Effect of a mother-baby delivery pack on institutional deliveries: A community intervention trial to address maternal mortality in rural Zambia.

OBJECTIVES: To test the effect of providing additional health education during antenatal care (ANC) and a mother-baby delivery pack on institutional deliveries in Monze, Zambia. SETTING: 16 primary health facilities conducting deliveries in the district. PARTICIPANT: A total of 5000 pregnant women at any gestation and age attending antenatal care (ANC) services in selected health facilities were eligible for enrolment into the study. Out of these, 4,500 (90%) were enrolled into and completed the study. A total of 3,882 (77.6%) were included in the analysis; 12.4% were not included in the analysis due to incomplete data. INTERVENTION: A three-year study (2012 to 2014) analysing baseline delivery data for 2012 and 2013 followed by a community intervention trial was conducted from January to December 2014. Health facilities on the western side were assigned to the intervention arm; those on the eastern side were in the control. In addition to the health education provided during routine ANC visits, participants in the intervention arm received health education and a mother-baby delivery pack when they arrived at the health facility for delivery. Participants in the control arm continued with routine ANC services. OUTCOME MEASURES: The primary measure was the number of institutional deliveries in both arms over the one-year period. Secondary measures were utilisation of ANC, post-natal care (PNC) and under-five clinic services. Descriptive statistics (frequencies, proportions, means and standard deviation) were computed to summarise participant characteristics. Chi-square and Independent T-tests were used to make comparisons between the two arms. One way analysis of variance (ANOVA) was used to test the effect of the intervention after one year (p-value<0.05). Analysis was conducted using R-studio statistical software version 4.2.1. The p-value<0.05 was considered significant. RESULTS: Analysis showed a 15.9% increase in the number of institutional deliveries and a significant difference in the mean number of deliveries between intervention and control arms after one year (F(1,46) = 18.85, p<0.001). Post hoc analysis showed a significant difference in the mean number of deliveries between the intervention and control arms for 2014 (p<0.001). Compared to the control arm, participants in the intervention arm returned earlier for PNC clinic visit, brought their children back and started the under-five clinic visits earlier. CONCLUSION: These findings provide evidence for the effectiveness of the mother-baby delivery pack and additional health education sessions on increasing institutional deliveries, PNC and under-five children's clinic utilisation in rural Zambia. TRIAL REGISTRATION: ISRCTN Registry (ISRCTN15439813 DOI 10.1186/ISRCTN15439813); Pan African Clinical Trial Registry (PACTR202212611709509).

Integration of new digital antenatal care tools using the WHO SMART guideline approach: Experiences from Rwanda and Zambia.

OBJECTIVES: Digital tools for decision-support and health records can address the protracted process of guideline adoption at local levels and accelerate countries' implementation of new health policies and programmes. World Health Organization (WHO) launched the SMART Guidelines approach to support the uptake of clinical, public health, and data recommendations within digital systems. SMART guidelines are a package of tools that include Digital Adaptation Kits (DAKs), which distill WHO guidelines into a format that facilitates translation into digital systems. SMART Guidelines also include reference software applications known as digital modules. METHODS: This paper details the structured process to inform the adaptation of the WHO antenatal care (ANC) digital module to align with country-specific ANC packages for Zambia and Rwanda using the DAK. Digital landscape assessments were conducted to determine potential integrations between the ANC digital module and existing systems. A multi-stakeholder team consisting of Ministry of Health technical officers representing maternal health, HIV, digital health, and monitoring and evaluation at district and national levels was assembled to review existing guidelines to adapt the DAK. RESULTS: The landscape analysis resulted in considerations for integrating the ANC module into the broader digital ecosystems of both countries. Adaptations to the DAK included adding national services not reflected in the generic DAK and modification of decision support logic and indicators. Over 80% of the generic DAK content was consistent with processes for both countries. The adapted DAK will inform the customization of country-specific ANC digital modules. CONCLUSION: Both countries found that coordination between maternal and digital health leads was critical to ensuring requirements were accurately reflected within the ANC digital module. Additionally, DAKs provided a structured process for gathering requirements, reviewing and addressing gaps within existing systems, and aligning clinical content.

Integrating Sexual and Reproductive Health Services Within HIV Services: WHO Guidance.

