[Show abstract][Hide abstract] ABSTRACT: In Sub-Saharan Africa over one million newborns die annually. We developed a sustainable and scalable home-based counselling intervention for delivery by community volunteers in rural southern Tanzania to improve newborn care practices and survival. Here we report the effect on newborn care practices one year after full implementation.
[Show abstract][Hide abstract] ABSTRACT: Each year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings.
BMC Pregnancy and Childbirth 07/2014; 14(1):243. · 2.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Bacterial infections are a leading cause of the 2·9 million annual neonatal deaths. Treatment is usually based on clinical diagnosis of possible severe bacterial infection (pSBI). To guide programme planning, we have undertaken the first estimates of neonatal pSBI, by sex and by region, for sub-Saharan Africa, south Asia, and Latin America.
We included data for pSBI incidence in neonates of 32 weeks' gestation or more (or birthweight ≥1500 g) with livebirth denominator data, undertaking a systematic review and forming an investigator group to obtain unpublished data. We calculated pooled risk estimates for neonatal pSBI and case fatality risk, by sex and by region. We then applied these risk estimates to estimates of livebirths in sub-Saharan Africa, south Asia, and Latin America to estimate cases and associated deaths in 2012.
We included data from 22 studies, for 259 944 neonates and 20 196 pSBI cases, with most of the data (18 of the 22 studies) coming from the investigator group. The pooled estimate of pSBI incidence risk was 7·6% (95% CI 6·1–9·2%) and the case-fatality risk associated with pSBI was 9·8% (7·4–12·2). We estimated that in 2012 there were 6·9 million cases (uncertainty range 5·5 million–8·3 million) of pSBI in neonates needing treatment: 3·5 million (2·8 million–4·2 million) in south Asia, 2·6 million (2·1 million–3·1 million) in sub-Saharan Africa, and 0·8 million (0·7 million–1·0 million) in Latin America. The risk of pSBI was greater in boys (risk ratio 1·12, 95% CI 1·06–1·18) than girls. We estimated that there were 0·68 million (0·46 million–0·92 million) neonatal deaths associated with pSBI in 2012.
The need-to-treat population for pSBI in these three regions is high, with ten cases of pSBI diagnosed for each associated neonatal death. Deaths and disability can be reduced through improved prevention, detection, and case management.
The Wellcome Trust and the Bill & Melinda Gates Foundation through grants to Child Health Epidemiology Reference Group (CHERG) and Save the Children's Saving Newborn Lives programme.
[Show abstract][Hide abstract] ABSTRACT: In this Series paper, we review trends since the 2005 Lancet Series on Neonatal Survival to inform acceleration of progress for newborn health post-2015. On the basis of multicountry analyses and multi-stakeholder consultations, we propose national targets for 2035 of no more than 10 stillbirths per 1000 total births, and no more than 10 neonatal deaths per 1000 livebirths, compatible with the under-5 mortality targets of no more than 20 per 1000 livebirths. We also give targets for 2030. Reduction of neonatal mortality has been slower than that for maternal and child (1–59 months) mortality, slowest in the highest burden countries, especially in Africa, and reduction is even slower for stillbirth rates. Birth is the time of highest risk, when more than 40% of maternal deaths (total about 290 000) and stillbirths or neonatal deaths (5·5 million) occur every year. These deaths happen rapidly, needing a rapid response by health-care workers. The 2·9 million annual neonatal deaths worldwide are attributable to three main causes: infections (0·6 million), intrapartum conditions (0·7 million), and preterm birth complications (1·0 million). Boys have a higher biological risk of neonatal death, but girls often have a higher social risk. Small size at birth—due to preterm birth or small-for-gestational-age (SGA), or both—is the biggest risk factor for more than 80% of neonatal deaths and increases risk of post-neonatal mortality, growth failure, and adult-onset non-communicable diseases. South Asia has the highest SGA rates and sub-Saharan Africa has the highest preterm birth rates. Babies who are term SGA low birthweight (10·4 million in these regions) are at risk of stunting and adult-onset metabolic conditions. 15 million preterm births, especially of those younger than 32 weeks' gestation, are at the highest risk of neonatal death, with ongoing post-neonatal mortality risk, and important risk of long-term neurodevelopmental impairment, stunting, and non-communicable conditions. 4 million neonates annually have other life-threatening or disabling conditions including intrapartum-related brain injury, severe bacterial infections, or pathological jaundice. Half of the world's newborn babies do not get a birth certificate, and most neonatal deaths and almost all stillbirths have no death certificate. To count deaths is crucial to change them. Failure to improve birth outcomes by 2035 will result in an estimated 116 million deaths, 99 million survivors with disability or lost development potential, and millions of adults at increased risk of non-communicable diseases after low birthweight. In the post-2015 era, improvements in child survival, development, and human capital depend on ensuring a healthy start for every newborn baby—the citizens and workforce of the future.
