports, but 25 (45%) reported facility deaths only. The number of maternal deaths reviewed was reported in 33 (59%) reports, and 17 (30%) calculated review completion rates. While 48 (86%) reports provided recommendations for improving MDSR, evidence of actions based on prior recommendations was absent from 40 (71%) of subsequent reports. MDSR reports currently vary in content and in how response efforts are documented. Comprehensive reports could improve accountability and effectiveness of the system by providing feedback to MDSR stakeholders and information for action. A standard reporting template may improve the quality and comparability of MDSR data and their use for preventing future maternal deaths. |
Individual, community, and health facility predictors of postnatal care utilization in rural Tanzania: A multilevel analysis
Serbanescu F , Abeysekara P , Ruiz A , Schmitz M , Dominico S , Hsia J , Stupp P . Glob Health Sci Pract 2023 11 (4) INTRODUCTION: Postnatal care (PNC) is an underused service in the continuum of care for mothers and infants in sub-Saharan Africa. There is little evidence on health facility characteristics that influence PNC utilization. Understanding PNC use in the context of individual, community, and health facility characteristics may help in the development of programs for increased use. METHODS: We analyzed data from 4,353 women with recent births in Kigoma Region, Tanzania, and their use of PNC (defined as at least 1 checkup in a health facility in the region within 42 days of delivery). We used a mixed-effects multilevel logistic regression analysis to explain PNC use while accounting for household, individual, and community characteristics from a regionwide population-based reproductive health survey and for distance to and adequacy of proximal health facilities from a health facility assessment. RESULTS: PNC utilization rate was low (15.9%). Women had significantly greater odds of PNC if they had a high level of decision-making autonomy (adjusted odds ratio [aOR]: 1.56; 95% confidence interval [CI]=1.11, 2.17); had a companion at birth (aOR: 1.57; 95% CI=1.19, 2.07); had cesarean delivery (aOR: 2.27; 95% CI=1.47, 3.48); resided in Kasulu district (aOR: 3.28; 95% CI=1.94, 5.52); or resided in a community that had at least 1 adequate health facility within 5 km (aOR: 2.15; 95% CI=1.06, 3.88). CONCLUSION: Women's decision-making autonomy and presence of companionship at birth, as well as proximity to a health facility with adequate infrastructure, equipment, and workforce, were associated with increased PNC use. More efforts toward advocating for the health benefits of PNC using multiple channels and increasing quality of care in health facilities, including companionship at birth, can increase utilization rates. |
Maternal death surveillance efforts: notification and review coverage rates in 30 low-income and middle-income countries, 2015-2019
Serbanescu F , Monet JP , Whiting-Collins L , Moran AC , Hsia J , Brun M . BMJ Open 2023 13 (2) e066990 OBJECTIVE: Performance of maternal death surveillance and response (MDSR) relies on the system's ability to identify and notify all maternal deaths and its ability to review all maternal deaths by a committee. Unified definitions for indicators to assess these functions are lacking. We aim to estimate notification and review coverage rates in 30 countries between 2015 and 2019 using standardised definitions. DESIGN: Repeat cross-sectional surveys provided the numerators for the coverage indicators; United Nations (UN)-modelled expected country maternal deaths provided the denominators. SETTING: 30 low-income and middle-income countries responding to the Maternal Health Thematic Fund annual surveys conducted by the UN Population Fund between 2015 and 2019. OUTCOME MEASURES: Notification coverage rate ([Formula: see text]) was calculated as the proportion of expected maternal deaths that were notified at the national level annually; review coverage rate ([Formula: see text]) was calculated as the proportion of expected maternal deaths that were reviewed annually. RESULTS: The average annual [Formula: see text] for all countries increased from 17% in 2015 to 28% in 2019; the average annual [Formula: see text] increased from 8% to 13%. Between 2015 and 2019, 22 countries (73%) reported increases in the [Formula: see text]-with an average increase of 20 (SD 18) percentage points-and 24 countries (80%) reported increases in [Formula: see text] by 7 (SD 11) percentage points. Low values of [Formula: see text] contrasts with country-published review rates, ranging from 46% to 51%. CONCLUSION: MDSR systems that count and review all maternal deaths can deliver real-time information that could prompt immediate actions and may improve maternal health. Consistent and systematic documentation of MDSR efforts may improve national and global monitoring. Assessing the notification and review functions using coverage indicators is feasible, not affected by fluctuations in data completeness and reporting, and can objectively capture progress. |
A qualitative evaluation and conceptual framework on the use of the Birth weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) matrix for perinatal health in Uganda
Dynes MM , Daniel GA , Mac V , Picho B , Asiimwe A , Nalutaaya A , Opio G , Kamara V , Kaharuza F , Serbanescu F . BMC Pregnancy Childbirth 2023 23 (1) 86 BACKGROUND: Perinatal mortality (newborn deaths in the first week of life and stillbirths) continues to be a significant global health threat, particularly in resource-constrained settings. Low-tech, innovative solutions that close the quality-of-care gap may contribute to progress toward the Sustainable Development Goals for health by 2030. From 2012 to 2018, the Saving Mothers, Giving Life Initiative (SMGL) implemented the Birth weight and Age-at-Death Boxes for Intervention and Evaluation System (BABIES) matrix in Western Uganda. The BABIES matrix provides a simple, standardized way to track perinatal health outcomes to inform evidence-based quality improvement strategies. METHODS: In November 2017, a facility-based qualitative evaluation was conducted using in-depth interviews with 29 health workers in 16 health facilities implementing BABIES in Uganda. Data were analyzed using directed content analysis across five domains: 1) perceived ease of use, 2) how the matrix was used, 3) changes in behavior or standard operating procedures after introduction, 4) perceived value of the matrix, and 5) program sustainability. RESULTS: Values in the matrix were easy to calculate, but training was required to ensure correct data placement and interpretation. Displaying the matrix on a highly visible board in the maternity ward fostered a sense of accountability for health outcomes. BABIES matrix reports were compiled, reviewed, and responded to monthly by interprofessional teams, prompting collaboration across units to fill data gaps and support perinatal death reviews. Respondents reported improved staff communication and performance appraisal, community engagement, and ability to track and link clinical outcomes with actions. Midwives felt empowered to participate in the problem-solving process. Respondents were motivated to continue using BABIES, although sustainability concerns were raised due to funding and staff shortages. CONCLUSIONS: District-level health systems can use data compiled from the BABIES matrix to inform policy and guide implementation of community-centered health practices to improve perinatal heath. Future work may consider using the Conceptual Framework on Use of the BABIES Matrix for Perinatal Health as a model to operationalize concepts and test the impact of the tool over time. |
