Facility-based active management of the third stage of labour: assessment of quality in six countries in sub-Saharan Africa.

OBJECTIVE: To assess the quality of facility-based active management of the third stage of labour in Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and the United Republic of Tanzania. METHODS: Between 2009 and 2012, using a cross-sectional design, 2317 women in 390 health facilities were directly observed during the third stage of labour. Observers recorded the use of uterotonic medicines, controlled cord traction and uterine massage. Facility infrastructure and supplies needed for active management were audited and relevant guidelines reviewed. FINDINGS: Most (94%; 2173) of the women observed were given oxytocin (2043) or another uterotonic (130). The frequencies of controlled cord traction and uterine massage and the timing of uterotonic administration showed considerable between-country variation. Of the women given a uterotonic, 1640 (76%) received it within three minutes of the birth. Uterotonics and related supplies were generally available onsite. Although all of the study countries had national policies and/or guidelines that supported the active management of the third stage of labour, the presence of guidelines in facilities varied across countries and only 377 (36%) of 1037 investigated providers had received relevant training in the previous three years. CONCLUSION: In the study countries, quality and coverage of the active management of the third stage of labour were high. However, to improve active management, there needs to be more research on optimizing the timing of uterotonic administration. Training on the use of new clinical guidelines and implementation research on the best methods to update such training are also needed.

Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa.

BACKGROUND: Poor quality of care at health facilities is a barrier to pregnant women and their families accessing skilled care. Increasing evidence from low resource countries suggests care women receive during labor and childbirth is sometimes rude, disrespectful, abusive, and not responsive to their needs. However, little is known about how frequently women experience these behaviors. This study is one of the first to report prevalence of respectful maternity care and disrespectful and abusive behavior at facilities in multiple low resource countries. METHODS: Structured, standardized clinical observation checklists were used to directly observe quality of care at facilities in five countries: Ethiopia, Kenya, Madagascar, Rwanda, and the United Republic of Tanzania. Respectful care was represented by 10 items describing actions the provider should take to ensure the client was informed and able to make choices about her care, and that her dignity and privacy were respected. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Clinical observers' open-ended comments were also analyzed to identify examples of disrespect and abuse. RESULTS: A total of 2164 labor and delivery observations were conducted at hospitals and health centers. Encouragingly, women overall were treated with dignity and in a supportive manner by providers, but many women experienced poor interactions with providers and were not well-informed about their care. Both physical and verbal abuse of women were observed during the study. The most frequently mentioned form of disrespect and abuse in the open-ended comments was abandonment and neglect. CONCLUSIONS: Efforts to increase use of facility-based maternity care in low income countries are unlikely to achieve desired gains if there is no improvement in quality of care provided, especially elements of respectful care. This analysis identified insufficient communication and information sharing by providers as well as delays in care and abandonment of laboring women as deficiencies in respectful care. Failure to adopt a patient-centered approach and a lack of health system resources are contributing structural factors. Further research is needed to understand these barriers and develop effective interventions to promote respectful care in this context.

The burden of injuries in Zambia: A call to research and action.

Injuries are predicted to become a greater cause of mortality than communicable diseases in sub-Saharan Africa by 2030, signaling a public health dilemma for governments and citizens in each country. This article uses epidemiological estimates of injuries in Zambia, considers the socio-economic impact of injuries, examines current policies for prevention, and provides a rapid situation analysis to help develop an action and research agenda for injury prevention in the country. It calls for better epidemiological data, capacity building for human resources, and adoption of evidence-based targets and interventions. For Zambia to reduce its burden of injuries, funding for research and training should be integral to the future of its national health agenda.

Estimating the Burden of Disability From Road Traffic Injuries in 5 Low- and Middle-Income Countries: Protocol for a Prospective Observational Study.