[Show abstract][Hide abstract] ABSTRACT: Nearly a decade ago, The Lancet published the Neonatal Survival Series, with an ambitious call for integration of newborn care across the continuum of reproductive, maternal, newborn, and child health and nutrition (RMNCH). In this first of five papers in the Every Newborn Series, we consider what has changed during this decade, assessing progress on the basis of a systematic policy heuristic including agenda-setting, policy formulation and adoption, leadership and partnership, implementation, and evaluation of effect. Substantial progress has been made in agenda setting and policy formulation for newborn health, as witnessed by the shift from maternal and child health to maternal, newborn, and child health as a standard. However, investment and large-scale implementation have been disappointingly small, especially in view of the size of the burden and potential for rapid change and synergies throughout the RMNCH continuum. Moreover, stillbirths remain invisible on the global health agenda. Hence that progress in improvement of newborn survival and reduction of stillbirths lags behind that of maternal mortality and deaths for children aged 1–59 months is not surprising. Faster progress is possible, but with several requirements: clear communication of the interventions with the greatest effect and how to overcome bottlenecks for scale-up; national leadership, and technical capacity to integrate and implement these interventions; global coordination of partners, especially within countries, in provision of technical assistance and increased funding; increased domestic investment in newborn health, and access to specific commodities and equipment where needed; better data to monitor progress, with local data used for programme improvement; and accountability for results at all levels, including demand from communities and mortality targets in the post-2015 framework. Who will step up during the next decade to ensure decision making in countries leads to implementation of stillbirth and newborn health interventions within RMNCH programmes?
[Show abstract][Hide abstract] ABSTRACT: Background:Neonatal mortality and morbidity are increasingly recognized as important globally, but detailed estimates of neonatal morbidity from conditions and long-term consequences are yet to be published.Methods:We describe the general methods for systematic reviews, meta-analyses, and modeling used in this supplement, highlighting differences from the Global Burden of Disease (GBD2010) inputs and methods. For five conditions (preterm birth, retinopathy of prematurity, intrapartum-related conditions, neonatal infections, and neonatal jaundice), a standard three-step compartmental model was applied to estimate-by region, for 2010-the numbers of (i) affected births by sex, (ii) postneonatal survivors, and (iii) impaired postneonatal survivors. For conditions included in GBD2010 analyses (preterm birth and intrapartum-related conditions), impairment at all ages was estimated, and disability weights were applied to estimate years lived with disability (YLD) and summed with years of life lost (YLL) to calculate disability-adjusted life years (DALYs).Results:GBD2010 estimated neonatal conditions (preterm birth, intrapartum-related, neonatal sepsis, and "other neonatal") to be responsible for 202 million DALYs or 8.1% (7.3-9.0%) of the worldwide total. Mortality contributed 95% of the DALYs, and the estimated 26% reduction in neonatal condition DALYs since 1990 is primarily due to a 44% reduction in neonatal mortality rate due to these conditions, counterbalanced by increased numbers of babies born (17%). Impairment following neonatal conditions remained stable globally and is therefore relatively more important, especially in high- and middle-income countries. Crucial data gaps were identified.Conclusion:These results confirm neonatal conditions as a significant burden, reemphasizing the need to reduce deaths further, to count the linked 2.6 million stillbirths, and to better measure and address their long-term effects.
