Emma Sacks

Population-Based Incidence and Etiology of Community-Acquired Neonatal Bacteremia in Mirzapur, Bangladesh: An Observational Study

BACKGROUND To devise treatment strategies for neonatal infections, the population-level incidence and antibiotic susceptibility of pathogens must be defined. METHODS Surveillance for suspected neonatal sepsis was conducted in Mirzapur, Bangladesh, from February 2004 through November 2006. Community health workers assessed neonates on postnatal days 0, 2, 5, and 8 and referred sick neonates to a hospital, where blood was collected for culture from neonates with suspected sepsis. We estimated the incidence and pattern of community-acquired neonatal bacteremia and determined the antibiotic susceptibility profile of pathogens. RESULTS The incidence rate of community-acquired neonatal bacteremia was 3.0 per 1000 person-neonatal periods. Among the 30 pathogens identified, the most common was Staphylococcus aureus (n = 10); half of all isolates were gram positive. Nine were resistant to ampicillin and gentamicin or to ceftiaxone, and 13 were resistant to cotrimoxazole. CONCLUSION S. aureus was the most common pathogen to cause community-acquired neonatal bacteremia. Nearly 40% of infections were identified on days 0-3, emphasizing the need to address maternal and environmental sources of infection. The combination of parenteral procaine benzyl penicillin and an aminoglycoside is recommended for the first-line treatment of serious community-acquired neonatal infections in rural Bangladesh, which has a moderate level of neonatal mortality. Additional population-based data are needed to further guide national and global strategies.

Fair publication of qualitative research in health systems: a call by health policy and systems researchers

Fair publication of qualitative research in health systems : a call by health policy and systems researchers

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 6. strategies used by effective projects

BACKGROUND As part of our review of the evidence of the effectiveness of community-based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH), we summarize here the common delivery strategies of projects, programs and field research studies (collectively referred to as projects) that have demonstrated effectiveness in improving child mortality. Other articles in this series address specifically the effects of CBPHC on improving MNCH, while this paper explores the specific strategies used. METHODS We screened 12 166 published reports in PubMed of community-based approaches to improving maternal, neonatal and child health in high-mortality, resource-constrained settings from 1950-2015. A total of 700 assessments, including 148 reports from other publicly available sources (mostly unpublished evaluation reports and books) met the criteria for inclusion and were reviewed using a data extraction form. Here we identify and categorize key strategies used in project implementation. RESULTS Six categories of strategies for program implementation were identified, all of which required working in partnership with communities and health systems: (a) program design and evaluation, (b) community collaboration, (c) education for community-level staff, volunteers, beneficiaries and community members, (d) health systems strengthening, (e) use of community-level workers, and (f) intervention delivery. Four specific strategies for intervention delivery were identified: (a) recognition, referral, and (when possible) treatment of serious childhood illness by mothers and/or trained community agents, (b) routine systematic visitation of all homes, (c) facilitator-led participatory womens groups, and (d) health service provision at outreach sites by mobile health teams. CONCLUSIONS The strategies identified here provide useful starting points for program design in strengthening the effectiveness of CBPHC for improving MNCH.

Respectful maternal and newborn care: building a common agenda

In September, the World Health Organization released a statement on preventing and eliminating disrespect and abuse during facility-based childbirth. In addition to this important agenda, attention is also needed for the dignified care of newborns, who also deserve basic human rights and dignified care. In this commentary, we provide examples from the literature and other sources of where respectful care for newborns has been lacking and we give examples of opportunities for integration of maternal and newborn health care going forward. We illustrate the need for respectful treatment and consideration across the continuum of care: for mothers, stillbirths, and all newborns, including those born too soon and those who die in infancy. We explain the need to document cases of neglect and abuse, count all births and deaths, and to include newborns and stillbirths in the respectful care agenda and the post-2015 global reproductive care frameworks.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 4. child health findings.

Background We summarize the findings of assessments of projects, programs, and research studies (collectively referred to as projects) included in a larger review of the effectiveness of community–based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH). Findings on neonatal and child health are reported elsewhere in this series. Methods We searched PUBMED and other databases through December 2015, and included assessments that underwent data extraction. Data were analyzed to identify themes in interventions implemented, health outcomes, and strategies used in implementation. Results 152 assessments met inclusion criteria. The majority of assessments were set in rural communities. 72% of assessments included 1–10 specific interventions aimed at improving maternal health. A total of 1298 discrete interventions were assessed. Outcome measures were grouped into five main categories: maternal mortality (19% of assessments); maternal morbidity (21%); antenatal care attendance (50%); attended delivery (66%) and facility delivery (69%), with many assessments reporting results on multiple indicators. 15 assessments reported maternal mortality as a primary outcome, and of the seven that performed statistical testing, six reported significant decreases. Seven assessments measured changes in maternal morbidity: postpartum hemorrhage, malaria or eclampsia. Of those, six reported significant decreases and one did not find a significant effect. Assessments of community–based interventions on antenatal care attendance, attended delivery and facility–based deliveries all showed a positive impact. The community–based strategies used to achieve these results often involved community collaboration, home visits, formation of participatory women’s groups, and provision of services by outreach teams from peripheral health facilities. Conclusions This comprehensive and systematic review provides evidence of the effectiveness of CBPHC in improving key indicators of maternal morbidity and mortality. Most projects combined community– and facility–based approaches, emphasizing potential added benefits from such holistic approaches. Community–based interventions will be an important component of a comprehensive approach to accelerate improvements in maternal health and to end preventable maternal deaths by 2030.