BACKGROUND: Road traffic injuries (RTIs) are a leading cause of death and unintentional injuries globally. They claim 1.35 million lives and produce up to 50 million injuries each year, causing a major drain on health systems. Despite this high burden, there is a lack of robust data on the long-term consequences of RTIs, specifically the level of disability experienced by many survivors and its impact on their everyday lives. OBJECTIVE: This study aims to characterize RTIs, disability level, and related consequences affecting adult road traffic crash survivors in 5 low- and middle-income countries (LMICs). In addition, this study estimates the role of demographic and crash- and treatment-related factors in predicting adverse outcomes and disability as well as examining the disability level among patients with RTIs, likelihood of return to normal life, and the environmental factors that may influence these outcomes after discharge from the hospital. METHODS: This prospective observational study was conducted at selected hospitals in Bangladesh, Cambodia, Ethiopia, Mexico, and Zambia. The study sample included all adult patients with RTIs admitted to the hospital for at least 24 hours. Consecutive sampling was performed until the minimum required sample size of 400 was reached for each participating country. Data were collected from patients or their caregivers using a hospital-based surveillance tool administered at the participating sites as well as a telephone-based follow-up instrument administered 1, 3, and 6 months after discharge. Descriptive analysis and multivariate models will be used to estimate the contribution of a range of factors in predicting adverse outcomes, disability, and return to normal life. RESULTS: Enrollment began in June 2021 and was completed in April 2022. Follow-up data collection ended in September 2022. Data analysis is currently underway, with results expected for publication in mid-2023. Expected results include estimates of disability among patients with RTIs as well as identifying the predictors of adverse outcomes, disability, and the likelihood of return to normal life. CONCLUSIONS: Research findings will help better understand the long-term burden of disability from RTIs in the 5 LMICs and the challenges facing survivors of road traffic crashes. They will be used to inform interventions aimed at improving the health care, social, physical, and policy conditions in LMICs that can facilitate recovery and rehabilitation for patients with RTIs, reduce the burden of disability, and enhance their participation in society. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40985.

Global road safety 2010-18: An analysis of Global Status Reports.

BACKGROUND: Road traffic injuries (RTIs) pose a significant health burden with 1.35 million individuals dying on the world's roads annually. Nearly a decade ago, based on agreed road safety indicators, global commitments were encouraged to dramatically reduce this burden as part of the United Nation's Decade of Action for Road Safety 2011-2020. METHODS: The analysis was based on global level data from three Global Status Reports on Road Safety published by the World Health Organization in 2013, 2015, and 2018. A total of 161 countries that consistently reported statistics for all three reports were included in the analysis. Descriptive analyses, t-test, Wilcoxon rank-sum test, and Spearman's rank correlation were performed to evaluate past and current trends in road traffic deaths and countries' progress in achieving key road safety indicators. RESULTS: We found no significant decline in global road traffic death rates from 2010 to 2016 and in fact, death rates increased in low-income countries (LICs) and the African Region. Death rates were highly dependent on income level of the country, with deaths higher in low- and middle-income countries (LMICs) when compared to high-income countries (HICs). We found that the strength of enforcement of speed laws and child restraint laws increased from 2011 to 2017. However, we did not find a correlation between enforcement of the five key prevention policies (speeding, drink-driving, seatbelts, helmets, and child restraints) and death rate. In terms of advancement in achieving key road safety indicators, there was slow progress in adopting most of the recommended policies and practices based on the five pillars (road safety management, safer roads and mobility, safer vehicles, safer road users, and post-crash response). CONCLUSION: Despite global efforts during the past decade, road traffic deaths remain disproportionally high in LMICs and African countries as shown by global reports, and progress in achieving global road safety indicators is slow. Countries need to greatly accelerate the implementation of interventions proven to reduce RTIs in order to meet the goals of the second Decade of Action for Road Safety.

Community-based validation of assessment of newborn illnesses by trained community health workers in Sylhet district of Bangladesh.