Pediatric Research 12/2013; 74 Suppl 1:4-16. · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:Intrapartum hypoxic events ("birth asphyxia") may result in stillbirth, neonatal or postneonatal mortality, and impairment. Systematic morbidity estimates for the burden of impairment outcomes are currently limited. Neonatal encephalopathy (NE) following an intrapartum hypoxic event is a strong predictor of long-term impairment.Methods:Linear regression modeling was conducted on data identified through systematic reviews to estimate NE incidence and time trends for 184 countries. Meta-analyses were undertaken to estimate the risk of NE by sex of the newborn, neonatal case fatality rate, and impairment risk. A compartmental model estimated postneonatal survivors of NE, depending on access to care, and then the proportion of survivors with impairment. Separate modeling for the Global Burden of Disease 2010 (GBD2010) study estimated disability adjusted life years (DALYs), years of life with disability (YLDs), and years of life lost (YLLs) attributed to intrapartum-related events.Results:In 2010, 1.15 million babies (uncertainty range: 0.89-1.60 million; 8.5 cases per 1,000 live births) were estimated to have developed NE associated with intrapartum events, with 96% born in low- and middle-income countries, as compared with 1.60 million in 1990 (11.7 cases per 1,000 live births). An estimated 287,000 (181,000-440,000) neonates with NE died in 2010; 233,000 (163,000-342,000) survived with moderate or severe neurodevelopmental impairment; and 181,000 (82,000-319,000) had mild impairment. In GBD2010, intrapartum-related conditions comprised 50.2 million DALYs (2.4% of total) and 6.1 million YLDs.Conclusion:Intrapartum-related conditions are a large global burden, mostly due to high mortality in low-income countries. Universal coverage of obstetric care and neonatal resuscitation would prevent most of these deaths and disabilities. Rates of impairment are highest in middle-income countries where neonatal intensive care was more recently introduced, but quality may be poor. In settings without neonatal intensive care, the impairment rate is low due to high mortality, which is relevant for the scale-up of basic neonatal resuscitation.
Pediatric Research 12/2013; 74 Suppl 1:50-72. · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:Survivors of neonatal infections are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified and yet important for program priority setting. Systematic reviews and meta-analyses were undertaken and applied in a three-step compartmental model to estimate NDI cases after severe neonatal bacterial infection in South Asia, sub-Saharan Africa, and Latin America in neonates of >32 wk gestation (or >1,500 g).Methods:We estimated cases of sepsis, meningitis, pneumonia, or no severe bacterial infection from among estimated cases of possible severe bacterial infection ((pSBI) step 1). We applied respective case fatality risks ((CFRs) step 2) and the NDI risk among survivors (step 3). For neonatal tetanus, incidence estimates were based on the estimated deaths, CFRs, and risk of subsequent NDI.Results:For 2010, we estimated 1.7 million (uncertainty range: 1.1-2.4 million) cases of neonatal sepsis, 200,000 (21,000-350,000) cases of meningitis, 510,000 cases (150,000-930,000) of pneumonia, and 79,000 cases (70,000-930,000) of tetanus in neonates >32 wk gestation (or >1,500 g). Among the survivors, we estimated moderate to severe NDI after neonatal meningitis in 23% (95% confidence interval: 19-26%) of survivors, 18,000 (2,700-35,000) cases, and after neonatal tetanus in 16% (6-27%), 4,700 cases (1,700-8,900).Conclusion:Data are lacking for impairment after neonatal sepsis and pneumonia, especially among those of >32 wk gestation. Improved recognition and treatment of pSBI will reduce neonatal mortality. Lack of follow-up data for survivors of severe bacterial infections, particularly sepsis, was striking. Given the high incidence of sepsis, even minor NDI would be of major public health importance. Prevention of neonatal infection, improved case management, and support for children with NDI are all important strategies, currently receiving limited policy attention.
Pediatric Research 12/2013; 74 Suppl 1:73-85. · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:In 2010, there were an estimated 15 million preterm births worldwide (<37 wk gestation). Survivors are at risk of adverse outcomes, and burden estimation at global and regional levels is critical for priority setting.Methods:Systematic reviews and meta-analyses were undertaken to estimate the risk of long-term neurodevelopmental impairment for surviving preterm babies according to the level of care. A compartmental model was used to estimate the number of impaired postneonatal survivors following preterm birth in 2010. A separate model (DisMod-MR) was used to estimate years lived with disability (YLDs) for the global burden of disease 2010 study. Disability adjusted life years (DALYs) were calculated as the sum of YLDs and years of life lost (YLLs).Results:In 2010, there were an estimated 13 million preterm births who survived beyond the first month. Of these, 345,000 (2.7%, uncertainty range: 269,000-420,000) were estimated to have moderate or severe neurodevelopmental impairment, and a further 567,000 (4.4%, (445,000-732,000)) were estimated to have mild neurodevelopmental impairment. Many more have specific learning or behavioral impairments or reduced physical or mental health. Fewest data are available where the burden is heaviest. Preterm birth was responsible for 77 million DALYs, 3.1% of the global total, of which only 3 million were YLDs.Conclusion:Most preterm births (>90%) survive without neurodevelopmental impairment. Developing effective means of prevention of preterm birth should be a longer term priority, but major burden reduction could be made immediately with improved coverage and quality of care. Improved newborn care would reduce mortality, especially in low-income countries and is likely to reduce impairment in survivors, particularly in middle-income settings.
