51 research outputs found
Pathways of the determinants of unfavourable birth outcomes in Kenya
Full text linkThis paper explores the pathways of the determinants of unfavourable birth outcomes, such as premature birth, the size of the baby at birth, and Caesarean section deliveries in Kenya, using graphical loglinear chain models. The results show that a number of factors which do not have direct associations with unfavourable birth outcomes contribute to these outcomes indirectly through intermediate factors. Marital status, the desirability of a pregnancy, the use of family planning, and access to health facilities have no direct associations with poor birth outcomes, such as premature births and the small size of the baby at birth, but are linked to these outcomes through antenatal care. Antenatal care is identified as a central link between various socio- demographic or reproductive factors and birth outcomes
Using Clinical Cascades to Measure Health Facilities’ Obstetric Emergency Readiness: Testing the Cascades Model Using Cross-Sectional Facility Data in East Africa
No full textThis dataset was used in a facility-based cross-sectional analysis in which we (1) measured facility readiness to manage common obstetric emergencies using the clinical cascades and signal function tracers; (2) compared these readiness estimates by facility characteristics; and (3) measured cascading drop-offs in resources.
Data were collected in 2016 from 23 hospitals (10 designated comprehensive emergency obstetric care (CEmOC) facilities) in Migori County, western Kenya, and Busoga Region, eastern Uganda, in the Preterm Birth Initiative (PTBi) study in East Africa. Research assistants used standardised forms to visually identify emergency resources during the on-site
physical inventory of resources. They captured data about facility characteristics, obstetric drugs, consumable supplies,
durable goods and the presence of emergency guidelines and protocols. Researchers recorded both the presence/absence of the item and its location (ie, unit). In this analysis, we used a resource’s presence or absence at the facility level to estimate facility-level readiness regardless of the unit in which the items were located.
Baseline data were used to estimate a facility’s readiness to manage common obstetric emergencies using WHO’s Service Readiness Index (SRI)/signal function tracers and the clinical cascade model. We compared emergency readiness using the proportion of facilities with tracers (signal functions) and the proportion with resources for identifying and treating the emergency (cascade stages 1 and 2)
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Effect of a quality improvement intervention for management of preterm births on outcomes of all births in Kenya and Uganda: A secondary analysis from a facility-based cluster randomized trial
Full text linkBackgroundA large proportion of early neonatal deaths occur at the time or on the first day of birth. The Preterm Birth Initiative East Africa (PTBi EA) set out to decrease mortality among preterm births through improving quality of facility-based intrapartum care. The PTBi EA cluster randomized trial's primary analysis showed the package reduced intrapartum stillbirth and neonatal death among preterm infants. This secondary analysis examines the impact of the PTBi intervention package on stillbirth and predischarge newborn deaths combined, among all births in 20 participating facilities in Kenya and Uganda.MethodsEligible facilities were pair-matched and randomly assigned (1:1) into either the intervention or the control group. All facilities received support for data strengthening and a modified World Health Organization (WHO) Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. We abstracted data from maternity registers.ResultsOf the total 29 442 births that were included, Kenya had 8468 and 6465 births and Uganda had 8719 and 5790 births, in the control and intervention arms, respectively. There were 935 stillbirths and predischarge newborn deaths in the control arm and 439 in the intervention arm. The adjusted odds ratio (aOR) for the effect of the intervention on the combined outcome, among all births, was 0.96 (95% confidence interval (CI) = 0.69-1.32), which was different by country: Kenya - 1.12 (95% CI = 0.72-1.73); Uganda - 0.65 (95% CI = 0.44-0.98); Pinteraction = 0.025. These trends were similar after excluding the PTBi primary cohort.ConclusionsThe intervention package improved survival among all births in Uganda but not in Kenya. These results suggest the importance of context and facility differences that were observed between the two countries.RegistrationThis trial is registered with ClinicalTrials.gov, NCT03112018
Implementing an intrapartum package of interventions to improve quality of care to reduce the burden of preterm birth in Kenya and Uganda
No full textBACKGROUND: Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication. METHODS: Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative. RESULTS: In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake. CONCLUSION: Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up. The trial is registered at ClinicalTrials.gov NCT03112018 , registered December 2016, posted April 2017
East Africa preterm birth initiative birth register data (March 2016 - October 2016)
No full textAbstract
Objective: Preterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility, routine data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the validity of the PTBi-EA eligibility criteria.