A comprehensive approach to improving emergency obstetric and newborn care in Kigoma, Tanzania
Dominico S , Serbanescu F , Mwakatundu N , Kasanga MG , Chaote P , Subi L , Maro G , Prasad N , Ruiz A , Mongo W , Schmidt K , Lobis S . Glob Health Sci Pract 2022 10 (2) INTRODUCTION: To address high levels of maternal mortality in Kigoma, Tanzania, stakeholders increased women's access to high-quality comprehensive emergency obstetric and newborn care (EmONC) by decentralizing services from hospitals to health centers where EmONC was delivered mostly by associate clinicians and nurses. To ensure that women used services, implementers worked to continuously improve and sustain quality of care while creating demand. METHODS: Program evaluation included periodic health facility assessments, pregnancy outcome monitoring, and enhanced maternal mortality detection region-wide in program- and nonprogram-supported health facilities. RESULTS: Between 2013 and 2018, the average number of lifesaving interventions performed per facility increased from 2.8 to 4.7. The increase was higher in program-supported than nonprogram-supported health centers and dispensaries. The institutional delivery rate increased from 49% to 85%; the greatest increase occurred through using health centers (15% to 25%) and dispensaries (21% to 46%). The number of cesarean deliveries almost doubled, and the population cesarean delivery rate increased from 2.6% to 4.5%. Met need for emergency obstetric care increased from 44% to 61% while the direct obstetric case fatality rate declined from 1.8% to 1.4%. The institutional maternal mortality ratio across all health facilities declined from 303 to 174 deaths per 100,000 live births. The total stillbirth rate declined from 26.7 to 12.8 per 1,000 births. The predischarge neonatal mortality rate declined from 10.7 to 7.6 per 1,000 live births. Changes in case fatality rate and maternal mortality were driven by project-supported facilities. Changes in neonatal mortality varied depending on facility type and program support status. CONCLUSION: Decentralizing high-quality comprehensive EmONC delivered mostly by associate clinicians and nurses led to significant improvements in the availability and utilization of lifesaving care at birth in Kigoma. Dedicated efforts to sustain high-quality EmONC along with supplemental programmatic components contributed to the reduction of maternal and perinatal mortality. |
Improving maternal and reproductive health in Kigoma, Tanzania: A 13-year initiative
Prasad N , Mwakatundu N , Dominico S , Masako P , Mongo W , Mwanshemele Y , Maro G , Subi L , Chaote P , Rusibamayila N , Ruiz A , Schmidt K , Kasanga MG , Lobis S , Serbanescu F . Glob Health Sci Pract 2022 10 (2) The Program to Reduce Maternal Deaths in Tanzania was a 13-year (2006-2019) effort in the Kigoma region that evolved over 3 phases to improve and sustain the availability of, access to, and demand for high-quality maternal and reproductive health care services. The Program intended to bring high-quality care closer to more communities. Cutting across the Program was the routine collection of monitoring and evaluation data. The Program achieved significant reductions in maternal and perinatal mortality, a significant increase in the modern contraceptive prevalence rate, and a significant decline in the unmet need for contraception. By 2017, it was apparent that the Program was on track to meet or surpass many of the targets established by the Government of Tanzania. Over the following 2-plus years, efforts to sustain Program interventions intensified. In April 2019, the Program fully transitioned to Government of Tanzania oversight. Four key lessons were learned during implementation that are relevant to governments, donors, and implementing organizations working to reduce maternal mortality: (1) multistakeholder partnerships are critical; (2) demand creation for services, while critical, must rest on a foundation of well-functioning and high-quality clinical services; (3) it is imperative to not only collect robust monitoring and evaluation data, but to be responsive in real time to what the data reveal; and, (4) it is necessary to develop a deliberate sustainability strategy from the start. The Program in Kigoma demonstrates that decentralizing high-quality maternal and reproductive health services in remote, low-resource settings is both feasible and effective and should be considered in places with similar contexts. By embedding the Program in the existing health system, and through efforts to build local capacity, the improvements seen in Kigoma are likely to be sustained. Follow-up evaluations are planned, providing an opportunity to more directly assess sustainability. |
Context matters: Strategies to improve maternal and newborn health services in Sub-Saharan Africa
Serbanescu F , Kruk ME , Dominico S , Nimako K . Glob Health Sci Pract 2022 10 (2) Identifying context-appropriate features to maximize the effectiveness of maternal and newborn health interventions in sub-Saharan Africa is a prerequisite to successful programs. | Although effective evidence-based interventions at birth to save mother's and newborns' lives exist, challenges related to context-specific health system design and service quality hinder progress in reducing maternal and newborn mortality. To reduce maternal and newborn mortality, mothers should labor and deliver at a facility that can perform advanced services and provide appropriate care when complications arise. When designing and implementing maternal and newborn health programs, the local context should be centered to maximize the impact of these programs. | eng |
Factors Associated with Contraceptive Use in Sub-Saharan Africa
Kraft JM , Serbanescu F , Schmitz MM , Mwanshemele Y , Ruiz AG , Maro G , Chaote P . J Womens Health (Larchmt) 2021 31 (3) 447-457 Background: Globally 10% of women have an unmet need for contraception, with higher rates in sub-Saharan Africa. Programs to improve family planning (FP) outcomes require data on how service characteristics (e.g., geographic access, quality) and women's characteristics are associated with contraceptive use. Materials and Methods: We combined data from health facility assessments (2018 and 2019) and a population-based regional household survey (2018) of married and in-union women ages 15-49 in the Kigoma Region of Tanzania. We assessed the associations between contraceptive use and service (i.e., distance, methods available, personnel) and women's (e.g., demographic characteristics, fertility experiences and intentions, attitudes toward FP) characteristics. Results: In this largely rural sample (n = 4,372), 21.7% of women used modern reversible contraceptive methods. Most variables were associated with contraceptive use in bivariate analyses. In multivariate analyses, access to services located <2 km of one's home that offered five methods (adjusted odds ratio [aOR] = 1.57, confidence interval [CI] = 1.18-2.10) and had basic amenities (aOR = 1.66, CI = 1.24-2.2) increased the odds of contraceptive use. Among individual variables, believing that FP benefits the family (aOR = 3.65, CI = 2.18-6.11) and believing that contraception is safe (aOR = 2.48, CI = 1.92-3.20) and effective (aOR = 3.59, CI = 2.63-4.90) had strong associations with contraceptive use. Conclusions: Both service and individual characteristics were associated with contraceptive use, suggesting the importance of coordination between efforts to improve access to services and social and behavior change interventions that address motivations, knowledge, and attitudes toward FP. |
