Quality of care and access to care at birth in low- and middle-income countries

Over two million newborns die at birth or during their first week of life every year. The majority of early neonatal deaths occur in low- and middle-income countries (LMICs) and could be prevented with high-quality care at birth. This thesis studied quality of care and geographic and socioeconomic inequalities in access to care at birth in LMICs. Furthermore, the aim was to elucidate whether birth in a facility improves newborn survival. Quality of emergency obstetric and newborn care, routine care and non-medical care were studied through a health facility assessment in seven districts of Brong Ahafo region in Ghana. Clinical vignettes were used to assess competence of health professionals in managing obstetric emergencies. The effects of two distal determinants (distance to a health facility and socioeconomic inequalities) on early neonatal mortality and on facility delivery were studied; Distance effects were studied using Demographic and Health Survey (DHS) data from rural Malawi and Zambia and Health Facility Census data from both countries. Socioeconomic inequalities were quantified using DHS data on 679,818 live births from 72 LMICs. Hospitals and large health centres provided the highest quality of care, managed the most patients and employed the most competent staff among the 64 delivery facilities in Brong Ahafo region. Quality of care was poor in the smallest facilities. Although coverage of facility delivery was fairly high at 68%, coverage of high-quality care was only 18%. Lack of health provider competence limited emergency care more than shortages of necessary drugs and equipment for management of these emergencies. Although distance to a health facility was a strong barrier to delivery care in rural Malawi and Zambia, proximity to a delivery facility was not associated with lower early neonatal mortality. Similarly, while socioeconomic inequalities in coverage of delivery care were found to be large in the 72 countries studied, inequalities in early neonatal mortality by wealth and education were small in most countries and compared with inequalities in facility delivery and postneonatal infant mortality. The findings of this thesis point to insufficient quality of care at birth in the seven districts of Brong Ahafo region in Ghana, in Malawi and Zambia and in many DHS countries. Early neonatal mortality remains a global health problem that has not been solved by increasing coverage with institutional deliveries. Improving quality of care should be prioritised in the future.Maailmassa kuolee vuosittain yli kaksi miljoonaa lasta synnytyksen tai ensimmäisen elinviikon aikana. Kuolleisuus on suurinta matalan tulotason ja keskitulotason maissa Afrikassa ja Aasiassa. Suurin osa varhaisen vastasyntyneisyyskauden kuolemista voitaisiin kuitenkin estää, jos synnytyksen hoito olisi korkealaatuista. Väitöskirjassa tutkittiin synnytyksen hoidon laatua ja saatavuutta 64 synnytyssairaalassa Brong Ahafon alueella Ghanassa, Malawissa ja Sambiassa sekä laajassa 72 matalan ja keskitulotason maata kattavassa analyysissä, jossa oli mukana yhteensä 679 818 syntymää. Väitöskirjassa verrattiin sosioekonomisia ja maantieteellisiä eroja hoidon saatavuudessa ja varhaisessa vastasyntyneisyyskuolleisuudessa. Tavoitteena oli arvioida, pelastaako synnytyksen hoito synnytyssairaalassa vastasyntyneiden henkiä. Synnytysten hoidon laatu oli matala kaikilla hoidon neljällä osa-alueella eli perushoidossa, synnyttäjän ja vastasyntyneen hätätilanteiden hoidossa sekä ei-lääketieteellisessä hoidossa Brong Ahafon alueella. Lääkärit, kätilöt ja sairaanhoitajat saivat korkeammat pisteet hätätilanteiden hoidon osaamista kartoittavissa potilastapauksissa kuin pienissä sairaaloissa työskentelevät henkilöt. Puutteet henkilökunnan osaamisessa saattoivatkin rajoittaa hätätilanteiden hoitoa enemmän kuin puutteet hoitovälineiden tai lääkkeiden saatavuudessa. Lyhyt maantieteellinen etäisyys kotoa synnytyssairaalaan lisäsi laitossynnytyksen todennäköisyyttä Malawissa ja Sambiassa. Lyhyempi etäisyys ei kuitenkaan vähentänyt varhaista vastasyntyneisyyskuolleisuutta. Analyysit koskien 72 matalan tulotason ja keskitulotason maata osoittivat, että sosioekonomiset erot vastasyntyneisyyskuolleisuudessa olivat pieniä verrattuna eroihin laitossynnytyksissä ja vastasyntyneisyyskauden jälkeisessä imeväiskuolleisuudessa. Tulokset viittaavat siihen, että syntymä sairaalassa ei useimmiten parantanut vastasyntyneen ennustetta kotona syntyneeseen lapseen verrattuna. Synnytyksen hoidon laatu oli puutteellista valtaosassa tutkimukseen osallistuneista synnytyssairaaloista Brong Ahafon alueella Ghanassa, Malawissa ja Sambiassa sekä useissa matalan tulotason ja keskitulotason maassa. Varhainen vastasyntyneisyyskuolleisuus on maailmanlaajuinen ongelma, jota synnytyssairaaloiden ja laitossynnytysten määrän lisääminen ei ole valitettavasti ratkaissut. Tämän vuoksi maiden, joissa on korkea vastasyntyneiden kuolleisuus, tulisi laitossynnytysten määrän lisäämisen sijaan keskittyä synnytysten hoidon laadun varmistamiseen ja parantamiseen

Aneurysmaattiseen lukinkalvonalaiseen verenvuotoon sairastuneen potilaan tehohoito

