10 research outputs found
Knowledge, perceptions and practices regarding schistosomiasis among women living in a highly endemic rural district in Zimbabwe: implications on infections among preschool-aged children
No full textAbstract
Background
Schistosomiasis primarily affects poor and neglected communities due to their lack of safe water and sanitation facilities. In an effort to improve intervention strategies, the present study investigated the association of socio-demographic characteristics of women with their existing knowledge, perceptions and practices (KPP) in five urogenital schistosomiasis endemic rural communities in Zimbabwe.
Methods
In February 2016, a cross sectional study was conducted in which 426 women in rural Madziwa area, Shamva District were interviewed using a pretested structured questionnaire seeking their KPP and socio-demographic characteristics. Logistic regression analysis was performed to identify socio-demographic factors associated with the KPP variables.
Results
Among the 426 participants, 93.7% knew about schistosomiasis, while 97.7 and 87.5% understood the disease transmission and methods for prevention, respectively. A significantly higher percentage of women aged ≥ 30 years compared to those < 30 years indicated that infertility is a complication of untreated chronic schistosomiasis (OR: 1.7, 95% CI: 0.9–3.0). Compared to women who had no history of infection, those who had been infected before were more likely to think that they were currently infected (OR: 3.7, 95% CI: 2.4–6.0). Bathing in unsafe water sources was more common in non-apostolic compared to apostolic followers (OR: 2.1, 95% CI: 1.2–3.7). Sole use of unsafe water for domestic purposes was significantly higher in uneducated women compared to the educated (OR: 1.8, 95% CI: 1.0–3.1). Compared to women of the Chakondora community, those in Chihuri, Nduna and Kaziro were more likely to know that dysuria is a symptom of schistosomiasis while those in Chihuri were also likely to allow young children to perform water contact activities (OR: 2.9, 95% CI: 1.5–5.5).
Conclusions
Despite the high level of schistosomiasis awareness, some women had inadequate knowledge about the mode of transmission and preventive measures for schistosomiasis. Socio-demographic characteristics were associated with the KPP of women. Thus, disease control efforts should consider socio-demographic factors, which may influence the knowledge, perceptions and practices of occupants in a given setting.Copyright © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. The attached file is the published version of the article.NHM Repositor
Early detection and a treatment bundle strategy for postpartum haemorrhage: a mixed-methods process evaluation
No full textBackground:
Postpartum haemorrhage is a leading cause of maternal mortality. A multicountry, cluster-randomised trial (E-MOTIVE) demonstrated a 60% reduction in adverse postpartum haemorrhage outcomes. The E-MOTIVE intervention included early postpartum haemorrhage detection using calibrated blood-collection drapes, followed by a postpartum haemorrhage treatment bundle (ie, uterine massage, oxytocics, tranexamic acid, intravenous fluids, examination and escalation [MOTIVE]), supported by implementation strategies. We report a mixed-methods process evaluation assessing the implementation of the E-MOTIVE intervention in Kenya, Nigeria, South Africa, and Tanzania.
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Methods:
In this mixed-methods process evaluation, data sources were observations of health workers providing clinical care to pregnant women and pregnant people during vaginal birth and postpartum haemorrhage at intervention sites, and surveys and qualitative interviews with health workers at intervention and control sites. Intervention sites received the calibrated drapes, MOTIVE bundle, and implementation strategies and control sites used uncalibrated drapes. Primary implementation outcomes included fidelity, adoption, adaptation, acceptability, feasibility, and contamination to the calibrated drape, MOTIVE bundle, and implementation strategies.
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Findings:
Between June 1, 2022, and Jan 31, 2023, 2578 births were observed, 295 pregnant women and people had postpartum haemorrhage, 47 qualitative interviews were done, and 889 surveys were completed. Fidelity to calibrated drape use was high (birth observations 2578 [100%] of 2578; survey 451 [98·3%] of 459). Among health workers, calibrated drape acceptability was high; however, they reported barriers to pregnant women's and people's acceptability. Fidelity to postpartum haemorrhage treatment bundle delivery was high (birth observations 286 [96·9%] of 295), with moderate to high fidelity in median time from postpartum haemorrhage diagnosis to final treatment initiation (≤15 min initiation time in 191 [66·8%] of 295 birth observations, 16–20 min in 42 [14·7%] birth observations), and high acceptability and feasibility. Research midwives participated in clinical assessments after birth and bundle delivery in some sites (mixed fidelity).