Pediatric Research 12/2013; 74 Suppl 1:17-34. · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:Rhesus (Rh) disease and extreme hyperbilirubinemia (EHB) result in neonatal mortality and long-term neurodevelopmental impairment, yet there are no estimates of their burden.Methods:Systematic reviews and meta-analyses were undertaken of national prevalence, mortality, and kernicterus due to Rh disease and EHB. We applied a compartmental model to estimate neonatal survivors and impairment cases for 2010.Results:Twenty-four million (18% of 134 million live births ≥32 wk gestational age from 184 countries; uncertainty range: 23-26 million) were at risk for neonatal hyperbilirubinemia-related adverse outcomes. Of these, 480,700 (0.36%) had either Rh disease (373,300; uncertainty range: 271,800-477,500) or developed EHB from other causes (107,400; uncertainty range: 57,000-131,000), with a 24% risk for death (114,100; uncertainty range: 59,700-172,000), 13% for kernicterus (75,400), and 11% for stillbirths. Three-quarters of mortality occurred in sub-Saharan Africa and South Asia. Kernicterus with Rh disease ranged from 38, 28, 28, and 25/100,000 live births for Eastern Europe/Central Asian, sub-Saharan African, South Asian, and Latin American regions, respectively. More than 83% of survivors with kernicterus had one or more impairments.Conclusion:Failure to prevent Rh sensitization and manage neonatal hyperbilirubinemia results in 114,100 avoidable neonatal deaths and many children grow up with disabilities. Proven solutions remain underused, especially in low-income countries.
Pediatric Research 12/2013; 74 Suppl 1:86-100. · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This article is part of a supplement jointly funded by Save the Children's Saving Newborn Lives programme through a grant from The Bill & Melinda Gates Foundation and March of Dimes Foundation and published in collaboration with the Partnership for Maternal, Newborn and Child Health and the World Health Organization (WHO). The original article was published in PDF format in the WHO Report "Born Too Soon: the global action report on preterm birth" (ISBN 978 92 4 150343 30), which involved collaboration from more than 50 organizations. The article has been reformatted for journal publication and has undergone peer review according to Reproductive Health's standard process for supplements and may feature some variations in content when compared to the original report. This co-publication makes the article available to the community in a full-text format.This second paper in the Born Too Soon supplement presents a review of the epidemiology of preterm birth, and its burden globally, including priorities for action to improve the data. Worldwide an estimated 11.1% of all livebirths in 2010 were born preterm (14.9 million babies born before 37 weeks of gestation), with preterm birth rates increasing in most countries with reliable trend data. Direct complications of preterm birth account for one million deaths each year, and preterm birth is a risk factor in over 50% of all neonatal deaths. In addition, preterm birth can result in a range of long-term complications in survivors, with the frequency and severity of adverse outcomes rising with decreasing gestational age and decreasing quality of care. The economic costs of preterm birth are large in terms of immediate neonatal intensive care, ongoing long-term complex health needs, as well as lost economic productivity. Preterm birth is a syndrome with a variety of causes and underlying factors usually divided into spontaneous and provider-initiated preterm births. Consistent recording of all pregnancy outcomes, including stillbirths, and standard application of preterm definitions is important in all settings to advance both the understanding and the monitoring of trends. Context specific innovative solutions to prevent preterm birth and hence reduce preterm birth rates all around the world are urgently needed. Strengthened data systems are required to adequately track trends in preterm birth rates and program effectiveness. These efforts must be coupled with action now to implement improved antenatal, obstetric and newborn care to increase survival and reduce disability amongst those born too soon.
