Jonathan Spector

Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program

Background Most maternal deaths, intrapartum-related stillbirths, and newborn deaths in low income countries are preventable but simple, effective methods for improving safety in institutional births have not been devised. Checklist-based interventions aid management of complex or neglected tasks and have been shown to reduce harm in healthcare. We hypothesized that implementation of the WHO Safe Childbirth Checklist program, a novel childbirth safety program for institutional births incorporating a 29-item checklist, would increase delivery of essential childbirth practices linked with improved maternal and perinatal health outcomes. Methods and Findings A pilot, pre-post-intervention study was conducted in a sub-district level birth center in Karnataka, India between July and December 2010. We prospectively observed health workers that attended to women and newborns during 499 consecutively enrolled birth events and compared these with observed practices during 795 consecutively enrolled birth events after the introduction of the WHO Safe Childbirth Checklist program. Twenty-nine essential practices that target the major causes of childbirth-related mortality, such as hand hygiene and uterotonic administration, were evaluated. The primary end point was the average rate of successful delivery of essential childbirth practices by health workers. Delivery of essential childbirth-related care practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p<0.001). There was significant improvement in the delivery of 28 out of 29 individual practices. No adverse outcomes relating to the intervention occurred. Study limitations are the pre-post design, potential Hawthorne effect, and focus on processes of care versus health outcomes. Conclusions Introduction of the WHO Safe Childbirth Checklist program markedly improved delivery of essential safety practices by health workers. Future study will determine if this program can be implemented at scale and improve health outcomes.

Designing the WHO Safe Childbirth Checklist program to improve quality of care at childbirth

Poor‐quality care during institutional births in low‐ and middle‐income countries is a major contributing factor to preventable maternal and newborn harm, but progress has been slow in identifying effective methods to address these deficiencies at scale. Based on the success of checklist programs in other disciplines, WHO led the design and field testing of the WHO Safe Childbirth Checklist—a 29‐item tool that targets the major causes of maternal and newborn mortality globally.

Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review

BackgroundAudits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries.MethodsWe performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews.ResultsThirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified.ConclusionsAudits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.

An open-access, mobile compatible, electronic patient register for rheumatic heart disease ('eRegister') based on the World Heart Federation's framework for patient registers.

Summary Background Rheumatic heart disease (RHD) remains a major disease burden in low-resource settings globally. Patient registers have long been recognised to be an essential instrument in RHD control and elimination programmes, yet to date rely heavily on paper-based data collection and non-networked data-management systems, which limit their functionality. Objectives To assess the feasibility and potential benefits of producing an electronic RHD patient register. Methods We developed an eRegister based on the World Heart Federation’s framework for RHD patient registers using CommCare, an open-source, cloud-based software for health programmes that supports the development of customised data capture using mobile devices. Results The resulting eRegistry application allows for simultaneous data collection and entry by field workers using mobile devices, and by providers using computer terminals in clinics and hospitals. Data are extracted from CommCare and are securely uploaded into a cloud-based database that matches the criteria established by the WHF framework. The application can easily be tailored to local needs by modifying existing variables or adding new ones. Compared with traditional paper-based data-collection systems, the eRegister reduces the risk of data error, synchronises in real-time, improves clinical operations and supports management of field team operations. Conclusions The user-friendly eRegister is a low-cost, mobile, compatible platform for RHD treatment and prevention programmes based on materials sanctioned by the World Heart Federation. Readily adaptable to local needs, this paperless RHD patient register program presents many practical benefits.