Birth companionship in a government health system: a pilot study in Kigoma, Tanzania
Chaote P , Mwakatundu N , Dominico S , Mputa A , Mbanza A , Metta M , Lobis S , Dynes M , Mbuyita S , McNab S , Schmidt K , Serbanescu F . BMC Pregnancy Childbirth 2021 21 (1) 304 BACKGROUND: Having a companion of choice throughout childbirth is an important component of good quality and respectful maternity care for women and has become standard in many countries. However, there are only a few examples of birth companionship being implemented in government health systems in low-income countries. To learn if birth companionship was feasible, acceptable and led to improved quality of care in these settings, we implemented a pilot project using 9 intervention and 6 comparison sites (all government health facilities) in a rural region of Tanzania. METHODS: The pilot was developed and implemented in Kigoma, Tanzania between July 2016 and December 2018. Women delivering at intervention sites were given the choice of having a birth companion with them during childbirth. We evaluated the pilot with: (a) project data; (b) focus group discussions; (c) structured and semi-structured interviews; and (d) service statistics. RESULTS: More than 80% of women delivering at intervention sites had a birth companion who provided support during childbirth, including comforting women and staying by their side. Most women interviewed at intervention sites were very satisfied with having a companion during childbirth (96-99%). Most women at the intervention sites also reported that the presence of a companion improved their labor, delivery and postpartum experience (82-97%). Health providers also found companions very helpful because they assisted with their workload, alerted the provider about changes in the woman's status, and provided emotional support to the woman. When comparing intervention and comparison sites, providers at intervention sites were significantly more likely to: respond to women who called for help (p = 0.003), interact in a friendly way (p < 0.001), greet women respectfully (p < 0.001), and try to make them more comfortable (p = 0.003). Higher proportions of women who gave birth at intervention sites reported being "very satisfied" with the care they received (p < 0.001), and that the staff were "very kind" (p < 0.001) and "very encouraging" (p < 0.001). CONCLUSION: Birth companionship was feasible and well accepted by health providers, government officials and most importantly, women who delivered at intervention facilities. The introduction of birth companionship improved women's experience of birth and the maternity ward environment overall. |
Beyond adequate: Factors associated with quality of antenatal care in western Tanzania
Young MR , Morof D , Lathrop E , Haddad L , Blanton C , Maro G , Serbanescu F . Int J Gynaecol Obstet 2020 151 (3) 431-437 OBJECTIVE: To determine quality of antenatal care (ANC). Most literature focuses on ANC attendance and services. Less is known about quality of care (QoC). METHOD: Data were analyzed from the 2016 Kigoma Reproductive Health Survey, a population-based survey of reproductive-aged women. Women with singleton term live births were included and principal component analysis (PCA) was used to create an ANC quality index using linear combinations of weights of the first principal component. Nineteen variables were selected for the index. The index was then used to assign a QoC score for each woman and linear regression used to identify factors associated with receiving higher QoC. RESULTS: A total of 3178 women received some ANC. Variables that explained the most variance in the QoC index included: gave urine (0.35); gave blood (0.34); and blood pressure measured (0.30). In multivariable linear regression, factors associated with higher QoC included: ANC at a hospital (versus dispensary); older age; higher level of education; working outside the home; higher socioeconomic status; and having lower parity. CONCLUSION: Using PCA methods, several basic components of ANC including maternal physical assessment were identified as important indicators of quality. This approach provides an affordable and effective means of evaluating ANC programs. |
Factors associated with local herb use during pregnancy and labor among women in Kigoma region, Tanzania, 2014-2016
Fukunaga R , Morof D , Blanton C , Ruiz A , Maro G , Serbanescu F . BMC Pregnancy Childbirth 2020 20 (1) 122 BACKGROUND: Despite research suggesting an association between certain herb use during pregnancy and delivery and postnatal complications, herbs are still commonly used among pregnant women in sub-Sahara Africa (SSA). This study examines the factors and characteristics of women using local herbs during pregnancy and/or labor, and the associations between local herb use and postnatal complications in Kigoma, Tanzania. METHODS: We analyzed data from the 2016 Kigoma Tanzania Reproductive Health Survey (RHS), a regionally representative, population-based survey of reproductive age women (15-49 years). We included information on each woman's most recent pregnancy resulting in a live birth during January 2014-September 2016. We calculated weighted prevalence estimates and used multivariable logistic regression to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for factors associated with use of local herbs during pregnancy and/or labor, as well as factors associated with postnatal complications. RESULTS: Of 3530 women, 10.9% (CI: 9.0-13.1) used local herbs during their last pregnancy and/or labor resulting in live birth. The most common reasons for taking local herbs included stomach pain (42.9%) and for the health of the child (25.5%). Adjusted odds of local herb use was higher for women reporting a home versus facility-based delivery (aOR: 1.6, CI: 1.1-2.2), having one versus three or more prior live births (aOR: 1.8, CI: 1.4-2.4), and having a household income in the lowest versus the highest wealth tercile (aOR: 1.4, CI: 1.1-1.9). Adjusted odds of postnatal complications were higher among women who used local herbs versus those who did not (aOR: 1.5, CI: 1.2-1.9), had four or more antenatal care visits versus fewer (aOR: 1.4, CI: 1.2-1.2), and were aged 25-34 (aOR: 1.1, CI: 1.0-1.3) and 35-49 (aOR: 1.3, CI: 1.0-1.6) versus < 25 years. CONCLUSIONS: About one in ten women in Kigoma used local herbs during their most recent pregnancy and/or labor and had a high risk of postnatal complications. Health providers may consider screening pregnant women for herb use during antenatal and delivery care as well as provide information about any known risks of complications from herb use. |
Authors' Response to "Saving Mothers, Giving Life: Don't Neglect the Health Systems Element"
