Quality Indicators and Outcomes of Emergency Caesarean Deliveries at a District-level Maternity Hospital

The objective of this research study is to identify quality indicators of cesarean deliveries and determine their relationship to neonatal and maternal morbidity and mortality in one high volume maternity hospital in Lilongwe, Malawi. Demographic, perioperative, and postoperative data were collected on all cesarean deliveries over three months. Indicators of quality (antibiotic administration, use of oxytocin, decision-to-incision time, and uterine incision type) were compared to maternal morbidities (postpartum hemorrhage, fistula and wound infection) and neonatal mortality. Causes of delays in decision to incision time were identified. 513 cesarean deliveries were performed during the study period, with no maternal deaths and 39 neonatal deaths. Adherence to oxytocin and antibiotic administration was high but not complete, with greater adherence to the former (97.1% vs 82.6%). The decision to incision time between women with and without neonatal deaths was similar (1.62 hours vs 1.49 hours, p=0.41). Most delays were attributed to a busy operating theatre (49.1%) and delayed transfer to the operating theatre (26.9%). Uterine rupture and cesarean hysterectomy were associated with an outcome of neonatal death (p<0.001). Infrastructure and personnel limitations are major barriers to the improvement of quality of cesarean deliveries. Future endeavors towards quality improvement must address these deficiencies. (Afr J Reprod Health 2015; 19[3]: 61-67). Keywords: obstetrics, international, quality, low resource L'objectif de cette étude est d'identifier les indicateurs de qualité de césariennes et de déterminer leur relation à la morbidité et la mortalité néonatale et maternelle dans un hôpital de la maternité de volume élevé à Lilongwe, au Malawi. Démographique, périopératoire, et les données post-opératoires ont été recueillies sur tous les accouchements par césarienne plus de trois mois. Indicateurs de qualité (l'administration d'antibiotiques, l'utilisation de l'ocytocine, l e temps de décision à l'incision, et de l'utérus de type d'incision) ont été comparés à de morbidité maternelle (hémorragie post-partum, la fistule et infection de la plaie) et la mortalité néonatale. Les causes de retards dans la prise à l'incision du temps ont été identifiés. 513 césariennes ont été effectuées au cours de la période de l'étude, aucun décès maternels et 39 décès néonatals. L'adhésion à l'ocytocine et l'administration d'antibiotiques était haute mais pas complet, avec une plus grande adhésion à l'ancien (97,1% vs 82,6%). La décision d'incision de temps entre les femmes avec et sans décès néonatals était similaire (1,62 vs 1,49 heures heures, p = 0,41). La plupart des retards ont été attribués à un théâtre chargé d'exploitation (49,1%) et le transfert retardé au théâtre d'exploitation (26,9%). La rupture utérine et l'hystérectomie césarienne ont été associées à un résultat de décès néonatal (p <0,001). Infrastructure et du personnel des limitations sont des obstacles majeurs à l'amélioration de la qualité des accouchements par césarienne. Les efforts futurs vers amélioration de la qualité doivent combler ces lacunes. (Afr J Reprod Health 2015; 19[3]: 61-67). Mots-clés: obstétrique, internationale, de qualité, à faible ressourc

Assessment of laboratory test utilization for HIV/AIDS care in urban ART clinics of Lilongwe, Malawi

Background: The 2011 Malawi HIV guidelines promote CD4 monitoring for pre-ART assessment and considering HIVRNA monitoring for ART response assessment, while some clinics used CD4 for both. We assessed clinical ordering practices as compared to guidelines, and determined whether the samples were successfully and promptly processed. Methods: We conducted a retrospective review of all patients seen in from August 2010 through July 2011,, in two urban HIV-care clinics that utilized 6-monthly CD4 monitoring regardless of ART status. We calculated the percentage of patients on whom clinicians ordered CD4 or HIVRNA analysis. For all samples sent, we determined rates of successful labprocessing, and mean time to returned results. Results: Of 20581 patients seen, 8029 (39%) had at least one blood draw for CD4 count. Among pre-ART patients, 2668/2844 (93.8%) had CD4 counts performed for eligibility. Of all CD4 samples sent, 8082/9207 (89%) samples were successfully processed. Of those, mean time to processing was 1.6 days (s.d 1.5) but mean time to results being available to clinician was 9.3 days (s.d. 3.7). Regarding HIVRNA, 172 patients of 17737 on ART had a blood draw and only 118/213 (55%) samples were successfully processed. Mean processing time was 39.5 days (s.d. 21.7); mean time to results being available to clinician was 43.1 days (s.d. 25.1). During the one-year evaluated, there were multiple lapses in processing HIVRNA samples for up to 2 months. Conclusions: Clinicians underutilize CD4 and HIVRNA as monitoring tools in HIV care. Laboratory processing failures and turnaround times are unacceptably high for viral load analysis. Alternative strategies need to be considered in order to meet laboratory monitoring needs