Access to essential technologies for safe childbirth: a survey of health workers in Africa and Asia

BackgroundThe reliable availability of health technologies, defined as equipment, medicines, and consumable supplies, is essential to ensure successful childbirth practices proven to prevent avoidable maternal and newborn mortality. The majority of global maternal and newborn deaths take place in Africa and Asia, yet few data exist that describe the availability of childbirth-related health technologies in these regions. We conducted a cross-sectional survey of health workers in Africa and Asia in order to profile the availability of health technologies considered to be essential to providing safe childbirth care.MethodsHealth workers in Africa and Asia were surveyed using a web-based questionnaire. A list of essential childbirth-related health technologies was drawn from World Health Organization guidelines for preventing and managing complications associated with the major causes of maternal and newborn mortality globally. Demographic data describing each birth center were obtained and health workers reported on the availability of essential childbirth-related health technologies at their centers. Comparison analyses were conducted using Rao-Scott chi-square test statistics.ResultsHealth workers from 124 birth centers in 26 African and 15 Asian countries participated. All facilities exhibited gaps in the availability of essential childbirth-related health technologies. Availability was significantly reduced in birth centers that had lower birth volumes and those from lower income countries. On average across all centers, health workers reported the availability of 18 of 23 essential childbirth-related health technologies (79%; 95% CI, 74%, 84%). Low-volume facilities suffered severe shortages; on average, these centers reported reliable availability of 13 of 23 technologies (55%; 95% CI, 39%, 71%).ConclusionsSubstantial gaps exist in the availability of essential childbirth-related health technologies across health sector levels in Africa and Asia. Strategies that facilitate reliable access to vital health technologies in these regions are an urgent priority.

Open-source mobile digital platform for clinical trial data collection in low-resource settings.

Background Governments, universities and pan-African research networks are building durable infrastructure and capabilities for biomedical research in Africa. This offers the opportunity to adopt from the outset innovative approaches and technologies that would be challenging to retrofit into fully established research infrastructures such as those regularly found in high-income countries. In this context we piloted the use of a novel mobile digital health platform, designed specifically for low-resource environments, to support high-quality data collection in a clinical research study. Objective Our primary aim was to assess the feasibility of a using a mobile digital platform for clinical trial data collection in a low-resource setting. Secondarily, we sought to explore the potential benefits of such an approach. Methods The investigative site was a research institute in Nairobi, Kenya. We integrated an open-source platform for mobile data collection commonly used in the developing world with an open-source, standard platform for electronic data capture in clinical trials. The integration was developed using common data standards (Clinical Data Interchange Standards Consortium (CDISC) Operational Data Model), maximising the potential to extend the approach to other platforms. The system was deployed in a pharmacokinetic study involving healthy human volunteers. Results The electronic data collection platform successfully supported conduct of the study. Multidisciplinary users reported high levels of satisfaction with the mobile application and highlighted substantial advantages when compared with traditional paper record systems. The new system also demonstrated a potential for expediting data quality review. Discussion and Conclusions This pilot study demonstrated the feasibility of using a mobile digital platform for clinical research data collection in low-resource settings. Sustainable scientific capabilities and infrastructure are essential to attract and support clinical research studies. Since many research structures in Africa are being developed anew, stakeholders should consider implementing innovative technologies and approaches.

Practical criteria for maternal near miss needed for low-income settings.

The clinical, management, and laboratory-based markers that WHO uses to define maternal nearmissed deaths will surely support benchmarking of maternal care in much of the world. Unfortunately, the utility of the criteria, and therefore that of the maternity severity index cited in João Paulo Souza and colleagues’ report (May 18, p 1747), is limited in low-resource settings where the need is greatest. None of the laboratory-based criteria (eg, pH, PaO2, and lactate) and very few of the management-based criteria (eg, dialysis and vasoactive drug management) are likely to be applicable in parts of Africa and Asia where most severe maternal harm occurs. In north India, we recently found that even seemingly straightforward clinical criteria (such as shock, gasping, and clotting failure) could not be reliably identifi ed by front-line health workers who routinely care for sick mothers. Of the 25 criteria listed only loss of consciousness, stroke, status epilepticus, blood transfusion, and cardiopulmonary resuscitation could be used—and only after modifi cation of the WHO official definitions. This problem is not restricted to community-based births; most health facilities (up to and including districtlevel hospitals) were poorly positioned to make use of these markers. WHO is at the leading edge of the fight for maternal and newborn survival, and its maternal near-miss approach is another example of its pioneering activities in this area. A welcome contribution now would be to extend on this work and provide stakeholders in low-income countries with a standard set of practical criteria by which they too can track progress in improving maternal care.