Serbanescu F , Conlon CM , Kaharuza F , Musumali M . Glob Health Sci Pract 2019 7 (4) 610-611 On behalf of the Saving Mothers, Giving Life (SMGL) Technical Working Group, we would like to thank Holt and Simpson1 for their valuable insights. We also appreciate their interest in finding out more about the planning and implementation process of the initiative, the challenges encountered, and the adaptations needed to account for contextual factors in each country. | | We agree with the authors on the importance of bringing attention to the valuable experiences and lessons learned during the implementation and course of the SMGL activities, including the activities directly related to health systems strengthening (HSS). We generally agree with the points raised regarding a lesser focus on the evaluation of the process of implementation of the SMGL initiative in the supplement in favor of highlighting the outcomes and impacts of the initiative on maternal and newborn health. However, we beg to differ that the implementation experiences of SGML are “not well documented.” | | The articles constituting the supplement do not represent an exhaustive account of all aspects of the SMGL initiative. The select articles published in the supplement have largely focused on the outcomes of the initiative at its conclusion after 5 years of implementation. They add to already published accounts about the initial planning, implementation, and monitoring and evaluation of the SMGL interventions, including a comprehensive external evaluation of inputs and processes undertaken during the first year of the initiative.2 They also add to the article by Kruk and colleagues that focused on the effects of the SMGL on the health systems in Uganda and Zambia during Phase 1.3 |
Referral transit time between sending and first-line receiving health facilities: a geographical analysis in Tanzania
Schmitz MM , Serbanescu F , Arnott GE , Dynes M , Chaote P , Msuya AA , Chen YN . BMJ Glob Health 2019 4 e001568 Background: Timely, high-quality obstetric services are vital to reduce maternal and perinatal mortality. We spatially modelled referral pathways between sending and receiving health facilities in Kigoma Region, Tanzania, identifying communication and transportation delays to timely care and inefficient links within the referral system. Methods: We linked sending and receiving facilities to form facility pairs, based on information from a 2016 Health Facility Assessment. We used an AccessMod cost-friction surface model, incorporating road classifications and speed limits, to estimate direct travel time between facilities in each pair. We adjusted for transportation and communications delays to create a total travel time, simulating the effects of documented barriers in this referral system. Results: More than half of the facility pairs (57.8%) did not refer patients to facilities with higher levels of emergency obstetric care. The median direct travel time was 25.9 min (range: 4.4-356.6), while the median total time was 106.7 min (22.9-371.6) at the moderate adjustment level. Total travel times for 30.7% of facility pairs exceeded 2 hours. All facility pairs required some adjustments for transportation and communication delays, with 94.0% of facility pairs' total times increasing. Conclusion: Half of all referral pairs in Kigoma Region have travel time delays nearly exceeding 1 hour, and facility pairs referring to facilities providing higher levels of care also have large travel time delays. Combining cost-friction surface modelling estimates with documented transportation and communications barriers provides a more realistic assessment of the effects of inter-facility delays on referral networks, and can inform decision-making and potential solutions in referral systems within resource-constrained settings. |
Geospatial analysis for reproductive, maternal, newborn, child and adolescent health: gaps and opportunities
Matthews Z , Rawlins B , Duong J , Molla YB , Moran AC , Singh K , Serbanescu F , Tatem AJ , Nilsen K . BMJ Glob Health 2019 4 e001702 Reproductive, maternal, newborn, child and adolescent health (RMNCAH) indicators, such as the maternal mortality ratio, often serve as a litmus test for health system performance, because women’s and children’s health lies at the core of any health system.1 The health and survival of women and children does not depend on a single intervention, but on packages of interventions delivered at all levels of the health system. Mapping and tracking RMNCAH therefore captures changes in wider health system performance. But mapping has traditionally been the domain of disease-specific tracking, providing useful, but limited snapshots of progress embedded in vertical intervention mechanisms. Although disease-specific spatial mapping and research are effective ways to identify geographic inequities and to inform service provision, geographic and spatial analyses of RMNCAH have the potential to provide a broader perspective. But such analyses, especially for routine RMNCAH care provision, have been underused despite their potential to inform programmes and policies in low/middle-income countries. This commentary also argues that visualisation of RMNCAH data provides a potent social accountability and decision-making tool. Given the topic’s importance, a supplement on the use of geographic information systems (GIS) in RMNCAH is long overdue. |
Best practices in availability, management and use of geospatial data to guide reproductive, maternal, child and adolescent health programmes
Molla YB , Nilsen K , Singh K , Ruktanonchai CW , Schmitz MM , Duong J , Serbanescu F , Moran AC , Matthews Z , Tatem AJ . BMJ Glob Health 2019 4 e001406 The commentary provides a set of considerations and some examples for reproductive, maternal, newborn, child and adolescent health (RMNCAH) programmes that wish to use geospatial data. | Monitoring RMNCAH data trends or change over time and estimating disease burden remain major challenges due to limited reliable geolocated data sources, inconsistent spatial denominators and technical capacity needs. | Increased availability of spatial data, such as satellite imagery and geolocated survey and facility data, coupled with recent methodological refinements, has created new opportunities for use of geographic information systems to achieve spatial disaggregation of RMNCAH data and highlights subnational monitoring among vulnerable populations. | More refined geospatial analyses can help to close the gap for countries with high maternity-related deaths and suffering. |
Saving Mothers, Giving Life: It takes a system to save a mother
Conlon CM , Serbanescu F , Marum L , Healey J , LaBrecque J , Hobson R , Levitt M , Kekitiinwa A , Picho B , Soud F , Spigel L , Steffen M , Velasco J , Cohen R , Weiss W . Glob Health Sci Pract 2019 7 S6-s26 BACKGROUND: Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public-private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. IMPLEMENTATION: The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. RESULTS: Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (-13% in Uganda and -36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. CONCLUSION: A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality. |
"Every Newborn-BIRTH" protocol: observational study validating indicators for coverage and quality of maternal and newborn health care in Bangladesh, Nepal and Tanzania
Day LT , Ruysen H , Gordeev VS , Gore-Langton GR , Boggs D , Cousens S , Moxon SG , Blencowe H , Baschieri A , Rahman AE , Tahsina T , Zaman SB , Hossain T , Rahman QS , Ameen S , El Arifeen S , Kc A , Shrestha SK , Kc NP , Singh D , Jha AK , Jha B , Rana N , Basnet O , Joshi E , Paudel A , Shrestha PR , Jha D , Bastola RC , Ghimire JJ , Paudel R , Salim N , Shamb D , Manji K , Shabani J , Shirima K , Mkopi N , Mrisho M , Manzi F , Jaribu J , Kija E , Assenga E , Kisenge R , Pembe A , Hanson C , Mbaruku G , Masanja H , Amouzou A , Azim T , Jackson D , Kabuteni TJ , Mathai M , Monet JP , Moran A , Ram P , Rawlins B , Saebo JI , Serbanescu F , Vaz L , Zaka N , Lawn JE . J Glob Health 2019 9 (1) 010902 Background: To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels. Methods: EN-BIRTH is an observational study including >20 000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses. Conclusions: To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths. |