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Interpretation:
This process evaluation shows generally high levels of fidelity, feasibility, and acceptability of the calibrated drape and treatment bundle across evaluation methods and countries. The E-MOTIVE intervention should be included in national policies, with consideration for health workforce, supplies, and medication issues, which might need addressing for successful implementation.
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Funding:
The Bill and Melinda Gates Foundation and the UNDP–UNFPA–UNICEF–WHO–World Bank Special Programme of Research, Development and Research Training in Human Reproduction, a co-sponsored programme of WHO
Development and piloting of implementation strategies to support delivery of a clinical intervention for postpartum hemorrhage in four sub-Saharan Africa countries
No full textAbstract: Introduction: Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality. A new clinical intervention (E-MOTIVE) holds the potential to improve early PPH detection and management. We aimed to develop and pilot implementation strategies to support uptake of this intervention in Kenya, Nigeria, South Africa, and Tanzania. Methods: Implementation strategy development: We triangulated findings from qualitative interviews, surveys and a qualitative evidence synthesis to identify current PPH care practices and influences on future intervention implementation. We mapped influences using implementation science frameworks to identify candidate implementation strategies before presenting these at stakeholder consultation and design workshops to discuss feasibility, acceptability, and local adaptations. Piloting: The intervention and implementation strategies were piloted in 12 health facilities (3 per country) over 3 months. Interviews (n1/458), case report forms (n1/41,269), and direct observations (18 vaginal births, 7 PPHs) were used to assess feasibility, acceptability, and fidelity. Results: Implementation strategy development: Key influences included shortages of drugs, supplies, and staff, limited in-service training, and perceived benefits of the intervention (e.g., more accurate PPH detection and reduced PPH mortality). Proposed implementation strategies included a PPH trolley, on-site simulation-based training, champions, and audit and feedback. Country-specific adaptations included merging the E-MOTIVE intervention with national maternal health trainings, adapting local PPH protocols, and PPH trollies depending on staff needs. Piloting: Intervention and implementation strategy fidelity differed within and across countries. Calibrated drapes resulted in earlier and more accurate PPH detection but were not consistently used at the start. Implementation strategies were feasible to deliver; however, some instances of limited use were observed (e.g., PPH trolley and skills practice after training). Conclusion: Systematic intervention development, piloting, and process evaluation helped identify initial challenges related to intervention fidelity, which were addressed ahead of a larger- scale effectiveness evaluation. This has helped maximize the internal validity of the trial
When Is Postpartum Haemorrhage Treatment Initiated? A Nested Observational Study Within the E‐MOTIVE Trial
No full textObjective: To compare the frequency and timing of postpartum haemorrhage (PPH) treatment initiation between hospitals implementing the MOTIVE treatment bundle (which consisted of uterine Massage, Oxytocic drugs, Tranexamic acid, IntraVenous fluids and Examination) and those following usual care.Design: Nested prospective observational study.Setting: Hospitals in Nigeria, Kenya, Tanzania and South Africa participating in the E-MOTIVE trial.Population or Sample: Healthcare workers treating PPH.Methods: Between June and December 2022, we observed healthcare workers for 1–2 weeks in 39 E-MOTIVE and 39 usual care hospitals across Nigeria, Kenya, Tanzania, and South Africa managing vaginal birth and treating PPH. We descriptively compared the frequency and timing from PPH detection to treatment initiation of individual treatments and the MOTIVE bundle, between E-MOTIVE care and usual care.Results: Among 2578 observations in E-MOTIVE care hospitals, 295 (11%) PPHs were treated, and among 2834 observations in usual care hospitals, 219 (8%) PPHs were treated. In E-MOTIVE care hospitals, 97% (286/295) of women with PPH received the MOTIVE bundle, compared to 36% (79/219) in usual care. Median initiation times for the first component were similar (0 vs. 1 min), but E-MOTIVE care hospitals achieved faster initiation of all components (13 min, IQR 6–18) compared to usual care (18 min, IQR 10–25). In total, 79% (233/295) of women in E-MOTIVE care had all components initiated within 20 min, compared to 22% (48/219) in usual care.Conclusions: Timely and comprehensive management of PPH using the MOTIVE bundle, particularly initiating all components within 15–20 min, was commonly observed in the E-MOTIVE care hospitals. Scaling up E-MOTIVE care should emphasise timely bundle initiation to strengthen PPH treatment and improve maternal health outcomes in low-and-middle-income countries