Reproductive Health 11/2013; 10(Suppl 1):S2. · 1.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background Babies with low birthweight (<2500 g) are at increased risk of early mortality. However, low birthweight includes babies born preterm and with fetal growth restriction, and not all these infants have a birthweight less than 2500 g. We estimated the neonatal and infant mortality associated with these two characteristics in low-income and middle-income countries. Methods For this pooled analysis, we searched all available studies and identifi ed 20 cohorts (providing data for 2 015 019 livebirths) from Asia, Africa, and Latin America that recorded data for birthweight, gestational age, and vital statistics through 28 days of life. Study dates ranged from 1982 through to 2010. We calculated relative risks (RR) and risk diff erences (RD) for mortality associated with preterm birth (<32 weeks, 32 weeks to <34 weeks, 34 weeks to <37 weeks), small-for-gestational-age (SGA; babies with birthweight in the lowest third percentile and between the third and tenth percentile of a US reference population), and preterm and SGA combinations. Findings Pooled overall RRs for preterm were 6·82 (95% CI 3·56–13·07) for neonatal mortality and 2·50 (1·48–4·22) for post-neonatal mortality. Pooled RRs for babies who were SGA (with birthweight in the lowest tenth percentile of the reference population) were 1·83 (95% CI 1·34–2·50) for neonatal mortality and 1·90 (1·32–2·73) for post-neonatal mortality. The neonatal mortality risk of babies who were both preterm and SGA was higher than that of babies with either characteristic alone (15·42; 9·11–26·12). Interpretation Many babies in low-income and middle-income countries are SGA. Preterm birth aff ects a smaller number of neonates than does SGA, but is associated with a higher mortality risk. The mortality risks associated with both characteristics extend beyond the neonatal period. Diff erentiation of the burden and risk of babies born preterm and SGA rather than with low birthweight could guide prevention and management strategies to speed progress towards Millennium Development Goal 4—the reduction of child mortality.
The Lancet 06/2013; 382:417–25. · 39.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Powders containing iron and other micronutrients are recommended as a strategy to prevent nutritional anaemia and other micronutrient deficiencies in children. We assessed the effects of provision of two micronutrient powder formulations, with or without zinc, to children in Pakistan. METHODS: We did a cluster randomised trial in urban and rural sites in Sindh, Pakistan. A baseline survey identified 256 clusters, which were randomly assigned (within urban and rural strata, by computer-generated random numbers) to one of three groups: non-supplemented control (group A), micronutrient powder without zinc (group B), or micronutrient powder with 10 mg zinc (group C). Children in the clusters aged 6 months were eligible for inclusion in the study. Powders were to be given daily between 6 and 18 months of age; follow-up was to age 2 years. Micronutrient powder sachets for groups B and C were identical except for colour; investigators and field and supervisory staff were masked to composition of the micronutrient powders until trial completion. Parents knew whether their child was receiving supplementation, but did not know whether the powder contained zinc. Primary outcomes were growth, episodes of diarrhoea, acute lower respiratory tract infection, fever, and incidence of admission to hospital. This trial is registered with ClinicalTrials.gov, number NCT00705445. RESULTS: The trial was done between Nov 1, 2008, and Dec 31, 2011. 947 children were enrolled in group A clusters, 910 in group B clusters, and 889 in group C clusters. Micronutrient powder administration was associated with lower risk of iron-deficiency anaemia at 18 months compared with the control group (odds ratio [OR] for micronutrient powder without zinc=0·20, 95% CI 0·11-0·36; OR for micronutrient powder with zinc=0·25, 95% CI 0·14-0·44). Compared with the control group, children in the group receiving micronutrient powder without zinc gained an extra 0·31 cm (95% CI 0·03-0·59) between 6 and 18 months of age and children receiving micronutrient powder with zinc an extra 0·56 cm (0·29-0·84). We recorded strong evidence of an increased proportion of days with diarrhoea (p=0·001) and increased incidence of bloody diarrhoea (p=0·003) between 6 and 18 months in the two micronutrient powder groups, and reported chest indrawing (p=0·03). Incidence of febrile episodes or admission to hospital for diarrhoea, respiratory problems, or febrile episodes did not differ between the three groups. INTERPRETATION: Use of micronutrient powders reduces iron-deficiency anaemia in young children. However, the excess burden of diarrhoea and respiratory morbidities associated with micronutrient powder use and the very small effect on growth recorded suggest that a careful assessment of risks and benefits must be done in populations with malnourished children and high diarrhoea burdens. FUNDING: Bill & Melinda Gates Foundation.