OBJECTIVES: To validate trained community health workers' recognition of signs and symptoms of newborn illnesses and classification of illnesses using a clinical algorithm during routine home visits in rural Bangladesh. METHODS: Between August 2005 and May 2006, 288 newborns were assessed independently by a community health worker and a study physician. Based on a 20-sign algorithm, sick neonates were classified as having very severe disease, possible very severe disease or no disease. The physician's assessment was considered as the gold standard. RESULTS: Community health workers correctly classified very severe disease in newborns with a sensitivity of 91%, specificity of 95% and kappa value of 0.85 (P < 0.001). Community health workers' recognition showed a sensitivity of more than 60% and a specificity of 97-100% for almost all signs and symptoms. CONCLUSION: Community health workers with minimal training can use a diagnostic algorithm to identify severely ill newborns with high validity.

Cross-sectional observational assessment of quality of newborn care immediately after birth in health facilities across six sub-Saharan African countries.

OBJECTIVE: To present information on the quality of newborn care services and health facility readiness to provide newborn care in 6 African countries, and to advocate for the improvement of providers' essential newborn care knowledge and skills. DESIGN: Cross-sectional observational health facility assessment. SETTING: Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and Tanzania. PARTICIPANTS: Health workers in 643 facilities. 1016 health workers were interviewed, and 2377 babies were observed in the facilities surveyed. MAIN OUTCOME MEASURES: Indicators of quality of newborn care included (1) provision of immediate essential newborn care: thermal care, hygienic cord care, and early and exclusive initiation of breast feeding; (2) actual and simulated resuscitation of asphyxiated newborn infants; and (3) knowledge of health workers on essential newborn care, including resuscitation. RESULTS: Sterile or clean cord cutting instruments, suction devices, and tables or firm surfaces for resuscitation were commonly available. 80% of newborns were immediately dried after birth and received clean cord care in most of the studied facilities. In all countries assessed, major deficiencies exist for essential newborn care supplies and equipment, as well as for health worker knowledge and performance of key routine newborn care practices, particularly for immediate skin-to-skin contact and breastfeeding initiation. Of newborns who did not cry at birth, 89% either recovered on their own or through active steps taken by the provider through resuscitation with initial stimulation and/or ventilation. 11% of newborns died. Assessment of simulated resuscitation using a NeoNatalie anatomic model showed that less than a third of providers were able to demonstrate ventilation skills correctly. CONCLUSIONS: The findings shared in this paper call attention to the critical need to improve health facility readiness to provide quality newborn care services and to ensure that service providers have the necessary equipment, supplies, knowledge and skills that are critical to save newborn lives.

Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21st standard: analysis of CHERG datasets.

Objectives To estimate small for gestational age birth prevalence and attributable neonatal mortality in low and middle income countries with the INTERGROWTH-21st birth weight standard.Design Secondary analysis of data from the Child Health Epidemiology Reference Group (CHERG), including 14 birth cohorts with gestational age, birth weight, and neonatal follow-up. Small for gestational age was defined as infants weighing less than the 10th centile birth weight for gestational age and sex with the multiethnic, INTERGROWTH-21st birth weight standard. Prevalence of small for gestational age and neonatal mortality risk ratios were calculated and pooled among these datasets at the regional level. With available national level data, prevalence of small for gestational age and population attributable fractions of neonatal mortality attributable to small for gestational age were estimated.Setting CHERG birth cohorts from 14 population based sites in low and middle income countries.Main outcome measures In low and middle income countries in the year 2012, the number and proportion of infants born small for gestational age; number and proportion of neonatal deaths attributable to small for gestational age; the number and proportion of neonatal deaths that could be prevented by reducing the prevalence of small for gestational age to 10%.Results In 2012, an estimated 23.3 million infants (uncertainty range 17.6 to 31.9; 19.3% of live births) were born small for gestational age in low and middle income countries. Among these, 11.2 million (0.8 to 15.8) were term and not low birth weight (≥2500 g), 10.7 million (7.6 to 15.0) were term and low birth weight (<2500 g) and 1.5 million (0.9 to 2.6) were preterm. In low and middle income countries, an estimated 606 500 (495 000 to 773 000) neonatal deaths were attributable to infants born small for gestational age, 21.9% of all neonatal deaths. The largest burden was in South Asia, where the prevalence was the highest (34%); about 26% of neonatal deaths were attributable to infants born small for gestational age. Reduction of the prevalence of small for gestational age from 19.3% to 10.0% in these countries could reduce neonatal deaths by 9.2% (254 600 neonatal deaths; 164 800 to 449 700).Conclusions In low and middle income countries, about one in five infants are born small for gestational age, and one in four neonatal deaths are among such infants. Increased efforts are required to improve the quality of care for and survival of these high risk infants in low and middle income countries.