Clinical care processes for early postpartum haemorrhage diagnosis: a nested observational study within the E-MOTIVE trial
No full textBackground: Postpartum haemorrhage (PPH) is the leading cause of maternal mortality, particularly in low- and- middle-income countries. The E-MOTIVE trial demonstrated a 60% reduction in severe PPH and related complications with the E-MOTIVE intervention compared to usual care. This nested observational study explored clinical care practices between the time of vaginal birth and the removal of the obstetric drape. Specifically, we assessed the frequency of postpartum maternal assessments, including blood pressure, pulse, uterine tone, vaginal blood flow, and cumulative blood loss assessment—unique to the intervention. We also evaluated diagnostic methods, and blood loss thresholds used for PPH, and how these practices may have contributed to differences in PPH diagnosis and outcomes between E-MOTIVE intervention hospitals and usual care hospitals. Methods: This prospective observational study, nested within the E-MOTIVE trial, involved passive, direct observations of healthcare workers providing postpartum care to women and managing PPH across 78 hospitals in Nigeria, Kenya, Tanzania, and South Africa. We conducted a descriptive analysis of the frequency and timing of postpartum maternal assessments, diagnostic methods and blood loss thresholds used to diagnose PPH, comparing clinical practices between E-MOTIVE care and usual care. Results: Between June and December 2022, the study included 2,578 women at E-MOTIVE care hospitals and 2,834 at usual care hospitals. At E-MOTIVE hospitals, 88% (2,272/2,578) of women received at least one postpartum maternal assessment, 71% (1,825/2,578) at least two, 57% (1,479/2,578) at least three, and 48% (1,234/2,578) four, with assessments conducted earlier and more frequently than at usual care hospitals. Objective blood loss quantification improved diagnosis, with the most common method and blood loss threshold at E-MOTIVE hospitals being ≥300 mL plus at least one abnormal clinical sign, used in 47% (140/295) of PPHs. Postpartum haemorrhage was diagnosed earlier and more frequently at E-MOTIVE hospitals: 76% (223/295) within 30 min, 97% (287/295) within 60 min, and 100% 295/295) within 90 min (median: 17 min; IQR 11–30), compared to 54% (119/219), 79% (173/219), 96% (210/219) respectively, and 100% within 134 min in usual care (median: 26 min; IQR 13–56). Discussion: Frequent and timely postpartum maternal assessments, along with objective blood loss thresholds of with at least one abnormal clinical sign and ≥500 mL may enhance early PPH diagnosis. The first 90 min postpartum has been identified as a critical window for early diagnosis, termed the “Golden 90 min for PPH diagnosis.” Incorporating these insights into clinical training and guidelines may support improved maternal outcomes related to PPH
Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage
No full textBACKGROUND: Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum hemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle. METHODS: We conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum hemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum hemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group). Hospitals in the control group provided usual care. The primary outcome was a composite of severe postpartum hemorrhage (blood loss, ≥1000 ml), laparotomy for bleeding, or maternal death from bleeding. Key secondary implementation outcomes were the detection of postpartum hemorrhage and adherence to the treatment bundle. RESULTS: A total of 80 secondary-level hospitals across Kenya, Nigeria, South Africa, and Tanzania, in which 210,132 patients underwent vaginal delivery, were randomly assigned to the intervention group or the usual-care group. Among hospitals and patients with data, a primary-outcome event occurred in 1.6% of the patients in the intervention group, as compared with 4.3% of those in the usual-care group (risk ratio, 0.40; 95% confidence interval [CI], 0.32 to 0.50; P<0.001). Postpartum hemorrhage was detected in 93.1% of the patients in the intervention group and in 51.1% of those in the usual-care group (rate ratio, 1.58; 95% CI, 1.41 to 1.76), and the treatment bundle was used in 91.2% and 19.4%, respectively (rate ratio, 4.94; 95% CI, 3.88 to 6.28). CONCLUSIONS: Early detection of postpartum hemorrhage and use of bundled treatment led to a lower risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding, than usual care among patients having vaginal delivery. (Funded by the Bill and Melinda Gates Foundation; E-MOTIVE ClinicalTrials.gov number, NCT04341662.)
