Prognostic algorithms for post-discharge readmission and mortality among mother-infant dyads: an observational study protocol

IntroductionIn low-income country settings, the first six weeks after birth remain a critical period of vulnerability for both mother and newborn. Despite recommendations for routine follow-up after delivery and facility discharge, few mothers and newborns receive guideline recommended care during this period. Prediction modelling of post-delivery outcomes has the potential to improve outcomes for both mother and newborn by identifying high-risk dyads, improving risk communication, and informing a patient-centered approach to postnatal care interventions. This study aims to derive post-discharge risk prediction algorithms that identify mother-newborn dyads who are at risk of re-admission or death in the first six weeks after delivery at a health facility.MethodsThis prospective observational study will enroll 7,000 mother-newborn dyads from two regional referral hospitals in southwestern and eastern Uganda. Women and adolescent girls aged 12 and above delivering singletons and twins at the study hospitals will be eligible to participate. Candidate predictor variables will be collected prospectively by research nurses. Outcomes will be captured six weeks following delivery through a follow-up phone call, or an in-person visit if not reachable by phone. Two separate sets of prediction models will be built, one set of models for newborn outcomes and one set for maternal outcomes. Derivation of models will be based on optimization of the area under the receiver operator curve (AUROC) and specificity using an elastic net regression modelling approach. Internal validation will be conducted using 10-fold cross-validation. Our focus will be on the development of parsimonious models (5–10 predictor variables) with high sensitivity (>80%). AUROC, sensitivity, and specificity will be reported for each model, along with positive and negative predictive values.DiscussionThe current recommendations for routine postnatal care are largely absent of benefit to most mothers and newborns due to poor adherence. Data-driven improvements to postnatal care can facilitate a more patient-centered approach to such care. Increasing digitization of facility care across low-income settings can further facilitate the integration of prediction algorithms as decision support tools for routine care, leading to improved quality and efficiency. Such strategies are urgently required to improve newborn and maternal postnatal outcomes. Clinical trial registrationhttps://clinicaltrials.gov/, identifier (NCT05730387)

The dynamics of commodity return comovements

We compare factor models with respect to their ability to explain commodity futures return comovements. A simple one-factor model based on the first principal component extracted from a panel of commodity returns outperforms a macroeconomic model, and explains most of the realized comovements. We find that intersectoral correlations display more time variations than intrasectoral correlations. Dissecting the evidence further, we find that comovements are driven by the variation of the factor as opposed to exposure to it. Our results cast doubt on the persistence of the effects of financialization and emphasize the importance of the dynamics of the factor variance

Policies and clinical practices relating to the management of gestational diabetes mellitus in the public health sector, South Africa – a qualitative study

BACKGROUND: Women with a prior gestational diabetes have an increased lifetime risk of developing type 2 diabetes. Although post-partum follow-up for GDM women is essential to prevent progression to type 2 diabetes, it is poorly attended. The need for health systems interventions to support postpartum follow-up for GDM women is evident, but there is little knowledge of actual current practice. The aim of this study was to explore current policies and clinical practices relating to antenatal and post-natal care for women with GDM in South Africa, as well as health sector stakeholders’ perspectives on the barriers to – and opportunities for – delivering an integrated mother - baby health service that extends beyond the first week post-partum, to the infant’s first year of life. METHODS: Following a document review of policy and clinical practice guidelines, in-depth interviews were conducted with 11 key informants who were key policy makers, health service managers and clinicians working in the public health services in South Africa’s two major cities (Johannesburg and Cape Town). Data were analysed using qualitative content analysis procedures. RESULTS: The document review and interviews established that it is policy that health services adhere to international guidelines for GDM diagnosis and management, in addition to locally developed guidelines and protocols for clinical practice. All key informants confirmed that lack of postpartum follow-up for GDM women is a significant problem. Health systems barriers include fragmentation of care and the absence of standardised postnatal care for post-GDM women. Key informants also raised patient - related challenges including lack of perceived future risk of developing type 2 diabetes and non-attendance for postpartum follow up, as barriers to postnatal care for GDM women. All participants supported integrated primary health services but cautioned against overloading health workers. CONCLUSION: Although there is alignment between international guidelines, local policy and reported clinical practice in the management of GDM, there is a gap in continuation of care in the postpartum period. Health systems interventions that support and facilitate active follow-up for women with prior GDM are needed if high rates of progression to type 2 diabetes are to be avoided

Chamas for Change: an integrated community-based strategy of peer support in pregnancy and infancy in Kenya