[Show abstract][Hide abstract] ABSTRACT: The prospect of eliminating onchocerciasis from Africa by mass treatment with ivermectin has been rejuvenated following recent successes in foci in Mali, Nigeria and Senegal. Elimination prospects depend strongly on local transmission conditions and therefore on pre-control infection levels. Pre-control infection levels in Africa have been mapped largely by means of nodule palpation of adult males, a relatively crude method for detecting infection. We investigated how informative pre-control nodule prevalence data are for estimating the pre-control prevalence of microfilariae (mf) in the skin and discuss implications for assessing elimination prospects.
We analyzed published data on pre-control nodule prevalence in males aged ≥20 years and mf prevalence in the population aged ≥5 years from 148 African villages. A meta-analysis was performed by means of Bayesian hierarchical multivariate logistic regression, accounting for measurement error in mf and nodule prevalence, bioclimatic zones, and other geographical variation. There was a strong positive correlation between nodule prevalence in adult males and mf prevalence in the general population. In the forest-savanna mosaic area, the pattern in nodule and mf prevalence differed significantly from that in the savanna or forest areas.
We provide a tool to convert pre-control nodule prevalence in adult males to mf prevalence in the general population, allowing historical data to be interpreted in terms of elimination prospects and disease burden of onchocerciasis. Furthermore, we identified significant geographical variation in mf prevalence and nodule prevalence patterns warranting further investigation of geographical differences in transmission patterns of onchocerciasis.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: To determine the effectiveness of birth plans in increasing use of skilled care at delivery and in the postnatal period among antenatal care (ANC) attendees in a rural district with low occupancy of health units for delivery but high antenatal care uptake in northern Tanzania. METHODS: Cluster randomised trial in Ngorongoro district, Arusha region, involving 16 health units (8 per arm). Nine hundred and five pregnant women at 24 weeks of gestation and above (404 in the intervention arm) were recruited and followed up to at least 1 month postpartum. RESULTS: Skilled delivery care uptake was 16.8% higher in the intervention units than in the control [95% CI 2.6-31.0; P = 0.02]. Postnatal care utilisation in the first month of delivery was higher (difference in proportions: 30.0% [95% CI 1.3-47.7; P < 0.01]) and also initiated earlier (mean duration 6.6 ± 1.7 days vs. 20.9 ± 4.4 days, P < 0.01) in the intervention than in the control arm. Women's and providers' reports of care satisfaction (received or provided) did not differ greatly between the two arms of the study (difference in proportion: 12.1% [95% CI -6.3-30.5] P = 0.17 and 6.9% [95% CI -3.2-17.1] P = 0.15, respectively). CONCLUSION: Implementation of birth plans during ANC can increase the uptake of skilled delivery and post delivery care in the study district without negatively affecting women's and providers' satisfaction with available ANC services. Birth plans should be considered along with the range of other recommended interventions as a strategy to improve the uptake of maternal health services.
Tropical Medicine & International Health 02/2013; · 2.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the effectiveness of two types of WHO recommended facility based audits (criterion-based clinical audits, CBCA, and patient-centred case reviews, PCCR) to improve the responsiveness of West African district hospitals to obstetric emergencies, we conducted a cluster-randomised trial in 36 district and regional hospitals in Benin, Burkina Faso and Niger. The level of intervention and analysis was the hospital. As outcomes we chose (1) a quality of care score based on the compliance with WHO/IMPAC guidelines for the management of obstetric emergencies, (2) the delay between decision for and start of emergency caesarean sections, and (3) perinatal mortality due to asphyxia. The sample size of 12 hospitals per arm, contributing each 60 near-miss cases during an observation period of two years, was determined to detect an increase of the mean quality score from 30 to 40% with 90% power, or a decrease of the in-hospital asphyxia mortality rate from 5% to 3%.
Eligible were first line referral hospitals run by or under the supervision of the Mininstry of Health, providing emergency caesarean sections 24/7, performing a minimum of 50 caesarean sections and 1000 deliveries per year and agreeing to participate in the study. Hospitals were excluded if CBCA or case reviews were already in place, or if security concerns compromised their accessibility for the research team.