Methods: We conducted a retrospective analysis of maternity register data from March – September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3rd and 97th birth weight percentiles for GA of the INTERGROWTH-21st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA <37 weeks, 2) recorded GA <37 weeks, excluding implausible GAs, 3) birth weight <2500g, and 4) PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks.
Results: In both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%.
Conclusions: Maternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks adjusted for these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability.Funding provided by: Bill and Melinda Gates FoundationCrossref Funder Registry ID: http://dx.doi.org/10.13039/100000865Award Number
Working with what you have: How the East Africa Preterm Birth Initiative used gestational age data from facility maternity registers.
Full text linkObjectivePreterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the strength of the PTBi-EA eligibility criteria.MethodsWe conducted a retrospective analysis of maternity register data from March-September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3rd and 97th birth weight percentiles for GA of the INTERGROWTH-21st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA ResultsIn both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%.ConclusionsMaternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks accommodated these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability
Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect.
Full text linkBACKGROUND: Of 136 million babies born annually, around 10 million require assistance to breathe. Each year 814,000 neonatal deaths result from intrapartum-related events in term babies (previously "birth asphyxia") and 1.03 million from complications of prematurity. No systematic assessment of mortality reduction from tactile stimulation or resuscitation has been published. OBJECTIVE: To estimate the mortality effect of immediate newborn assessment and stimulation, and basic resuscitation on neonatal deaths due to term intrapartum-related events or preterm birth, for facility and home births. METHODS: We conducted systematic reviews for studies reporting relevant mortality or morbidity outcomes. Evidence was assessed using GRADE criteria adapted to provide a systematic approach to mortality effect estimates for the Lives Saved Tool (LiST). Meta-analysis was performed if appropriate. For interventions with low quality evidence but strong recommendation for implementation, a Delphi panel was convened to estimate effect size. RESULTS: We identified 24 studies of neonatal resuscitation reporting mortality outcomes (20 observational, 2 quasi-experimental, 2 cluster randomized controlled trials), but none of immediate newborn assessment and stimulation alone. A meta-analysis of three facility-based studies examined the effect of resuscitation training on intrapartum-related neonatal deaths (RR= 0.70, 95%CI 0.59-0.84); this estimate was used for the effect of facility-based basic neonatal resuscitation (additional to stimulation). The evidence for preterm mortality effect was low quality and thus expert opinion was sought. In community-based studies, resuscitation training was part of packages with multiple concurrent interventions, and/or studies did not distinguish term intrapartum-related from preterm deaths, hence no meta-analysis was conducted. Our Delphi panel of 18 experts estimated that immediate newborn assessment and stimulation would reduce both intrapartum-related and preterm deaths by 10%, facility-based resuscitation would prevent a further 10% of preterm deaths, and community-based resuscitation would prevent further 20% of intrapartum-related and 5% of preterm deaths. CONCLUSION: Neonatal resuscitation training in facilities reduces term intrapartum-related deaths by 30%. Yet, coverage of this intervention remains low in countries where most neonatal deaths occur and is a missed opportunity to save lives. Expert opinion supports smaller effects of neonatal resuscitation on preterm mortality in facilities and of basic resuscitation and newborn assessment and stimulation at community level. Further evaluation is required for impact, cost and implementation strategies in various contexts. FUNDING: This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to the Saving Newborn Lives program of Save the Children, through Save the Children US
Pregnancy outcomes in facility deliveries in Kenya and Uganda: A large cross-sectional analysis of maternity registers illuminating opportunities for mortality prevention.