Development and Piloting of Implementation Strategies to Support Delivery of a Clinical Intervention for Postpartum Hemorrhage in Four sub-Saharan Africa Countries
No full textIntroduction: Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality. A new clinical intervention (E-MOTIVE) holds the potential to improve early PPH detection and management. We aimed to develop and pilot implementation strategies to support uptake of this intervention in Kenya, Nigeria, South Africa, and Tanzania. Methods: Implementation strategy development: We triangulated findings from qualitative interviews, surveys and a qualitative evidence synthesis to identify current PPH care practices and influences on future intervention implementation. We mapped influences using implementation science frameworks to identify candidate implementation strategies before presenting these at stakeholder consultation and design workshops to discuss feasibility, acceptability, and local adaptations. Piloting: The intervention and implementation strategies were piloted in 12 health facilities (3 per country) over 3 months. Interviews (n=58), case report forms (n=1,269), and direct observations (18 vaginal births, 7 PPHs) were used to assess feasibility, acceptability, and fidelity. Results: Implementation strategy development: Key influences included shortages of drugs, supplies, and staff, limited in-service training, and perceived benefits of the intervention (e.g., more accurate PPH detection and reduced PPH mortality). Proposed implementation strategies included a PPH trolley, on-site simulation-based training, champions, and audit and feedback. Country-specific adaptations included merging the E-MOTIVE intervention with national maternal health trainings, adapting local PPH protocols, and PPH trollies depending on staff needs. Piloting: Intervention and implementation strategy fidelity differed within and across countries. Calibrated drapes resulted in earlier and more accurate PPH detection but were not consistently used at the start. Implementation strategies were feasible to deliver; however, some instances of limited use were observed (e.g., PPH trolley and skills practice after training). Conclusion: Systematic intervention development, piloting, and process evaluation helped identify initial challenges related to intervention fidelity, which were addressed ahead of a larger-scale effectiveness evaluation. This has helped maximize the internal validity of the trial.</p
When are postpartum haemorrhages diagnosed? A nested observational study within the E-MOTIVE cluster-randomised trial
No full textBackgroundThe definition of primary postpartum haemorrhage as blood loss of 500 mL or more within 24 h after vaginal birth underemphasises the early postpartum hours due to limited data on the timing of postpartum haemorrhage diagnosis. Understanding postpartum haemorrhage diagnosis timing and diagnostic methods is important for guiding diagnostic and therapeutic strategies. The E-MOTIVE trial evaluated early postpartum haemorrhage diagnosis and a bundled treatment approach, which resulted in a 60% relative reduction in adverse outcomes from bleeding compared with usual care. We aimed to compare timing from vaginal birth to postpartum haemorrhage diagnosis and the diagnostic methods used among four African countries implementing the intervention from the E-MOTIVE trial.MethodsNested within the E-MOTIVE trial (NCT04341662), we conducted direct observations of health-care workers providing clinical care to postpartum women at 39 hospitals implementing the E-MOTIVE intervention across Nigeria, Kenya, Tanzania, and South Africa. One to two weeks of continuous observations were conducted from vaginal birth up to 2 h, between June 27, and Dec 18, 2022. Health-care workers were trained to use clinical judgement (ie, heavy vaginal blood loss, large blood clots expelled, or constant trickle) and various objective blood loss thresholds to diagnose postpartum haemorrhage. The objective blood loss thresholds used in Nigeria, Kenya, and Tanzania were 300 mL or more with at least one abnormal clinical sign (ie, pulse, blood pressure, uterine tone, and vaginal blood flow) or 500 mL or more. The objective blood loss threshold in South Africa was 500 mL or more. We descriptively analysed and compared timing from vaginal birth to postpartum haemorrhage diagnosis and diagnostic methods used between countries.FindingsOf 2578 women, 295 postpartum haemorrhages were diagnosed. The median time from vaginal birth to postpartum haemorrhage diagnosis was 15 min in Nigeria and Tanzania, 17 min in Kenya, and 30 min in South Africa. Diagnosis within 30 min ranged from 58% in South Africa to 86% in Tanzania. By 60 min, 96% to 100% of postpartum haemorrhages were diagnosed across all countries. All postpartum haemorrhages that required an intervention were diagnosed within 90 min. Nigeria, Kenya, and Tanzania commonly used blood loss of 300 mL or more combined with at least one abnormal clinical sign (47%, 65%, and 68%, respectively) while South Africa relied on a definition of 500 mL or more (81%) as the dominant diagnostic strategy.InterpretationIn countries where an objective blood loss threshold of 300 mL or more with at least one abnormal clinical sign was used, women received earlier interventions for postpartum bleeding, with a median time to diagnosis of 15–17 min. This was notably faster than in the country that predominantly used a 500 mL or more threshold, where the median time to diagnosis was 30 min. Regardless of whether the threshold was 300 mL or more with abnormal clinical signs or 500 mL or more alone, all postpartum haemorrhages were diagnosed within 90 min of vaginal birth