Background: Many women and children face the challenges of pregnancy and infancy without supportive relationships at home or in the community. To address this problem, the Academic Model Providing Access to Healthcare (AMPATH), in partnership with the Government of Kenya, launched Chama cha MamaToto, a peer-support model that groups women together at the start of their pregnancies. Central to our approach is the integration of microfinance into a group model that focuses on health education and relationship strengthening using a social fundraising platform well known to women: chamas. Chamas are effective networks through which women can meet regularly outside the home and pool resources. Using this existing cultural script, we developed these mother-child investment clubs in a rural district. Through their operation as a “table banking system”, members become shareholders in each other's futures, not only through the disbursement of loans, but also by keeping each other accountable to healthy practices for themselves and their children. The meetings provide opportunities for community health workers (CHWs) to efficiently disseminate health information, organise referrals, and build relationships with women and infants. Methods: In 2012, 32 Government of Kenya CHWs recruited more than 400 pregnant and breastfeeding women to 16 chamas in Bunyala subcounty, Kenya. These groups met fortnightly for 12 months. On joining, women pledged to participate for 1 year and to uphold the goals of the chama: support each other, attend prenatal care, deliver in a health facility, breastfeed exclusively for 6 months, adopt long-term family planning, save money, and become entrepreneurs. To evaluate the effect, acceptability, and sustainability of chamas, we compared data from a prospective cohort of women in chamas with a group of controls who did not belong to a chama, matched for age, parity, and location of prenatal care. Findings: We analysed data for 222 chama women and 115 controls, and found that compared with controls, women in chamas were 73% more likely to attend four recommended prenatal visits (64% vs 37%, p<0·001), 67% more likely to give birth in a health facility (84% vs 50%, p<0·001), 75% more likely to breastfeed exclusively to 6 months (82% vs 47%, p<0·001), and 98% more likely to receive the recommended homevisit from a CHW within 48h of birth (76% vs 38%, p<0·001). Furthermore, women in chamas were less likely to have a stillbirth or newborn death (2·4% vs 5·2%, p=0·083). Interpretation: Chamas can be tailored to increase the uptake of health services in pregnancy and infancy. Chamas for Change is designed to enable populations to sustain beneficial health effects beyond the funding period by equipping women with the peer and financial supports necessary to sustain change. As the programme enters its third year, we propose a cluster randomised trial of chamas across three counties and one million people as a population-wide strategy to rapidly and sustainably achieve health and gender equity outcomes. Funding: We received funding from Saving Lives at Birth and USAID PEPFAR

Promoting positive maternal, newborn, and child health behaviors through a group-based health education and microfinance program: a prospective matched cohort study in western Kenya

Background: Chamas for Change (Chamas) is a group-based health education and microfinance program for pregnant and postpartum women that aims to address inequities contributing to high rates of maternal and infant mortality in rural western Kenya. In this prospective matched cohort study, we evaluated the association between Chamas participation and facility-based delivery. We additionally explored the effect of participation on promoting other positive maternal, newborn and child health (MNCH) behaviors. Methods: We prospectively compared outcomes between a cohort of Chamas participants and controls matched for age, parity, and prenatal care location. Between October–December 2012, government-sponsored community health volunteers (CHV) recruited pregnant women attending their first antenatal care (ANC) visits at rural health facilities in Busia County to participate in Chamas. Women enrolled in Chamas agreed to attend group-based health education and microfinance sessions for one year; controls received the standard of care. We used descriptive analyses, multivariable logistic regression models, and random effect models to compare outcomes across cohorts 12 months following enrollment, with α set to 0.05. Results: Compared to controls (n = 115), a significantly higher proportion of Chamas participants (n = 211) delivered in a health facility (84.4% vs. 50.4%, p < 0.001), attended at least four ANC visits (64.0% vs. 37.4%, p < 0·001), exclusively breastfed to six months (82.0% vs. 47.0%, p < 0·001), and received a CHV home visit within 48 h postpartum (75.8% vs. 38.3%, p < 0·001). In multivariable models, Chamas participants were over five times as likely as controls to deliver in a health facility (OR 5.49, 95% CI 3.12–9.64, p < 0.001). Though not significant, Chamas participants experienced a lower proportion of stillbirths (0.9% vs. 5.2%), miscarriages (5.2% vs. 7.8%), infant deaths (2.8% vs. 3.4%), and maternal deaths (0.9% vs. 1.7%) compared to controls. Conclusions: Chamas participation was associated with increased odds of facility-based delivery compared to the standard of care in rural western Kenya. Larger proportions of program participants also practiced other positive MNCH behaviors. Our findings demonstrate Chamas’ potential to achieve population-level MNCH benefits; however, a larger study is needed to validate this observed effect. Trial registration: ClinicalTrials.gov, NCT03188250 (retrospectively registered 31 May 2017).Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacult

Risk factors for postpartum maternal mortality and hospital readmission in low- and middle-income countries: a systematic review

Abstract Background In low- and middle-income countries, approximately two thirds of maternal deaths occur in the postpartum period. Yet, care for women beyond 24 h after discharge is limited. The objective of this systematic review is to summarize current evidence on socio-demographic and clinical risk factors for (1) postpartum mortality and (2) postpartum hospital readmission. Methods A combination of keywords and subject headings (i.e. MeSH terms) for postpartum maternal mortality or readmission were searched. Articles published up to January 9, 2021 were identified in MEDLINE, EMBASE, and CINAHL databases, without language restrictions. Studies reporting socio-demographic or clinical risk factors for postpartum mortality or readmission within six weeks of delivery among women who delivered a livebirth in a low- or middle-income country were included. Data were extracted independently by two reviewers based on study characteristics, population, and outcomes. Included studies were assessed for quality and risk of bias using the Downs and Black checklist for ratings of randomized and non-randomized studies. Results Of 8783 abstracts screened, seven studies were included (total N = 387,786). Risk factors for postpartum mortality included Caesarean mode of delivery, nulliparity, low or very low birthweight, and shock upon admission. Risk factors for postpartum readmission included Caesarean mode of delivery, HIV positive serostatus, and abnormal body temperature. Conclusions Few studies reported individual socio-demographic or clinical risk factors for mortality or readmission after delivery in low- and middle-income countries; only Caesarean delivery was consistently reported. Further research is needed to identify factors that put women at greatest risk of post-discharge complications and mortality. Understanding post-discharge risk would facilitate targeted postpartum care and reduce adverse outcomes in women after delivery. Trial registration PROSPERO registration number: CRD42018103955