Improving viral load testing using a quality improvement approach in Blantyre, Malawi

Background Viral load (VL) testing coverage remains low particularly in resource limited countries despite recommendation by World Health Organization, and Malawi is no exception. A quality improvement (QI) approach was used to improve VL testing coverage from 27% to a target of 80% at an urban health facility in Malawi. Methods A QI study employing a time-series quasi-experimental design with no comparison group was conducted at Chilomoni health centre in Blantyre from April 2020 to July 2020. A retrospective record review of all patient records (257) from 8 weeks before the study was conducted to determine baseline VL testing coverage. Root cause analysis of low VL testing coverage was done using fish-bone tool and factors prioritized using a Pareto-chart. Priority factors included inadequate capacity to update electronic medical records and competing tasks. Change ideas were identified and prioritized using an effort-impact matrix. Two change ideas; re-orienting ART providers on VL test order in EMR and dedicated ART provider to serve VL tested patients were implemented and tested in 5 Plan-Do-Study-Act (PDSA) cycles from the Model for Improvement (MFI), each lasting one week. The latter was tested, and adapted in 3 cycles, and eventually adopted for monitoring for another 5 weeks. VL testing coverage was tracked throughout the study using run charts and p-charts. Results VL testing coverage increased from 27% to 71% by the end of the study, with children aged 0 to 14 years having the lowest coverage throughout the study. Conclusion The MFI as a QI approach improved VL testing coverage through implementation of contextualized change ideas. A reliable data system, leadership buy-in and commitment are important for sustained improvement. Future research should focus on evaluating sustainability of improved VL testing coverage at the health facility and assessing barriers to VL testing among the paediatric population

“Life is at a standstill” Quality of life after lower extremity trauma in Malawi

Low- and middle-income countries face a disproportionate burden of death and disability from injuries, many of which are due to road traffic accidents or falls. Lower extremity injuries in particular have implications not only for physical disabilities affecting work and school performance, but also for quality of life (QOL) of the individual. This qualitative study explores the psychosocial impact and QOL changes due to lower extremity injuries among trauma patients in central Malawi

Policy to practice: impact of GeneXpert MTB/RIF implementation on the TB spectrum of care in Lilongwe, Malawi

While previous research has provided evidence of the diagnostic accuracy of the GeneXpert MTB/RIF (GeneXpert), further information is needed about implementation in the real-world. This study evaluated the impact of the introduction of GeneXpert testing in a tertiary medical center according to the testing algorithm proposed by the National TB Control Program (NTP) guidelines

Who Starts? Factors Associated with Starting Antiretroviral Therapy among Eligible Patients in Two, Public HIV Clinics in Lilongwe, Malawi

BackgroundLighthouse Trust operates two, public, integrated HIV clinics, Lighthouse (LH) and Martin Preuss Center (MPC), in Lilongwe, Malawi. Approximately 20% of patients eligible for antiretroviral therapy (ART) do not start ART. We explore individual and geographic factors that influence whether ART-eligible patients initiate ART.MethodsAdult patients eligible for ART between 2008–2011 were included. Analysis was stratified by clinic. Using logistic regression, we evaluated factors associated with initiating ART including gender, age, body mass index (BMI), employment, tuberculosis (TB), eligible at initial registration, WHO stage, CD4, months in pre-ART care (from initial registration to eligibility date), and patient neighborhood distance to clinic.ResultsOf 14,216 study patients, 4841 were from LH; 9285 were from MPC. At LH and MPC, respectively, median age was 34.2 and 33.8 years; median BMI was 22.0 and 20.6; and median distance was 5.6 and 4.9 Km. In multivariate models, odds of starting ART was highest among those older than 35 years and those eligible for ART based on WHO stages 3–4 vs. those in WHO stages 1–2 with CD4<250. Patients with 1–12 months in pre-ART were at least 11 times more likely to start ART than peers with less pre-ART time. At LH, living 2.5–5 Km from the clinic increased the likelihood of starting ART over patients living closer.ConclusionsLength of the pre-ART period is the most significant predictor of starting ART among eligible patients. Better understanding of motivation for retention in pre-ART care may reduce attrition along the treatment cascade

High rates of cervical cancer among HIV-infected women at a referral hospital in Malawi

Cervical cancer is the most common cancer among women in Malawi. National guidelines recommend screening women aged 30–45 years every five years; however, no specific recommendations exist for women with HIV. We aimed to assess the frequency of high-grade dysplasia (CIN 2 or CIN3) and cervical cancer among women in central Malawi and to examine associations with CIN2+ (CIN2/3 or cancer)

Hyperlipidaemia in HIV-infected patients on lopinavir/ritonavir monotherapy in resource-limited settings

Cardiovascular disease (CVD) is an emerging concern for HIV-infected patients. Hyperlipidemia is a risk factor for CVD and a complication of protease-inhibitor-based antiretroviral therapy, but little is known about its incidence and risk factors in treated patients in resource-limited settings (RLS)