Early detection and a treatment bundle strategy for postpartum haemorrhage:a mixed-methods process evaluation
No full textBackgroundPostpartum haemorrhage is a leading cause of maternal mortality. A multicountry, cluster-randomised trial (E-MOTIVE) demonstrated a 60% reduction in adverse postpartum haemorrhage outcomes. The E-MOTIVE intervention included early postpartum haemorrhage detection using calibrated blood-collection drapes, followed by a postpartum haemorrhage treatment bundle (ie, uterine massage, oxytocics, tranexamic acid, intravenous fluids, examination and escalation [MOTIVE]), supported by implementation strategies. We report a mixed-methods process evaluation assessing the implementation of the E-MOTIVE intervention in Kenya, Nigeria, South Africa, and Tanzania.MethodsIn this mixed-methods process evaluation, data sources were observations of health workers providing clinical care to pregnant women and pregnant people during vaginal birth and postpartum haemorrhage at intervention sites, and surveys and qualitative interviews with health workers at intervention and control sites. Intervention sites received the calibrated drapes, MOTIVE bundle, and implementation strategies and control sites used uncalibrated drapes. Primary implementation outcomes included fidelity, adoption, adaptation, acceptability, feasibility, and contamination to the calibrated drape, MOTIVE bundle, and implementation strategies.FindingsBetween June 1, 2022, and Jan 31, 2023, 2578 births were observed, 295 pregnant women and people had postpartum haemorrhage, 47 qualitative interviews were done, and 889 surveys were completed. Fidelity to calibrated drape use was high (birth observations 2578 [100%] of 2578; survey 451 [98·3%] of 459). Among health workers, calibrated drape acceptability was high; however, they reported barriers to pregnant women's and people's acceptability. Fidelity to postpartum haemorrhage treatment bundle delivery was high (birth observations 286 [96·9%] of 295), with moderate to high fidelity in median time from postpartum haemorrhage diagnosis to final treatment initiation (≤15 min initiation time in 191 [66·8%] of 295 birth observations, 16–20 min in 42 [14·7%] birth observations), and high acceptability and feasibility. Research midwives participated in clinical assessments after birth and bundle delivery in some sites (mixed fidelity).InterpretationThis process evaluation shows generally high levels of fidelity, feasibility, and acceptability of the calibrated drape and treatment bundle across evaluation methods and countries. The E-MOTIVE intervention should be included in national policies, with consideration for health workforce, supplies, and medication issues, which might need addressing for successful implementation
Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage
No full textBACKGROUND: Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum hemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle.METHODS: We conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum hemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum hemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group). Hospitals in the control group provided usual care. The primary outcome was a composite of severe postpartum hemorrhage (blood loss, ≥1000 ml), laparotomy for bleeding, or maternal death from bleeding. Key secondary implementation outcomes were the detection of postpartum hemorrhage and adherence to the treatment bundle.RESULTS: A total of 80 secondary-level hospitals across Kenya, Nigeria, South Africa, and Tanzania, in which 210,132 patients underwent vaginal delivery, were randomly assigned to the intervention group or the usual-care group. Among hospitals and patients with data, a primary-outcome event occurred in 1.6% of the patients in the intervention group, as compared with 4.3% of those in the usual-care group (risk ratio, 0.40; 95% confidence interval [CI], 0.32 to 0.50; PCONCLUSIONS: Early detection of postpartum hemorrhage and use of bundled treatment led to a lower risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding, than usual care among patients having vaginal delivery. (Funded by the Bill and Melinda Gates Foundation; E-MOTIVE ClinicalTrials.gov number, NCT04341662.