Neonatal resuscitation capacity in Nepal.

Aim:  Perinatal asphyxia is a major contributor to the nearly 4 million neonatal deaths worldwide each year in resource‐limited settings. Neonatal resuscitation, a proven method for preventing newborn deaths, is effective only when local caregivers have proper training and access to essential supplies. There are few published data describing neonatal resuscitation capacity in Nepal, where neonatal mortality rates are high. The goal of this study was to quantify neonatal resuscitation capacity at birthing sites in urban and rural Nepal.

A programme to increase appropriate usage of benzathine penicillin for management of streptococcal pharyngitis and rheumatic heart disease in Zambia

Summary Rheumatic heart disease is highly prevalent and associated with substantial morbidity and mortality in many resourcepoor areas of the world, including sub-Saharan Africa.Primary and secondary prophylaxis with penicillin has beenshown to significantly improve outcomes and is recognisedto be the standard of care, with intra-muscular benzathine penicillin G recommended as the preferred agent by many technical experts. However, ensuring compliance with therapyhas proven to be challenging. As part of a public–privatepartnership initiative in Zambia, we conducted an educationaland access-to-medicine programme aimed at increasing appropriate use of benzathine penicillin for the preventionand management of rheumatic heart disease, according tonational guidelines. The programme was informed early onby identification of potential barriers to the administration ofinjectable penicillin, which included concern by health workers about allergic events. We describe this programme andreport initial signs of success, as indicated by increased useof benzathine penicillin. We propose that a similar approach may have benefits in rheumatic heart disease programmes in other endemic regions.

Do frontline health care providers know enough about artemisinin-based combination therapy to rationally treat malaria? A cross-sectional survey in Gezira State, Sudan

BackgroundIn 2004, artemisinin-based combination therapy (ACT) was introduced in Sudan for the treatment of malaria. The role of health care providers working in first-level health care facilities is central for the effective implementation of this revised malaria treatment policy. However, information about their level of ACT knowledge is inadequate. This study sought to describe frontline health care providers’ knowledge about the formulations and dose regimens of nationally recommended ACT in Sudan.MethodsThis cross-sectional study took place in Gezira State, Sudan. Data were gathered from five localities comprising forty primary health care facilities. A total of 119 health care providers participated in the study (72 prescribers and 47 dispensers). The primary outcome was the proportion of health care providers who were ACT knowledgeable, a composite indicator of health care providers’ ability to (1) define what combination therapy is; (2) identify the recommended first- and second-line treatments; and (3) correctly state the dose regimens for each.ResultsAll prescribers and 95.7% (46/47) of dispensers were aware of the new national malaria treatment policy. However, 93.1% (67/72) of prescribers compared to 87.2% (41/47) of dispensers recognized artesunate-sulphadoxine/pyrimethamine as the recommended first-line treatment in Sudan. Only a small number of prescribers and dispensers (9.4% and 13.6%, respectively) were able to correctly define the meaning of a combination therapy. Overall, only 22% (26/119, 95% CI 14.6-29.4) of health care providers were found to be ACT knowledgeable with no statistically significant difference between prescribers and dispensers.ConclusionOverall, ACT knowledge among frontline health care providers is very poor. This finding suggests that efforts are needed to improve knowledge of prescribers and dispensers working in first-level health care facilities, perhaps through implementing focused, provider-oriented training programmes. Additionally, a system for regularly monitoring and evaluating the quality of in-service training may be beneficial to ensure its responsiveness to the needs of the target health care providers.