Teema : neuroanestesiologi

Comparing socioeconomic inequalities between early neonatal mortality and facility delivery: Cross-sectional data from 72 low- and middle-income countries

Facility delivery should reduce early neonatal mortality. We used the Slope Index of Inequality and logistic regression to quantify absolute and relative socioeconomic inequalities in early neonatal mortality (0 to 6 days) and facility delivery among 679,818 live births from 72 countries with Demographic and Health Surveys. The inequalities in early neonatal mortality were compared with inequalities in postneonatal infant mortality (28 days to 1 year), which is not related to childbirth. Newborns of the richest mothers had a small survival advantage over the poorest in unadjusted analyses (−2.9 deaths/1,000; OR 0.86) and the most educated had a small survival advantage over the least educated (−3.9 deaths/1,000; OR 0.77), while inequalities in postneonatal infant mortality were more than double that in absolute terms. The proportion of births in health facilities was an absolute 43% higher among the richest and 37% higher among the most educated compared to the poorest and least educated mothers. A higher proportion of facility delivery in the sampling cluster (e.g. village) was only associated with a small  decrease in early neonatal mortality. In conclusion, while socioeconomically advantaged mothers had much higher use of a health facility at birth, this did not appear to convey a comparable survival advantage

Glymfaattinen järjestelmä avaa aivojen padot

Peer reviewe

Distance to Care, Facility Delivery and Early Neonatal Mortality in Malawi and Zambia

Peer reviewe

Rifampin Reduces the Plasma Concentrations of Oral and Intravenous Hydromorphone in Healthy Volunteers

Peer reviewe

Could dexmedetomidine be repurposed as a glymphatic enhancer?

Cerebrospinal fluid (CSF) flows through the central nervous system (CNS) via the glymphatic pathway to clear the interstitium of metabolic waste. In preclinical studies, glymphatic fluid flow rate increases with low central noradrenergic tone and slow-wave activity during natural sleep and general anesthesia. By contrast, sleep deprivation reduces glymphatic clearance and leads to intracerebral accumulation of metabolic waste, suggesting an underlying mechanism linking sleep disturbances with neurodegenerative diseases. The selective alpha(2)-adrenergic agonist dexmedetomidine is a sedative drug that induces slow waves in the electroencephalogram, suppresses central noradrenergic tone, and preserves glymphatic outflow. As recently developed dexmedetomidine formulations enable self-administration, we suggest that dexmedetomidine could serve as a sedative-hypnotic drug to enhance clearance of harmful waste from the brain of those vulnerable to neurodegeneration

Impact of results-based financing on effective obstetric care coverage : evidence from a quasi-experimental study in Malawi

Background: Results-based financing (RBF) describes health system approaches addressing both service quality and use. Effective coverage is a metric measuring progress towards universal health coverage (UHC). Although considered a means towards achieving UHC in settings with weak health financing modalities, the impact of RBF on effective coverage has not been explicitly studied. Methods: Malawi introduced the Results-Based Financing For Maternal and Neonatal Health (RBF4MNH) Initiative in 2013 to improve quality of maternal and newborn health services at emergency obstetric care facilities. Using a quasi-experimental design, we examined the impact of the RBF4MNH on both crude and effective coverage of pregnant women across four districts during the two years following implementation. Results: There was no effect on crude coverage. With a larger proportion of women in intervention areas receiving more effective care over time, the overall net increase in effective coverage was 7.1%-points (p = 0.07). The strongest impact on effective coverage (31.0%-point increase, p = 0.02) occurred only at lower cut-off level (60% of maximum score) of obstetric care effectiveness. Design-specific and wider health system factors likely limited the program's potential to produce stronger effects. Conclusion: The RBF4MNH improved effective coverage of pregnant women and seems to be a promising reform approach towards reaching UHC. Given the short study period, the full potential of the current RBF scheme has likely not yet been reached.Peer reviewe

Competence of health workers in emergency obstetric care : an assessment using clinical vignettes in Brong Ahafo region, Ghana

Objectives To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities. Design Cross-sectional Health Facility Assessment linked to population-based surveillance data. Setting 7 districts in Brong Ahafo region, Ghana. Participants Most experienced delivery care providers in all 64 delivery facilities in the 7 districts. Primary outcome measures Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant. Results Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p Conclusions Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care.Peer reviewe

Glymphatic-assisted perivascular brain delivery of intrathecal small gold nanoparticles

Nanoparticles are ultrafine particulate matter having considerable potential for treatment of central nervous system (CNS) disorders. Despite their tiny size, the blood-brain barrier (BBB) restricts their access to the CNS. Their direct cerebrospinal fluid (CSF) administration bypasses the BBB endothelium, but still fails to give adequate brain uptake. We present a novel approach for efficient CNS delivery of 111In-radiolabelled gold nanoparticles (AuNPs; 10-15 nm) via intra-cisterna magna administration, with tracking by SPECT imaging. To accelerate CSF brain influx, we administered AuNPs intracisternally in conjunction with systemic hypertonic saline, which dramatically increased the parenchymal AuNP uptake, especially in deep brain regions. AuNPs entered the CNS along periarterial spaces as visualized by MRI of gadolinium-labelled AuNPs and were cleared from brain within 24 h and excreted through the kidneys. Thus, the glymphatic-assisted perivascular network augment by systemic hypertonic saline is a pathway for highly efficient brain-wide distribution of small AuNPs.Peer reviewe