The costs and cost-effectiveness of a district-strengthening strategy to mitigate the 3 delays to quality maternal health care: Results From Uganda and Zambia
Johns B , Hangoma P , Atuyambe L , Faye S , Tumwine M , Zulu C , Levitt M , Tembo T , Healey J , Li R , Mugasha C , Serbanescu F , Conlon CM . Glob Health Sci Pract 2019 7 S104-s122 The primary objective of this study was to estimate the costs and the incremental cost-effectiveness of maternal and newborn care associated with the Saving Mothers, Giving Life (SMGL) initiative-a comprehensive district-strengthening approach addressing the 3 delays associated with maternal mortality-in Uganda and Zambia. To assess effectiveness, we used a before-after design comparing facility outcome data from 2012 (before) and 2016 (after). To estimate costs, we used unit costs collected from comparison districts in 2016 coupled with data on health services utilization from 2012 in SMGL-supported districts to estimate the costs before the start of SMGL. We collected data from health facilities, ministerial health offices, and implementing partners for the year 2016 in 2 SMGL-supported districts in each country and in 3 comparison non-SMGL districts (2 in Zambia, 1 in Uganda). Incremental costs for maternal and newborn health care per SMGL-supported district in 2016 was estimated to be US$845,000 in Uganda and $760,000 in Zambia. The incremental cost per delivery was estimated to be $38 in Uganda and $95 in Zambia. For the districts included in this study, SMGL maternal and newborn health activities were associated with approximately 164 deaths averted in Uganda and 121 deaths averted in Zambia in 2016 compared to 2012. In Uganda, the cost per death averted was $10,311, or $177 per life-year gained. In Zambia, the cost per death averted was $12,514, or $206 per life-year gained. The SMGL approach can be very cost-effective, with the cost per life-year gained as a percentage of the gross domestic product (GDP) being 25.6% and 16.4% in Uganda and Zambia, respectively. In terms of affordability, the SMGL approach could be paid for by increasing health spending from 7.3% to 7.5% of GDP in Uganda and from 5.4% to 5.8% in Zambia. |
Addressing the third delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring adequate and appropriate facility-based maternal and perinatal health care
Morof D , Serbanescu F , Goodwin MM , Hamer DH , Asiimwe AR , Hamomba L , Musumali M , Binzen S , Kekitiinwa A , Picho B , Kaharuza F , Namukanja PM , Murokora D , Kamara V , Dynes M , Blanton C , Nalutaaya A , Luwaga F , Schmitz MM , LaBrecque J , Conlon CM , McCarthy B , Kroelinger C , Clark T . Glob Health Sci Pract 2019 7 S85-s103 BACKGROUND: Saving Mothers, Giving Life (SMGL) is a 5-year initiative implemented in participating districts in Uganda and Zambia that aimed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care: seeking, reaching, and receiving. Approaches to addressing the third delay included adequate health facility infrastructure, specifically sufficient equipment and medications; trained providers to provide quality evidence-based care; support for referrals to higher-level care; and effective maternal and perinatal death surveillance and response. METHODS: SMGL used a mixed-methods approach to describe intervention strategies, outcomes, and health impacts. Programmatic and monitoring and evaluation data-health facility assessments, facility and community surveillance, and population-based mortality studies-were used to document the effectiveness of intervention components. RESULTS: During the SMGL initiative, the proportion of facilities providing emergency obstetric and newborn care (EmONC) increased from 10% to 25% in Uganda and from 6% to 12% in Zambia. Correspondingly, the delivery rate occurring in EmONC facilities increased from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia. Nearly all facilities had at least one trained provider on staff by the endline evaluation. Staffing increases allowed a higher proportion of health centers to provide care 24 hours a day/7 days a week by endline-from 74.6% to 82.9% in Uganda and from 64.8% to 95.5% in Zambia. During this period, referral communication improved from 93.3% to 99.0% in Uganda and from 44.6% to 100% in Zambia, and data systems to identify and analyze causes of maternal and perinatal deaths were established and strengthened. CONCLUSION: SMGL's approach was associated with improvements in facility infrastructure, equipment, medication, access to skilled staff, and referral mechanisms and led to declines in facility maternal and perinatal mortality rates. Further work is needed to sustain these gains and to eliminate preventable maternal and perinatal deaths. |
Addressing the second delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching appropriate maternal care in a timely manner
Ngoma T , Asiimwe AR , Mukasa J , Binzen S , Serbanescu F , Henry EG , Hamer DH , Lori JR , Schmitz MM , Marum L , Picho B , Naggayi A , Musonda G , Conlon CM , Komakech P , Kamara V , Scott NA . Glob Health Sci Pract 2019 7 S68-s84 BACKGROUND: Between June 2011 and December 2016, the Saving Mothers, Giving Life (SMGL) initiative in Uganda and Zambia implemented a comprehensive approach targeting the persistent barriers that impact a woman's decision to seek care (first delay), ability to reach care (second delay), and ability to receive adequate care (third delay). This article addresses how SMGL partners implemented strategies specifically targeting the second delay, including decreasing the distance to facilities capable of managing emergency obstetric and newborn complications, ensuring sufficient numbers of skilled birth attendants, and addressing transportation challenges. METHODS: Both quantitative and qualitative data collected by SMGL implementing partners for the purpose of monitoring and evaluation were used to document the intervention strategies and to describe the change in outputs and outcomes related to the second delay. Quantitative data sources included pregnancy outcome monitoring data in facilities, health facility assessments, and population-based surveys. Qualitative data were derived from population-level verbal autopsy narratives, programmatic reports and SMGL-related publications, and partner-specific evaluations that include focus group discussions and in-depth interviews. RESULTS: The proportion of deliveries in any health facility or hospital increased from 46% to 67% in Uganda and from 63% to 90% in Zambia between baseline and endline. Distance to health facilities was reduced by increasing the number of health facilities capable of providing basic emergency obstetric and newborn care services in both Uganda and Zambia-a 200% and 167% increase, respectively. Access to facilities improved through integrated transportation and communication services efforts. In Uganda there was a 6% increase in the number of health facilities with communication equipment and a 258% increase in facility deliveries supported by transportation vouchers. In Zambia, there was a 31% increase in health facilities with available transportation, and the renovation and construction of maternity waiting homes resulted in a 69% increase in the number of health facilities with associated maternity waiting homes. CONCLUSION: The collective SMGL strategies addressing the second delay resulted in increased access to delivery services as seen by the increase in the proportion of facility deliveries in SMGL districts, improved communication and transportation services, and an increase in the number of facilities with associated maternity waiting homes. Sustaining and improving on these efforts will need to be ongoing to continue to address the second delay in Uganda and Zambia. |