National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010.

BACKGROUND: National estimates for the numbers of babies born small for gestational age and the comorbidity with preterm birth are unavailable. We aimed to estimate the prevalence of term and preterm babies born small for gestational age (term-SGA and preterm-SGA), and the relation to low birthweight (<2500 g), in 138 countries of low and middle income in 2010. METHODS: Small for gestational age was defined as lower than the 10th centile for fetal growth from the 1991 US national reference population. Data from 22 birth cohort studies (14 low-income and middle-income countries) and from the WHO Global Survey on Maternal and Perinatal Health (23 countries) were used to model the prevalence of term-SGA births. Prevalence of preterm-SGA infants was calculated from meta-analyses. FINDINGS: In 2010, an estimated 32·4 million infants were born small for gestational age in low-income and middle-income countries (27% of livebirths), of whom 10·6 million infants were born at term and low birthweight. The prevalence of term-SGA babies ranged from 5·3% of livebirths in east Asia to 41·5% in south Asia, and the prevalence of preterm-SGA infants ranged from 1·2% in north Africa to 3·0% in southeast Asia. Of 18 million low-birthweight babies, 59% were term-SGA and 41% were preterm-SGA. Two-thirds of small-for-gestational-age infants were born in Asia (17·4 million in south Asia). Preterm-SGA babies totalled 2·8 million births in low-income and middle-income countries. Most small-for-gestational-age infants were born in India, Pakistan, Nigeria, and Bangladesh. INTERPRETATION: The burden of small-for-gestational-age births is very high in countries of low and middle income and is concentrated in south Asia. Implementation of effective interventions for babies born too small or too soon is an urgent priority to increase survival and reduce disability, stunting, and non-communicable diseases. FUNDING: Bill & Melinda Gates Foundation by a grant to the US Fund for UNICEF to support the activities of the Child Health Epidemiology Reference Group (CHERG).

Effect of knowledge of community health workers on essential newborn health care: a study from rural India.

BACKGROUND: This study explored the relationship between the knowledge of community health workers (CHWs)-anganwadi workers (AWWs) and auxiliary nurse midwives (ANMs)-and their antenatal home visit coverage and effectiveness of the visits, in terms of essential newborn health care practices at the household level in rural India. METHODS: We used data from 302 AWWs and 86 ANMs and data from recently delivered women (RDW) (n=13,023) who were residents of the CHW catchment areas and gave birth to a singleton live baby during 2004-05. Using principal component analysis, knowledge scores for preventive care and danger signs were computed separately for AWWs and ANMs and merged with RDW data. A multivariate logistic regression model was used to estimate the adjusted effect of knowledge level. A generalized estimating equation (GEE) was used to account for clustering. RESULTS: Coverage of antenatal home visits and newborn care practices were positively correlated with the knowledge level of AWWs and ANMs. Initiation of breastfeeding in the first hour of life (odds ratio 1.97; 95% confidence interval (CI): 1.55-2.49 for AWW, and odds ratio 1.62; 95% CI: 1.25-2.09 for ANM), clean cord care (odds ratio 2.03; 95% CI: 1.64-2.52 for AWW, and odds ratio 1.43; 95% CI: 1.17-1.75 for ANM) and thermal care (odds ratio 2.16; 95% CI: 1.64-2.85 for AWW and odds ratio 1.88; 95% CI: 1.43-2.48 for ANM) were significantly higher among women visited by AWWs or ANMs who had better knowledge compared with those with poor knowledge. CONCLUSION: CHWs' knowledge is one of the crucial aspects of health systems to improve the coverage of community-based newborn health care programmes as well as adherence to essential newborn care practices at the household level.