Troubleshooting obstetric spinal anaesthesia at district hospital level

Obstetric spinal anaesthesia is routinely used in South African district hospitals for caesarean sections, providing better maternal and neonatal outcomes than general anaesthesia in appropriate patients. However, practitioners providing anaesthesia in this context are usually generalists who practise anaesthesia infrequently and may be unfamiliar with dealing with complications of spinal anaesthesia or with conversion from spinal to general anaesthesia. This is compounded by challenges with infrastructure, shortages of equipment and sundries and a lack of context-sensitive guidelines and support from specialised anaesthetic services for district hospitals. This continuous professional development (CPD) article aims to provide guidance with respect to several key areas related to obstetric spinal anaesthesia, and to address common concerns and queries. We stress that good clinical practice is essential to avoid predictable, common complications, and hence a thorough preoperative preparation is essential. We further discuss clinical indications for preoperative blood testing, spinal needle choice, the use of isobaric bupivacaine, spinal hypotension, failed or partial spinal block and pain during the caesarean section. Where possible, relevant local and international guidelines are referenced for further reading and guidance, and a link to a presentation of this topic is provided.

Impacts of COVID-19 on contraceptive and abortion services in low- and middle-income countries: a scoping review

The COVID-19 pandemic has disproportionate effects on people living in low- and middle-income countries (LMICs), exacerbating weak health systems. We conducted a scoping review to identify, map, and synthesise studies in LMICs that measured the impact of COVID-19 on demand for, provision of, and access to contraceptive and abortion-related services, and reproductive outcomes of these impacts. Using a pre-established protocol, we searched bibliographic databases (December 2019–February 2021) and key grey literature sources (December 2019–April 2021). Of 71 studies included, the majority (61%) were not peer-reviewed, and 42% were based in Africa, 35% in Asia, 17% were multi-region, and 6% were in Latin America and the Caribbean. Most studies were based on data through June 2020. The magnitude of contraceptive service-related impacts varied widely across 55 studies (24 of which also included information on abortion). Nearly all studies assessing changes over time to contraceptive service provision noted declines of varying magnitude, but severe disruptions were relatively uncommon or of limited duration. Twenty-six studies addressed the impacts of COVID-19 on abortion and postabortion care (PAC). Overall, studies found increases in demand, reductions in provision and increases in barriers to accessing these services. The use of abortion services declined, but the use of PAC was more mixed with some studies finding increases compared to pre-COVID-19 levels. The impacts of COVID-19 varied substantially, including the country context, health service, and population studied. Continued monitoring is needed to assess impacts on these key health services, as the COVID-19 pandemic evolves.

An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania

Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap.

We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index.

71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients.

Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility’s construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration

Psychoeducation for psychological issues and birth preparedness in LMICs: A systematic review

Psychological issues usually accompany the pregnancy of first-time mothers and psychoeducational interventions might be effective in addressing these concerns and preparing first-time mothers for childbirth and the postnatal period. This study aimed to identify, analyse and synthesise the components as well as determine the effectiveness of psychoeducational interventions that are used for managing psychological issues and enhancing birth preparedness among primigravid women or couples in LMICs.

A systematic search of 12 databases (APA PsycINFO, Emcare, Embase, MEDLINE(R), Ovid Nursing, British Nursing Index, Health and Medical Collection, ProQuest, CINAHL, Cochrane, Hinari and PubMed) was conducted to identify relevant studies published between 1946 and October 2021. Quality of the included studies was appraised by the JBI critical appraisal tool and a narrative synthesis was conducted to analyse data extracted from included articles. The systematic review protocol is registered with PROSPERO (CRD42021237896).

The initial search yielded 8,658 articles. Sixteen articles including seven randomised controlled trials and nine non-randomised trials met the inclusion criteria and were selected and reviewed for quality. Thirty-nine outcomes were measured in the studies including psychological outcomes, birth preparedness outcomes and other outcomes. The design of the interventions included antenatal education that was delivered through lectures, role plays, trainings, and antenatal counselling. All the psychoeducational interventions had a significant effect (p <. 05; Cohen's d or Hedge’ g = 0.2 to 1.9) on certain psychological outcomes including childbirth attitude, fear of childbirth, depression, fear, and anxiety and birth preparedness outcomes.

Although first-time mothers experience a range of psychological issues during pregnancy, psychoeducational interventions were beneficial in addressing their psychological concerns. It would appear that these interventions are less expensive and could be easily implemented in LMICs. However, rigorous research like RCTs are hereby warranted to standardise the interventions and outcome assessment tools.

How Climate Change May Threaten Progress in Neonatal Health in the African Region

Climate change is likely to have wide-ranging impacts on maternal and neonatal health in Africa. Populations in low-resource settings already experience adverse impacts from weather extremes, a high burden of disease from environmental exposures, and limited access to high-quality clinical care. Climate change is already increasing local temperatures. Neonates are at high risk of heat stress and dehydration due to their unique metabolism, physiology, growth, and developmental characteristics. Infants in low-income settings may have little protection against extreme heat due to housing design and limited access to affordable space cooling. Climate change may increase risks to neonatal health from weather disasters, decreasing food security, and facilitating infectious disease transmission. Effective interventions to reduce risks from the heat include health education on heat risks for mothers, caregivers, and clinicians; nature-based solutions to reduce urban heat islands; space cooling in health facilities; and equitable improvements in housing quality and food systems. Reductions in greenhouse gas emissions are essential to reduce the long-term impacts of climate change that will further undermine global health strategies to reduce neonatal mortality.

