Keitshokile Dintle Mogobe

Monitoring maternity mortality in Botswana

This paper describes the maternity monitoring system in Botswana, developed in 1998, and the main methods used: maternal death and morbidity reviews at service delivery level, analysis by the National Maternal Mortality Audit Committee of data from the reviews as reported on two forms, perinatal reviews and surveys using process indicators. We carried out a study of these findings to examine whether the system was working well. Surveys using process indicators in 2001 and 2006 were analysed. Other data examined were from 2004–2006 and early 2007. The Maternal Death Notification Form was found to be comprehensive but not all health facilities were submitting them and some gave incomplete information. In 2001, 70% of pregnant women attended antenatal care but access to emergency obstetric care was uneven. In 2006, 28 facilities with maternity services surveyed were providing 24-hour delivery care, but laboratory, theatre and blood supplies were more limited, and only 50% of doctors and 67% of midwives had life-saving skills. Antibiotics were widely available, but there were shortages of magnesium sulphate, diazepam, oxytocics and manual vacuum aspiration kits. Recommendations for improvements have been made, training for skilled attendants is ongoing and a medical school has just opened at the University of Botswana. Résumé Le Botswana a instauré un système de surveillance de la maternité en 1998. Il utilise les analyses de la mortalité et de la morbidité maternelles au niveau de la prestation des services, l’étude par le Comité national de contrôle de la mortalité maternelle des données des analyses, telles que notifiées dans deux formulaires, les enquêtes périnatales à l’aide d’indicateurs de processus. On a étudié ces conclusions pour déterminer si le système fonctionne bien et on a analysé des enquêtes utilisant les indicateurs de processus en 2001 et 2006. D’autres données dataient de 2004–2006 et début 2007. Le formulaire de notification des décès maternels est complet, mais n’est pas envoyé par tous les centres de santé et donne parfois des informations fragmentaires. En 2001, 70% des femmes enceintes bénéficiaient de soins prénatals, mais l’accès aux soins obstétricaux d’urgence était inégal. En 2006, 28 maternités visées par l’enquête assuraient des accouchements 24 heures sur 24, mais l’accès aux laboratoires, aux salles d’opération et aux produits sanguins était plus limité, et seulement 50% des médecins et 67% des sages-femmes possédaient des compétences capables de sauver la vie. Les antibiotiques étaient largement disponibles, mais des pénuries de sulfate de magnésium, de diazépam, d’ocytociques et de trousses d’aspiration manuelle se produisaient. Des recommandations ont été formulées pour améliorer les services, la formation des agents qualifiés est en cours et une école de médecine vient d’ouvrir à l’Université du Botswana. Resumen En este artículo se describe el sistema de monitoreo de maternidad en Botsuana, creado en 1998, y los principales métodos utilizados: revisiones de morbimortalidad materna en los puntos de entrega de servicios, análisis por el Comité Nacional de Auditoría de Mortalidad Materna de los datos de las revisiones, conforme informados en dos formularios, revisiones y encuestas perinatales utilizando indicadores de proceso. Realizamos un estudio de estos hallazgos para examinar si el sistema funcionaba bien. Se analizaron las encuestas utilizando los indicadores de proceso en 2001 y 2006. Otros datos examinados fueron de 2004–2006 y principios de 2007. Se encontró que el Formulario de Notificación de Muerte Materna era completo, pero no todos los establecimientos de salud lo estaban llenando y algunos daban información incompleta. En 2001, el 70% de las mujeres embarazadas recibieron atención antenatal, pero no todas tenían acceso a los cuidados obstétricos de emergencia. En 2006, se estaba brindando atención a partos las 24 horas, en 28 establecimientos con servicios de maternidad encuestados, pero los suministros de laboratorio, quirófano y sangre estaban más limitados y sólo el 50% de los médicos y el 67% de las parteras contaban con habilidades para salvar vidas. Los antibióticos se conseguían con facilidad, pero había escasez de sulfato de magnesio, diazepán, oxitócicos e instrumental de aspiración manual endouterina. Se han hecho recomendaciones para mejoramientos, se continúa capacitando a parteras calificadas y se acaba de inaugurar la Facultad de Medicina de la Universidad de Botsuana.

Using qualitative methods for course evaluation: a case study from Botswana.

This article is a report of a qualitative evaluation of a course on human immunodeficiency virus/acquired immunodeficiency syndrome carried out jointly by faculty from Botswana and the United States at a university in Botswana. It demonstrates the importance of both international nurse educator expertise in impacting a major pandemic and the use of qualitative methods for course evaluation.