Among the 1.9 billion women of reproductive age worldwide in 2019, 1.1 billion need family planning and 270 million have an unmet need for contraception. For women and adolescent girls living with human immunodeficiency virus (HIV), using effective contraception reduces the mother-to-child transmission of HIV by preventing unintended pregnancies and enabling the planning and safer conception of desired pregnancies with optimal maternal and child health outcomes. The World Health Organization (WHO) recommends that sexual and reproductive health services, including contraception, may be integrated within HIV services. Integration is associated with increased offers and uptake of sexual and reproductive health services, including contraception, which is likely to result in improved downstream clinical outcomes. Integrating HIV and sexual and reproductive health services has been found to improve access, the quality of antenatal care and nurse productivity while reducing stigma and without compromising uptake of care. Research is encouraged to identify approaches to integration that lead to better uptake of sexual and reproductive health services, including contraception. Implementation research is encouraged to evaluate different strategies of integration in different health systems and social contexts; such research should include providing contraception, including long-acting contraception, in the context of less frequent clinical and ART refill visits.

Field performance evaluation of dual rapid HIV and syphilis tests in three antenatal care clinics in Zambia.

This cross-sectional study of 3212 pregnant women assessed the field performance, acceptability, and feasibility of two dual HIV/syphilis rapid diagnostic tests, the Chembio DPP HIV-syphilis Assay and the SD Bioline HIV/syphilis Duo in antenatal clinics. Sensitivity and specificity for HIV and syphilis were calculated compared to the rapid Determine HIV-1/2 with Uni-Gold to confirm positive results for HIV and the Treponema pallidum particle agglutination assay for syphilis. RPR titers ≥1:4 were used to define active syphilis detection. Acceptability and feasibility were assessed using self-reported questionnaires. For Chembio, the HIV sensitivity was 90.6% (95%CI = 87.4, 93.0) and specificity was 97.2% (95%CI = 96.2, 97.8); syphilis sensitivity was 68.6% (95%CI = 61.9, 74.6) and specificity was 98.5% (95%CI = 97.8, 98.9). For SD Bioline, HIV sensitivity was 89.4% (95%CI = 86.1, 92.0) and specificity was 96.3% (95%CI = 95.3, 97.1); syphilis sensitivity was 66.2% (95%CI = 59.4, 72.4) and specificity was 97.2% (95%CI = 96.4, 97.9). Using the reference for active syphilis, syphilis sensitivity was 84.7% (95%CI = 76.1, 90.6) for Chembio and 81.6% (95%CI = 72.7, 88.1) for SD Bioline. Both rapid diagnostic tests were assessed as highly acceptable and feasible. In a field setting, the performance of both rapid diagnostic tests was comparable to other published field evaluations and each was rated highly acceptable and feasible. These findings can be used to guide further research and proposed scale up in antenatal clinic settings.

Estimating disease burden of maternal syphilis and associated adverse pregnancy outcomes in India, Nigeria, and Zambia in 2012.

OBJECTIVE: To estimate maternal syphilis and its associated adverse pregnancy outcomes in India, Nigeria, and Zambia. METHODS: An online estimation tool was used to generate point estimates and uncertainty ranges of maternal syphilis and adverse pregnancy outcomes due to mother-to-child transmission (MTCT). The most recent data (2010-2012) on antenatal care coverage, syphilis seroprevalence, and syphilis screening and treatment coverage at the subnational level in India, Nigeria, and Zambia were used to estimate disease burden for 2012. Sensitivity analysis was conducted for three screening and treatment scenarios (current coverages, current coverages minus 20%, and ideal coverages consistent with WHO targets for eliminating MTCT of syphilis). RESULTS: A total of 103 960, 74 798, and 9072 pregnant women with probable active syphilis were estimated to occur in India, Nigeria, and Zambia, resulting in 53 187, 37 045, and 2973 adverse outcomes, respectively; approximately 1.6%, 4.8%, and 37.0% of these were averted under the current service coverages in India, Nigeria, and Zambia. The disease burden varied significantly in its subnational distribution within India and Nigeria, but was distributed evenly across Zambia. CONCLUSIONS: The obtained results suggest an ongoing, unaverted high burden of maternal syphilis and associated adverse outcomes in India, Nigeria, and Zambia. Screening and treatment for syphilis must be scaled-up significantly in these countries to achieve elimination of MTCT of syphilis.

Holding a country countdown to 2015 conference on Millennium Development Goals (MDGs) - the Zambian experience.

Initiatives such as the Country Countdown to 2015 Conference on Millennium Development Goals (MDGs) have provided countries with high maternal and child deaths like Zambia a platform to assess progress, discuss challenges and share lessons learnt as a conduit for national commitment to reaching and attaining the MDGs four and five. This paper discusses and highlights the process of holding a successful country countdown conference and shares Zambia's experience with other countries planning to organise country countdown to 2015 Conferences on MDGs.