Did saving mothers, giving life expand timely access to lifesaving care in Uganda A spatial district-level analysis of travel time to emergency obstetric and newborn care
Schmitz MM , Serbanescu F , Kamara V , Kraft JM , Cunningham M , Opio G , Komakech P , Conlon CM , Goodwin MM . Glob Health Sci Pract 2019 7 S151-s167 INTRODUCTION: Interventions for the Saving Mothers, Giving Life (SMGL) initiative aimed to ensure all pregnant women in SMGL-supported districts have timely access to emergency obstetric and newborn care (EmONC). Spatial travel-time analyses provide a visualization of changes in timely access. METHODS: We compared travel-time estimates to EmONC health facilities in SMGL-supported districts in western Uganda in 2012, 2013, and 2016. To examine EmONC access, we analyzed a categorical variable of travel-time duration in 30-minute increments. Data sources included health facility assessments, geographic coordinates of EmONC facilities, geolocated population estimates of women of reproductive age (WRA), and other road network and geographic sources. RESULTS: The number of EmONC facilities almost tripled between 2012 and 2016, increasing geographic access to EmONC. Estimated travel time to EmONC facilities declined significantly during the 5-year period. The proportion of WRA able to access any EmONC and comprehensive EmONC (CEmONC) facility within 2 hours by motorcycle increased by 18% (from 61.3% to 72.1%, P < .01) and 37% (from 51.1% to 69.8%, P < .01), respectively from baseline to 2016. Similar increases occurred among WRA accessing EmONC and CEmONC respectively if 4-wheeled vehicles (14% and 31% increase, P < .01) could be used. Increases in timely access were also substantial for nonmotorized transportation such as walking and/or bicycling. CONCLUSIONS: Largely due to the SMGL-supported expansion of EmONC capability, timely access to EmONC significantly improved. Our analysis developed a geographic outline of facility accessibility using multiple types of transportation. Spatial travel-time analyses, along with other EmONC indicators, can be used by planners and policy makers to estimate need and target underserved populations to achieve further gains in EmONC accessibility. In addition to increasing the number and geographic distribution of EmONC facilities, complementary efforts to make motorized transportation available are necessary to achieve meaningful increases in EmONC access. |
Impact of the Saving Mothers, Giving Life approach on decreasing maternal and perinatal deaths in Uganda and Zambia
Serbanescu F , Clark TA , Goodwin MM , Nelson LJ , Boyd MA , Kekitiinwa AR , Kaharuza F , Picho B , Morof D , Blanton C , Mumba M , Komakech P , Carlosama F , Schmitz MM , Conlon CM . Glob Health Sci Pract 2019 7 S27-s47 BACKGROUND: Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions. METHODS: SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities. RESULTS: Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country. CONCLUSIONS: MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths. |
Addressing the first delay in Saving Mothers, Giving Life districts in Uganda and Zambia: Approaches and results for increasing demand for facility delivery services
Serbanescu F , Goodwin MM , Binzen S , Morof D , Asiimwe AR , Kelly L , Wakefield C , Picho B , Healey J , Nalutaaya A , Hamomba L , Kamara V , Opio G , Kaharuza F , Blanton C , Luwaga F , Steffen M , Conlon CM . Glob Health Sci Pract 2019 7 S48-s67 Saving Mothers, Giving Life (SMGL), a 5-year initiative implemented in selected districts in Uganda and Zambia, was designed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care at birth. While originally the "Three Delays" model was designed to focus on curative services that encompass emergency obstetric care, SMGL expanded its application to primary and secondary prevention of obstetric complications. Prevention of the "first delay" focused on addressing factors influencing the decision to seek delivery care at a health facility. Numerous factors can contribute to the first delay, including a lack of birth planning, unfamiliarity with pregnancy danger signs, poor perceptions of facility care, and financial or geographic barriers. SMGL addressed these barriers through community engagement on safe motherhood, public health outreach, community workers who identified pregnant women and encouraged facility delivery, and incentives to deliver in a health facility. SMGL used qualitative and quantitative methods to describe intervention strategies, intervention outcomes, and health impacts. Partner reports, health facility assessments (HFAs), facility and community surveillance, and population-based mortality studies were used to document activities and measure health outcomes in SMGL-supported districts. SMGL's approach led to unprecedented community outreach on safe motherhood issues in SMGL districts. About 3,800 community health care workers in Uganda and 1,558 in Zambia were engaged. HFAs indicated that facility deliveries rose significantly in SMGL districts. In Uganda, the proportion of births that took place in facilities rose from 45.5% to 66.8% (47% increase); similarly, in Zambia SMGL districts, facility deliveries increased from 62.6% to 90.2% (44% increase). In both countries, the proportion of women delivering in facilities equipped to provide emergency obstetric and newborn care also increased (from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia). The districts documented declines in the number of maternal deaths due to not accessing facility care during pregnancy, delivery, and the postpartum period in both countries. This reduction played a significant role in the decline of the maternal mortality ratio in SMGL-supported districts in Uganda but not in Zambia. Further work is needed to sustain gains and to eliminate preventable maternal and perinatal deaths. |
"Every Newborn-INDEPTH" (EN-INDEPTH) study protocol for a randomised comparison of household survey modules for measuring stillbirths and neonatal deaths in five Health and Demographic Surveillance sites
Baschieri A , Gordeev VS , Akuze J , Kwesiga D , Blencowe H , Cousens S , Waiswa P , Fisker AB , Thysen SM , Rodrigues A , Biks GA , Abebe SM , Gelaye KA , Mengistu MY , Geremew BM , Delele TG , Tesega AK , Yitayew TA , Kasasa S , Galiwango E , Natukwatsa D , Kajungu D , Enuameh YA , Nettey OE , Dzabeng F , Amenga-Etego S , Newton SK , Manu AA , Tawiah C , Asante KP , Owusu-Agyei S , Alam N , Haider MM , Alam SS , Arnold F , Byass P , Croft TN , Herbst K , Kishor S , Serbanescu F , Lawn JE . J Glob Health 2019 9 (1) 010901 Background: Under-five and maternal mortality were halved in the Millennium Development Goals (MDG) era, with slower reductions for 2.6 million neonatal deaths and 2.6 million stillbirths. The Every Newborn Action Plan aims to accelerate progress towards national targets, and includes an ambitious Measurement Improvement Roadmap. Population-based household surveys, notably Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys, are major sources of population-level data on child mortality in countries with weaker civil registration and vital statistics systems, where over two-thirds of global child deaths occur. To estimate neonatal/child mortality and pregnancy outcomes (stillbirths, miscarriages, birthweight, gestational age) the most common direct methods are: (1) the standard DHS-7 with Full Birth History with additional questions on pregnancy losses