Building Trust and Relationships Between Patients and Providers: An Essential Complement to Health Literacy in HIV Care

&NA; Health literacy is important for access to and quality of HIV care. While most models of health literacy acknowledge the importance of the patient–provider relationship to disease management, a more nuanced understanding of this relationship is needed. Thematic analysis from 28 focus groups with HIV‐experienced patients (n = 135) and providers (n = 71) identified a long‐term and trusting relationship as an essential part of HIV treatment over the continuum of HIV care. We found that trust and relationship building over time were important for patients with HIV as well as for their providers. An expanded definition of health literacy that includes gaining a patients trust and engaging in a process of health education and information sharing over time could improve HIV care. Expanding clinical perspectives to include trust and the importance of the patient–provider relationship to a shared understanding of health literacy may improve patient experiences and engagement in care.

A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement

BackgroundIn 2007, 95% of women in Botswana delivered in health facilities with 73% attending at least 4 antenatal care visits. HIV-prevalence in pregnant women was 28.7%. The maternal mortality ratio in 2010 was 163 deaths per 100 000 live births versus the government target of 130 for that year, indicating that the Millennium Development Goal 5 was unlikely to be met. A root-cause analysis was carried out with the aim of determining the underlying causes of maternal deaths reported in 2010, to categorise contributory factors and to prioritise appropriate interventions based on the identified causes, to prevent further deaths.MethodsCase-notes for maternal deaths were reviewed by a panel of five clinicians, initially independently then discussed together to achieve consensus on assigning contributory factors, cause of death and whether each death was avoidable or not at presentation to hospital. Factors contributing to maternal deaths were categorised into organisational/management, personnel, technology/equipment/supplies, environment and barriers to accessing healthcare.ResultsFifty-six case notes were available for review from 82 deaths notified in 2010, with 0–4 contributory factors in 19 deaths, 5–9 in 27deaths and 9–14 in nine. The cause of death in one case was not ascertainable since the notes were incomplete. The high number of contributory factors demonstrates poor quality of care even where deaths were not avoidable: 14/23 (61%) of direct deaths were considered avoidable compared to 12/32 (38%) indirect deaths. Highest ranking categories were: failure to recognise seriousness of patients’ condition (71% of cases); lack of knowledge (67%); failure to follow recommended practice (53%); lack of or failure to implement policies, protocols and guidelines (44%); and poor organisational arrangements (35%). Half the deaths had some barrier to accessing health services.ConclusionsRoot-cause analysis demonstrates the interactions between patients, health professionals and health system in generating adverse outcomes for patients. The lessons provided indicate where training of undergraduate and postgraduate medical, midwifery and nursing students need to be intensified, with emphasis on evidence-based practice and adherence to protocols. Action plans and interventions aimed at changing the circumstances that led to maternal deaths can be implemented and re-evaluated.

Cultural Considerations in Theories of Adolescent Development: A Case Study from Botswana

Western studies of adolescent development are beginning to corporate not only the traditional ideas of nature and nurture, but also contextual factors such as culture, ecology and historical time. This article explores how adolescent development is influenced by both a specific culture (Botswana) and a specific ecological situation (the rampant HIV pandemic in that country). A case study of late adolescents living in this pandemic in Botswana helps broaden our traditional views of adolescent development.

Integrated Review of Barriers to Cervical Cancer Screening in Sub-Saharan Africa

PURPOSE The aim of this study was to review published studies to identify and describe barriers to Papanicolaou (Pap) smear screening among women in sub-Saharan Africa. DESIGN AND METHODS Guided by Coopers integrative review methodology, studies published between 2006 and 2015 were identified by searching electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, MEDLINE, ProQuest, and PsycINFO using specified search terms. Using this strategy, 224 articles were identified and screened for duplication and by reading titles, abstracts, and full texts. Seventeen articles met the inclusion criteria and were appraised using relevant tools for qualitative and quantitative designs. No relevant articles published in 2006, 2007, and 2014 were found. FINDINGS All 17 articles had good methodological quality and were included in the review. The studies were from 10 sub-Saharan countries and from different settings. Content analysis of the data revealed three major themes coded as client, provider, and system barriers. The most common client barriers were lack of knowledge and awareness about Pap smear screening, fear of cancer, belief of not being at risk for cervical cancer, and that a Pap smear is not important unless one is ill and cultural or religious factors. Provider barriers were failure to inform or encourage women to screen. Major system barriers were unavailability and inaccessibility of the Pap test. CONCLUSIONS The review provided evidence of barriers to Pap smear screening among sub-Saharan women. Although there were some variations from country to country, sub-Saharan countries share similar constraints to Pap smear screening. These findings have important implications for practice and policy. CLINICAL RELEVANCE Understanding the client, provider, and system barriers to cervical cancer screening could guide development of effective interventions.