After identifying 15 suitable hospitals in Benin, 15 in Burkina Faso and 6 in Niger, all hospitals received the baseline intervention consisting of training obstetric staff in the management of emergencies, and in essential clinical documentation including partogram use. During 6 months, baseline data were collected in all hospitals during monthly visits by research teams. After the baseline study, hospitals were randomised into the CBCA, RCCP and control arms. We used stratified and restricted randomsation to minimise baseline differences between arms, with country, type of hospital (district/regional) and participation in the anthropological case study (yes/no) as stratification, the three trial outcomes as restriction variables. Data were collected on a monthly basis. Analysis took the clustered nature of the data into account.
Qualitative and quantitative social science research and economic evaluation complemented the trial.
[Show abstract][Hide abstract] ABSTRACT: Maternal and perinatal mortality ratios stagnate at a high level in West Africa. Improving Emergency Obstetric and Newborn Care (EmONC) is thought to decrease them. Clinical audits aim at improving this care but robust evidence for their effectiveness is lacking.
The objectives of the epidemiological component of this study are to test the effectiveness of Criterion Based Clinical Audit (CBCA) and Patient Centred Case reviews (PCRC) in the context of Benin, Burkina Faso and Niger.
We conducted during 30 months a randomized controlled trial in 36 hospitals with 12 hospitals in each arm (CBCA, PCRC and Control). The primary outcome variables are (1) a quality of care score based on compliance with WHO clinical guidelines on the management of obstetric emergencies, (2) the delay between decision for and start of emergency caesarean sections, and (3) perinatal mortality due to asphyxia.
The preliminary results available showed no significant change in perinatal mortality due to asphyxia (p=0.36 and p= 0.71 respectively in the ACBC arm and RCCP arm). The median caesarean section delay decreased significantly from by 16 minutes in the ACBC arm (p=0.042), but did not significantly change in the RCCP arm (p=0.71). The analysis of the audits’ effect on the quality of care score is pending.
At this step of the data analysis, the results on the effectiveness of the two types of audits are somewhat mixed. However, the implementation level of audits was variable across all intervention hospitals and overall quite low. In further analyses we shall therefore investigate whether audits have been more effective in hospitals that have conducted a relatively high number auf audits.
[Show abstract][Hide abstract] ABSTRACT: Reducing neonatal mortality remains a challenge with an estimated 3.0 million neonatal deaths in 2011, three-quarters of these in sub-Saharan Africa and Southern Asia. The leading causes of neonatal death globally are complications of preterm birth, intrapartum-related causes and infections. While post-neonatal, under-5 deaths fell by 47% between 1990 and 2011, neonatal deaths only fell by 32% and they now account for 43% of all under-5 child deaths. This article reviews the progress in reducing neonatal deaths in high-burden countries and presents an overview of known effective interventions to reduce neonatal mortality and the challenges faced in implementing these in high-burden settings. Effective action is possible to reduce neonatal mortality, but innovative approaches to implementation will be required if these preventable deaths are to be avoided.
Tropical Medicine & International Health 01/2013; · 2.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Between 1999 and 2007, the Ministry of Health and Population in Egypt scaled up the Integrated Management of Childhood Illness (IMCI) strategy in 84% of public health facilities.
This retrospective analysis, using routinely available data from vital registration, aimed to assess the impact of IMCI implementation between 2000 and 2006 on child mortality. It also presents a systematic and comprehensive approach to scaling-up IMCI interventions and information on quality of child health services, using programme data from supervision and surveys.
We compared annual levels of under-five mortality in districts before and after they had started implementing IMCI. Mortality data were obtained from the National Bureau for Statistics for 254 districts for the years 2000-2006, 41 districts of which were excluded. For assessment of programme activities, we used information from the central IMCI data base, annual progress reports, follow-up after training visits and four studies on quality of child care in public health facilities.
Across 213 districts retained in the analysis, the estimated average annual rate of decline in under-five mortality was 3.3% before compared with 6.3% after IMCI implementation (p=0.0001). In 127 districts which started implementing IMCI between 2002 and 2005, the average annual rate of decline of under-five mortality was 2.6% (95% CI 1.1% to 4.1%) before compared with 7.3% (95% CI 5.8% to 8.7%) after IMCI implementation (p<0.0001). IMCI implementation also led to marked improvements in the quality of child health services.
IMCI implementation was associated with a doubling in the annual rate of under-five mortality reduction (3.3% vs 6.3%). This mortality impact is plausible, since substantial improvements occurred in quality of care provided to sick children in health facilities implementing IMCI.