Full text linkINTRODUCTION:As facility-based deliveries increase globally, maternity registers offer a promising way of documenting pregnancy outcomes and understanding opportunities for perinatal mortality prevention. This study aims to contribute to global quality improvement efforts by characterizing facility-based pregnancy outcomes in Kenya and Uganda including maternal, neonatal, and fetal outcomes at the time of delivery and neonatal discharge outcomes using strengthened maternity registers. METHODS:Cross sectional data were collected from strengthened maternity registers at 23 facilities over 18 months. Data strengthening efforts included provision of supplies, training on standard indicator definitions, and monthly feedback on completeness. Pregnancy outcomes were classified as live births, early stillbirths, late stillbirths, or spontaneous abortions according to birth weight or gestational age. Discharge outcomes were assessed for all live births. Outcomes were assessed by country and by infant, maternal, and facility characteristics. Maternal mortality was also examined. RESULTS:Among 50,981 deliveries, 91.3% were live born and, of those, 1.6% died before discharge. An additional 0.5% of deliveries were early stillbirths, 3.6% late stillbirths, and 4.7% spontaneous abortions. There were 64 documented maternal deaths (0.1%). Preterm and low birthweight infants represented a disproportionate number of stillbirths and pre-discharge deaths, yet very few were born at ≤1500g or <28w. More pre-discharge deaths and stillbirths occurred after maternal referral and with cesarean section. Half of maternal deaths occurred in women who had undergone cesarean section. CONCLUSION:Maternity registers are a valuable data source for understanding pregnancy outcomes including those mothers and infants at highest risk of perinatal mortality. Strengthened register data in Kenya and Uganda highlight the need for renewed focus on improving care of preterm and low birthweight infants and expanding access to emergency obstetric care. Registers also permit enumeration of pregnancy loss <28 weeks. Documenting these earlier losses is an important step towards further mortality reduction for the most vulnerable infants
Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda
No full textINTRODUCTION: Preterm birth is a leading cause of under-5 mortality, with the greatest burden in lower-resource settings. Strategies to improve preterm survival have been tested, but strategy costs are less understood. We estimate costs of a highly effective Preterm Birth Initiative (PTBi) intrapartum intervention package (data strengthening, WHO Safe Childbirth Checklist, simulation and team training, quality improvement collaboratives) and active control (data strengthening, Safe Childbirth Checklist). METHODS: In our analysis, we estimated costs incremental to current cost of intrapartum care (in 2020 1.11M in Kenya (0.74M in Uganda (0.86M in Kenya (0.28M in Uganda (16.36 in Kenya and $3.47 in Uganda. In each scenario and country, personnel made up at least 72% of total PTBi package costs. Total Scenario 2 costs in Uganda were consistently one-third those of Kenya, largely driven by differences in facility delivery volume and personnel salaries. CONCLUSIONS: If taken up and implemented, the PTBi package has the potential to save preterm lives, with potential steady-state (maintenance) costs that would be roughly 5-15% of total per-birth healthcare costs in Uganda and Kenya
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Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-randomised facility-based trial
No full textBackgroundAlthough gains in newborn survival have been achieved in many low-income and middle-income countries, reductions in stillbirth and neonatal mortality have been slow. Prematurity complications are a major driver of stillbirth and neonatal mortality. We aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised.MethodsThis unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. The study assessed outcomes of low-birthweight and preterm babies. Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention group or the control group. All facilities received maternity register data strengthening and a modified WHO Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. Liveborn or fresh stillborn babies who weighed between 1000 g and 2500 g, or less than 3000 g with a recorded gestational age of less than 37 weeks, were included in the analysis. We abstracted data from maternity registers for maternal and birth outcomes. Follow-up was done by phone or in person to identify the status of the infant at 28 days. The primary outcome was fresh stillbirth and 28-day neonatal mortality. This trial is registered with ClinicalTrials.gov, NCT03112018.FindingsBetween Oct 1, 2016, and April 30, 2019, 20 facilities were randomly assigned to either the intervention group (n=10) or the control group (n=10). Among 5343 eligible babies in these facilities, we assessed outcomes of 2938 newborn and fresh stillborn babies (1447 in the intervention and 1491 in the control group). 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group at 28 days (odds ratio 0·66, 95% CI 0·54-0·81). No harm or adverse effects were found.InterpretationFresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening.FundingBill & Melinda Gates Foundation
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