High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized

Background Maternal mortality due to abortion complications stands among the three leading causes of maternal death in Botswana where there is a restrictive abortion law. This study aimed at assessing the patterns and determinants of post-abortion complications. Methods A retrospective institution based cross-sectional study was conducted at four hospitals from January to August 2014. Data were extracted from patients’ records with regards to their socio-demographic variables, abortion complications and length of hospital stay. Descriptive statistics and bivariate analysis were employed. Result A total of 619 patients’ records were reviewed with a mean (SD) age of 27.12 (5.97) years. The majority of abortions (95.5%) were reported to be spontaneous and 3.9% of the abortions were induced by the patient. Two thirds of the patients were admitted as their first visit to the hospitals and one third were referrals from other health facilities. Two thirds of the patients were admitted as a result of incomplete abortion followed by inevitable abortion (16.8%). Offensive vaginal discharge (17.9%), tender uterus (11.3%), septic shock (3.9%) and pelvic peritonitis (2.4%) were among the physical findings recorded on admission. Clinically detectable anaemia evidenced by pallor was found to be the leading major complication in 193 (31.2%) of the cases followed by hypovolemic and septic shock 65 (10.5%). There were a total of 9 abortion related deaths with a case fatality rate of 1.5%. Self-induced abortion and delayed uterine evacuation of more than six hours were found to have significant association with post-abortion complications (p-values of 0.018 and 0.035 respectively). Conclusion Abortion related complications and deaths are high in our setting where abortion is illegal. Mechanisms need to be devised in the health facilities to evacuate the uterus in good time whenever it is indicated and to be equipped to handle the fatal complications. There is an indication for clinical audit on post-abortion care to insure implementation of standard protocol and reduce complications.

Integration of HIV care into maternal health services: a crucial change required in improving quality of obstetric care in countries with high HIV prevalence

BackgroundThe failure to reduce preventable maternal deaths represents a violation of women’s right to life, health, non-discrimination and equality. Maternal deaths result from weaknesses in health systems: inadequate financing of services, poor information systems, inefficient logistics management and most important, the lack of investment in the most valuable resource, the human resource of health workers. Inadequate senior leadership, poor communication and low staff morale are cited repeatedly in explaining low quality of healthcare. Vertical programmes undermine other service areas by creating competition for scarce skilled staff, separate reporting systems and duplication of training and tasks.DiscussionConfidential enquiries and other quality-improvement activities have identified underlying causes of maternal deaths, but depend on the health system to respond with remedies. Instead of separate vertical programmes for management of HIV, tuberculosis, and reproductive health, integration of care and joint management of pregnancy and HIV would be more effective. Addressing health system failures that lead to each woman’s death would have a wider impact on improving the quality of care provided in the health service as a whole. More could be achieved if existing resources were used more effectively. The challenge for African countries is how to get into practice interventions known from research to be effective in improving quality of care. Advocacy and commitment to saving women’s lives are crucial elements for campaigns to influence governments and policy -makers to act on the findings of these enquiries. Health professional training curricula should be updated to include perspectives on patients’ rights, communication skills, and integrated approaches, while using adult learning methods and problem-solving techniques.SummaryIn countries with high rates of Human Immunodeficiency Virus (HIV), indirect causes of maternal deaths from HIV-associated infections now exceed direct causes of hemorrhage, hypertension and sepsis. Advocacy for all pregnant HIV-positive women to be on anti-retroviral therapy must extend to improvements in the quality of service offered, better organised obstetric services and integration of clinical HIV care into maternity services. Improved communication and specialist support to peripheral facilities can be facilitated through advances in technology such as mobile phones.

Clinical use of blood and blood components in post‐abortion care in Botswana

Understanding the pattern and gaps in blood product utilisation in post‐abortion care is crucial for evidence‐based planning and priority setting.

Factors influencing infant‐feeding choices selected by HIV‐infected mothers: Perspectives from Zimbabwe

AIM To assess factors influencing infant-feeding methods selected by HIV-infected mothers. METHODS A descriptive quantitative study was conducted among 80 mothers with babies aged 0-6 months who were randomly selected and interviewed. Descriptive statistics were used to summarize the findings. RESULTS Factors considered by women in choosing the infant-feeding methods included sociocultural acceptability (58.8%), feasibility and support from significant others (35%), knowledge of the selected method (55%), affordability (61.2%), implementation of the infant-feeding method without interference (62.5%), and safety (47.5%). Exclusive breast-feeding was the most preferred method of infant feeding. Disclosure of HIV status by a woman to her partner is a major condition for successful replacement feeding method, especially within the African cultural context. However, disclosure of HIV status to the partner was feared by most women as only 16.2% of the women disclosed their HIV status to partners. CONCLUSION The factors considered by women in choosing the infant-feeding option were ability to implement the options without interference from significant others, affordability, and sociocultural acceptability. Knowledge of the selected option, its advantages and disadvantages, safety, and feasibility were also important factors. Nurses and midwives have to educate clients and support them in their choice of infant-feeding methods.