in the past 5 years (FBH(+)) or (2) a Full Pregnancy History (FPH). No direct comparison of these two methods has been undertaken, although descriptive analyses suggest that the FBH(+) may underestimate mortality rates particularly for stillbirths. Methods: This is the protocol paper for the Every Newborn-INDEPTH study (INDEPTH Network, International Network for the Demographic Evaluation of Populations and their Health Every Newborn, Every Newborn Action Plan), aiming to undertake a randomised comparison of FBH(+) and FPH to measure pregnancy outcomes in a household survey in five selected INDEPTH Network sites in Africa and South Asia (Bandim in urban and rural Guinea-Bissau; Dabat in Ethiopia; IgangaMayuge in Uganda; Kintampo in Ghana; Matlab in Bangladesh). The survey will reach >68 000 pregnancies to assess if there is >/=15% difference in stillbirth rates. Additional questions will capture birthweight, gestational age, birth/death certification, termination of pregnancy and fertility intentions. The World Bank's Survey Solutions platform will be tailored for data collection, including recording paradata to evaluate timing. A mixed methods assessment of barriers and enablers to reporting of pregnancy and adverse pregnancy outcomes will be undertaken. Conclusions: This large-scale study is the first randomised comparison of these two methods to capture pregnancy outcomes. Results are expected to inform the evidence base for survey methodology, especially in DHS, regarding capture of stillbirths and other outcomes, notably neonatal deaths, abortions (spontaneous and induced), birthweight and gestational age. In addition, this study will inform strategies to improve health and demographic surveillance capture of neonatal/child mortality and pregnancy outcomes. |
Client and provider factors associated with companionship during labor and birth in Kigoma Region, Tanzania
Dynes MM , Binzen S , Twentyman E , Nguyen H , Lobis S , Mwakatundu N , Chaote P , Serbanescu F . Midwifery 2018 69 92-101 BACKGROUND: Labor and birth companionship is a key aspect of respectful maternity care. Lack of companionship deters women from accessing facility-based delivery care, though formal and informal policies against companionship are common in sub-Saharan African countries. AIM: To identify client and provider factors associated with labor and birth companionship DESIGN: Cross-sectional evaluation among delivery clients and providers in 61 health facilities in Kigoma Region, Tanzania, April-July 2016. METHODS: Multilevel, mixed effects logistic regression analyses were conducted on linked data from providers (n=249) and delivery clients (n=935). Outcome variables were Companion in labor and Companion at the time of birth. FINDINGS: Less than half of women reported having a labor companion (44.7%) and 12% reported having a birth companion. Among providers, 26.1% and 10.0% reported allowing a labor and birth companion, respectively. Clients had significantly greater odds of having a labor companion if their provider reported the following traits: working more than 55 hours/week (aOR 2.46, 95% CI 1.23-4.97), feeling very satisfied with their job (aOR 3.66, 95% CI 1.36-9.85), and allowing women to have a labor companion (aOR 3.73, 95% CI 1.58-8.81). Clients had significantly lower odds of having a labor companion if their provider reported having an on-site supervisor (aOR 0.48, 95% CI 0.24-0.95). Clients had significantly greater odds of having a birth companion if they self-reported labor complications (aOR 2.82, 95% CI 1.02-7.81) and had a labor companion (aOR 44.74, 95% CI 11.99-166.91). Clients had significantly greater odds of having a birth companion if their provider attended more than 10 deliveries in the last month (aOR 3.43, 95% CI 1.08-10.96) compared to fewer deliveries. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These results suggest that health providers are the gatekeepers of companionship, and the work environment influences providers' allowance of companionship. Facilities where providers experience staff shortages and high workload may be particularly responsive to programmatic interventions that aim to increase staff acceptance of birth companionship. |
Client and provider factors associated with integration of family planning services among maternal and reproductive health clients in Kigoma Region, Tanzania: a cross-sectional study, April-July 2016
Dynes MM , Bernstein E , Morof D , Kelly L , Ruiz A , Mongo W , Chaote P , Bujari RN , Serbanescu F . Reprod Health 2018 15 (1) 152 BACKGROUND: Integration of family planning (FP) services into non-FP care visits is an essential strategy for reducing maternal and neonatal mortality through reduction of short birth intervals and unplanned pregnancies. METHODS: Cross-sectional surveys were conducted across 61 facilities in Kigoma Region, Tanzania, April-July 2016. Multilevel, mixed effects logistic regression analyses were conducted on matched data from providers (n = 330) and clients seeking delivery (n = 935), well-baby (n = 272), pregnancy loss (PL; n = 229), and other routine (postnatal, HIV/STI, other; n = 69) services. Outcomes of interest included receipt of FP information and a modern FP method (significance level p < 0.05). RESULTS: Clients had significantly greater odds of receiving FP information if the primary reason for seeking care was for PL versus (vs) any other types of care (aOR 1.97), had four or more pregnancies vs fewer (aOR 1.78), and had had a FP discussion with their partner vs no FP discussion (aOR 1.73). Clients had lower odds of receiving FP information if they were aged 40-49 vs 15-19 (aOR 0.50) and reported attending religious services at least weekly vs less frequently (aOR 0.61). Clients of providers who perceived that in-service training had helped vs had not helped job performance (aOR 2.27), and clients of providers having high vs low recent FP training index scores (aOR 1.58) had greater odds of receiving FP information. Clients had greater odds of receiving a modern method when they received information on two or more vs fewer methods (aOR 7.13), had had a FP discussion with their partner vs no discussion (aOR 5.87), if the primary reason for seeking care was for PL vs any other types of care (aOR 4.08), had zero vs one or more live births (aOR 3.92), made their own FP decisions vs not made own FP decisions (aOR 3.17), received FP information from two or more vs fewer sources (aOR 3.12), and were in the middle or high vs the low wealth tercile (aOR 1.99 and 2.30, respectively). Well-baby care clients, Other routine services clients, and married clients had significantly lower odds of receiving a method (aOR 0.14; aOR 0.08; and aOR 0.41, respectively) compared to their counterparts. CONCLUSIONS: Strategies that better integrate FP into routine care visits, encourage women to have FP discussions with their partners and providers, increase FP training among providers, and expand FP options and sources of information may help reduce the unmet need for FP, and ultimately lower maternal and neonatal mortality. |
Patient and provider determinants for receipt of three dimensions of respectful maternity care in Kigoma Region, Tanzania-April-July, 2016