Skin, thermal and umbilical cord care practices for neonates in southern, rural Zambia: a qualitative study

BackgroundIn Choma District, southern Zambia, the neonatal mortality rate is approximately 40 per 1000 live births and, although the rate is decreasing, many deliveries take place outside of formal facilities. Understanding local practices during the postnatal period is essential for optimizing newborn care programs.MethodsWe conducted 36 in-depth interviews, five focus groups and eight observational sessions with recently-delivered women, traditional birth attendants, and clinic and hospital staff from three sites, focusing on skin, thermal and cord care practices for newborns in the home.ResultsNewborns were generally kept warm by application of hats and layers of clothing. While thermal protection is provided for preterm and small newborns, the practice of nighttime bathing with cold water was common. The vernix was considered important for the preterm newborn but dangerous for HIV-exposed infants. Mothers applied various substances to the skin and umbilical cord, with special practices for preterm infants. Applied substances included petroleum jelly, commercial baby lotion, cooking oil and breastmilk. The most common substances applied to the umbilical cord were powders made of roots, burnt gourds or ash. To ward off malevolent spirits, similar powders were reportedly placed directly into dermal incisions, especially in ill children.ConclusionsThermal care for newborns is commonly practiced but co-exists with harmful practices. Locally appropriate behavior change interventions should aim to promote chlorhexidine in place of commonly-reported application of harmful substances to the skin and umbilical cord, reduce bathing of newborns at night, and address the immediate bathing of HIV-infected newborns.

Postpartum Hemorrhage Prevention: A Case Study in Northern Rural Honduras

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality globally. Safe Motherhood policies have been directed towards the reduction of PPH by recommending active management of third-stage labor as the standard of care. One component of active management involves routine use of a uterotonic agent within 1 minute of the delivery of the baby. A case study at Clínica Materno-Infantil, a free-standing public birth center in Honduras, is presented, focusing on methods to reduce PPH. The nursing staff was trained to estimate blood loss and in methods to manage PPH, including elements of active management of the third stage of labor. Medical records were reviewed and an analysis of PPH management compared to estimated blood loss (EBL) was conducted. There was no significant correlation between PPH management techniques and EBL (r = .060; P = .368). There was a statistically significant (P < .001) correlation between oxytocin administration and lower EBL (r = -.232), indicating that there was less blood loss when oxytocin was administered. At Clínica Materno-Infantil, routine use of a uterotonic agent appears beneficial and further implementation of active management of the third stage of labor appears warranted.

Postnatal care: increasing coverage, equity, and quality

As the Millennium Development Goals came to a close last year and we entered the new Sustainable Development Goals (SDGs) era the global health community took stock of accomplishments over the past decades and continuing challenges for the future. Despite impressive reductions in maternal and under-5 mortality rates neonatal mortality reduction continues to lag behind. Neonates account for an increasing share of child deaths now reaching almost half (45%) of the burden of under-5 mortality. It took a long time for the global health community to seriously address the quality of the content of antenatal care and intrapartum care beyond coverage indicators. We need to learn from this experience and ensure that quality and integration of postnatal care for mothers and neonates gets political attention and investment sooner. It is incumbent on us to accelerate the trajectory and talk about content and quality for postnatal care within continuing efforts to increase coverage and equity. The time to unpack the “black box” of postnatal care services delivery is now and greater attention should be provided to quality postnatal care in research policy and practice. The Global Strategy for Women’s Children’s and Adolescents’ Health 2016-2030 aims to help people survive thrive and transform; thus the new era cannot only be about survival but efforts must be made to improve and transform health systems. Quality needs to be understood and addressed if we are serious about reducing neonatal maternal and child mortality; progressing toward universal health coverage; and achieving the SDGs. (Excerpts)

Reduced postpartum hemorrhage after implementation of active management of the third stage of labor in rural Honduras

To assess outcomes after auxiliary nurses were trained and given resources to use active management of the third stage of labor (AMTSL) for all women giving birth in a low‐resource, low‐risk, rural, public birth center setting in northern rural Honduras.

Community Involvement in Health Systems Strengthening to Improve Global Health Outcomes: A Review of Guidelines and Potential Roles

Definitions of health systems strengthening (HSS) have been limited in their inclusion of communities, despite evidence that community involvement improves program effectiveness for many health interventions. We review 15 frameworks for HSS, highlighting how communities are represented and find few delineated roles for community members or organizations. This review raises the need for a cohesive definition of community involvement in HSS and well-described activities that communities can play in the process. We discuss how communities can engage with HSS in four different areas—planning and priority-setting; program implementation; monitoring, evaluation, and quality improvement; and advocacy—and how these activities could be better incorporated into key HSS frameworks. We argue for more carefully designed interactions between health systems policies and structures, planned health systems improvements, and local communities. These interactions should consider local community inputs, strengths, cultural and social assets, as well as limitations in and opportunities for increasing capacity for better health outcomes.