Exposure to family planning messages and contraceptive use among women of reproductive age in Sub-Saharan Africa: A crosssectional program impact evaluation study

Many women of reproductive age in sub Saharan Africa are not utilizing any contraceptive method which is contributing to the high burden of maternal mortality. This study determined the prevalence, trends, and the impact of exposure to family planning messages (FPM) on contraceptive use (CU) among women of reproductive age in sub-Saharan Africa (SSA). We utilized the most recent data from demographic and health surveys across 26 SSA countries between 2013 and 2019. We assessed the prevalence and trends and quantified the impact of exposure to FPM on contraceptive use using augmented inverse probability weighting with regression adjustment. Sensitivity analysis of the impact estimate was conducted using endogenous treatment effect models, inverse probability weighting, and propensity score with nearest-neighbor matching techniques. The study involved 328,386 women of reproductive age. The overall prevalence of CU and the percentage of women of reproductive age in SSA exposed to FPM were 31.1% [95% CI: 30.6–31.5] and 38.9% [95% CI: 38.8–39.4] respectively. Exposure to FPM increased CU by 7.1 percentage points (pp) [95% CI = 6.7, 7.4] among women of reproductive age in SSA. The impact of FPM on CU was highest in Central Africa [6.7 pp; 95% CI: [5.7–7.7] and lowest in Southern Africa [2.2 pp; 95% CI: [1.3-3.0]. There was a marginal decline in the impact estimate among adolescents (estimate = 6.0 pp [95% CI = 5.0, 8.0]). Exposure to FPM has contributed to an increase in CU among women of reproductive age. Programs that are geared towards intensifying exposure to FPM through traditional media in addition to exploring avenues for appropriate use of electronic media remain critical.

Recognise and Acknowledge Us: Views of Traditional Birth Attendants on Collaboration with Midwives for Maternal Health Care Services

Background. Traditional birth attendants have since ancient time provided care to pregnant women. As such, the collaboration between midwives and traditional birth attendant (TBAs) can be an essential effort towards the reduction of the maternal and neonatal mortality and morbidity rate especially in low- and middle-income countries (LMICs). This paper argues that the collaboration between traditional and formal health systems expands the reach and improves outcomes of community health care. The study is aimed at exploring the traditional birth attendant’s views on collaboration with midwives for maternal health care services at selected rural communities in South Africa (SA). Methods. The study was conducted in two rural communities in Tshwane and Johannesburg metropolitan districts from 15 June to 31 October 2021. The study followed the qualitative explorative and descriptive research design. The sampling technique was nonprobability purposive, and snowballing technique was also used to sample the key informants who are the traditional birth attendants also known as traditional healers and who provide maternal health care services in the respective communities. The access to these participants was through the gatekeepers, the Traditional Health Organisation Council (THO) council. Data collection was through semistructured in-depth interviews. Data were analysed thematically through the eight steps of Tesch. Results. Five main themes were identified which included the recognition of traditional birth attendants as enablers of collaboration, the envisaged value of the collaboration, processes required to foster collaboration, repositioning for new roles, and barriers to collaboration. Conclusion. The TBAs are ready to collaborate with the formal health care system, and all they require is for their services to maternal health care to be recognised and acknowledged.

The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial

The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)–led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings.

This trial assesses whether CHW’s use of a mobile health (mHealth)–facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district.

A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care.

The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively).

Home-based post–c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy.

Delineating natural catchment health districts with routinely collected health data from women’s travel to give birth in Ghana

Health service areas are essential for planning, policy and managing public health interventions. In this study, we delineate health service areas from routinely collected health data as a robust geographic basis for presenting access to maternal care indicators.

A zone design algorithm was adapted to delineate health service areas through a cross-sectional, ecological study design. Health sub-districts were merged into health service areas such that patient flows across boundaries were minimised. Delineated zones and existing administrative boundaries were used to provide estimates of access to maternal health services. We analysed secondary data comprising routinely collected health records from 32,921 women attending 27 hospitals to give birth, spatial demographic data, a service provision assessment on the quality of maternal healthcare and health sub-district boundaries from Eastern Region, Ghana.

Clear patterns of cross border movement to give birth emerged from the analysis, but more women originated closer to the hospitals. After merging the 250 sub-districts in 33 districts, 11 health service areas were created. The minimum percent of internal flows of women giving birth within any health service area was 97.4%. Because the newly delineated boundaries are more “natural” and sensitive to observed flow patterns, when we calculated areal indicator estimates, they showed a marked improvement over the existing administrative boundaries, with the inclusion of a hospital in every health service area.

Health planning can be improved by using routine health data to delineate natural catchment health districts. In addition, data-driven geographic boundaries derived from public health events will improve areal health indicator estimates, planning and interventions.

Spatial clustering of maternal health services utilization and its associated factors in Tanzania: Evidence from 2015/2016 Tanzania Demographic Health Survey

Background: Utilization of maternal health services is the most significant component of safe motherhood, with severe effects on mother and child health. Though early and timely utilization of maternal health care services is recommended, many women do not access them. This study is aimed at examining the spatial clustering of maternal health services utilization and its associated socio-economic factors in Tanzania.

Methods: The secondary data analysis was conducted using Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. Spatial clusters of high and low use of maternal health care were detected using the Bernoulli model implemented in SaTScan™ software. The multiple logistic regression model was used to identify the predictors of maternal health services utilization in Tanzania.

Results: The Spatial analysis revealed that antenatal care and delivery care are heterogeneous across regions. High utilization was detected in Eastern and East-central regions, while low utilization was detected in northern and northwest regions. Moreover, mother’s age, education level, wealth status, and several children were identified as predictors of the use of antenatal care and delivery care.

Conclusion: Results suggest spatial variation across the regions, though the data are insufficient to identify factors associated with a specific cluster. More data and analysis are needed to establish factors associated with high and low utilization of maternal health care services.