Dynes MM , Twentyman E , Kelly L , Maro G , Msuya AA , Dominico S , Chaote P , Rusibamayila R , Serbanescu F . Reprod Health 2018 15 (1) 41 BACKGROUND: Lack of respectful maternity care (RMC) is increasingly recognized as a human rights issue and a key deterrent to women seeking facility-based deliveries. Ensuring facility-based RMC is essential for improving maternal and neonatal health, especially in sub-Saharan African countries where mortality and non-skilled delivery care remain high. Few studies have attempted to quantitatively identify patient and delivery factors associated with RMC, and none has modeled the influence of provider characteristics on RMC. This study aims to help fill these gaps through collection and analysis of interviews linked between clients and providers, allowing for description of both patient and provider characteristics and their association with receipt of RMC. METHODS: We conducted cross-sectional surveys across 61 facilities in Kigoma Region, Tanzania, from April to July 2016. Measures of RMC were developed using 21-items in a Principal Components Analysis (PCA). We conducted multilevel, mixed effects generalized linear regression analyses on matched data from 249 providers and 935 post-delivery clients. The outcomes of interest included three dimensions of RMC-Friendliness/Comfort/Attention; Information/Consent; and Non-abuse/Kindness-developed from the first three components of PCA. Significance level was set at p < 0.05. RESULTS: Significant client-level determinants for perceived Friendliness/Comfort/Attention RMC included age (30-39 versus 15-19 years: Coefficient [Coef] 0.63; 40-49 versus 15-19 years: Coef 0.79) and self-reported complications (reported complications versus did not: Coef - 0.41). Significant provider-level determinants included perception of fair pay (Perceives fair pay versus unfair pay: Coef 0.46), cadre (Nurses/midwives versus Clinicians: Coef - 0.46), and number of deliveries in the last month (11-20 versus < 11 deliveries: Coef - 0.35). Significant client-level determinants for Information/Consent RMC included labor companionship (Companion versus none: Coef 0.37) and religiosity (Attends services at least weekly versus less often: Coef - 0.31). Significant provider-level determinants included perception of fair pay (Perceives fair pay versus unfair: Coef 0.37), weekly work hours (Coef 0.01), and age (30-39 versus 20-29 years: Coef - 0.34; 40-49 versus 20-29 years: Coef - 0.58). Significant provider-level determinants for Non-abuse/Kindness RMC included the predictors of age (age 50+ versus 20-29 years: Coef 0.34) and access to electronic mentoring (Access to two mentoring types versus none: Coef 0.37). CONCLUSIONS: These findings illustrate the value of including both client and provider information in the analysis of RMC. Strategies that address provider-level determinants of RMC (such as equitable pay, work environment, access to mentoring platforms) may improve RMC and subsequently address uptake of facility delivery. |
Geographic access modeling of emergency obstetric and neonatal care in Kigoma Region, Tanzania: Transportation schemes and programmatic implications
No Chen Y , Schmitz MM , Serbanescu F , Dynes MM , Maro G , Kramer MR . Glob Health Sci Pract 2017 5 (3) 430-445 BACKGROUND: Access to transportation is vital to reducing the travel time to emergency obstetric and neonatal care (EmONC) for managing complications and preventing adverse maternal and neonatal outcomes. This study examines the distribution of travel times to EmONC in Kigoma Region, Tanzania, using various transportation schemes, to estimate the proportion of live births (a proxy indicator of women needing delivery care) with poor geographic access to EmONC services. METHODS: The 2014 Reproductive Health Survey of Kigoma Region identified 4 primary means of transportation used to travel to health facilities: walking, cycling, motorcycle, and 4-wheeled motor vehicle. A raster-based travel time model was used to map the 2-hour travel time catchment for each mode of transportation. Live birth density distributions were aggregated by travel time catchments, and by administrative council, to estimate the proportion of births with poor access. RESULTS: Of all live births in Kigoma Region, 13% occurred in areas where women can reach EmONC facilities within 2 hours on foot, 33% in areas that can be reached within 2 hours only by motorized vehicles, and 32% where it is impossible to reach EmONC facilities within 2 hours. Over 50% of births in 3 of the 8 administrative councils had poor estimated access. In half the councils, births with poor access could be reduced to no higher than 12% if all female residents had access to motorized vehicles. CONCLUSION: Significant differences in geographic access to EmONC in Kigoma Region, Tanzania, were observed both by location and by primary transportation type. As most of the population may only have good EmONC access when using mechanized or motorized vehicles, bicycles and motorcycles should be incorporated into the health transportation strategy. Collaboration between private transportation sectors and obstetric service providers could improve access to EmONC services among most populations. In areas where residents may not access EmONC facilities within 2 hours regardless of the type of transportation used, upgrading EmONC capacity among nearby non-EmONC facilities may be required to improve accessibility. |
Rapid reduction of maternal mortality in Uganda and Zambia through the Saving Mothers, Giving Life initiative: results of year 1 evaluation
Serbanescu F , Goldberg HI , Danel I , Wuhib T , Marum L , Obiero W , McAuley J , Aceng J , Chomba E , Stupp PW , Conlon CM . BMC Pregnancy Childbirth 2017 17 (1) 42 BACKGROUND: Achieving maternal mortality reduction as a development goal remains a major challenge in most low-resource countries. Saving Mothers, Giving Life (SMGL) is a multi-partner initiative designed to reduce maternal mortality rapidly in high mortality settings through community and facility evidence-based interventions and district-wide health systems strengthening that could reduce delays to appropriate obstetric care. METHODS: An evaluation employing multiple studies and data collection methods was used to compare baseline maternal outcomes to those during Year 1 in SMGL pilot districts in Uganda and Zambia. Studies include health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and population-based investigation of community maternal deaths. Population-based evaluation used standard approaches and comparable indicators to measure outcome and impact, and to allow comparison of the SMGL implementation in unique country contexts. RESULTS: The evaluation found a 30% reduction in the population-based maternal mortality ratio (MMR) in Uganda during Year 1, from 452 to 316 per 100,000 live births. The MMR in health facilities declined by 35% in each country (from 534 to 345 in Uganda and from 310 to 202 in Zambia). The institutional delivery rate increased by 62% in Uganda and 35% in Zambia. The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 25 in Uganda and from 7 to 11 in Zambia. Partial EmONC care became available in many more low and mid-level facilities. Cesarean section rates for all births increased by 23% in Uganda and 15% in Zambia. The proportion of women with childbirth complications delivered in EmONC facilities rose by 25% in Uganda and 23% in Zambia. Facility case fatality rates fell from 2.6 to 2.0% in Uganda and 3.1 to 2.0% in Zambia. CONCLUSIONS: Maternal mortality ratios fell significantly in one year in Uganda and Zambia following the introduction of the SMGL model. This model employed a comprehensive district system strengthening approach. The lessons learned from SMGL can inform policymakers and program managers in other low and middle income settings where similar approaches could be utilized to rapidly reduce preventable maternal deaths. |
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