Emergency obstetrical complications in a rural African setting (Kayes, Mali) : the link between spatial access and maternal mortality

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Measuring and evaluating quality of care in referral maternities in Mali and Senegal in the context of overlapping interventions

Dans cette thèse, nous décrivons les résultats d’un projet de recherche visant à mesurer et évaluer la qualité des soins obstétricaux des hôpitaux de référence au Mali et au Sénégal. Dans ces pays, la mortalité maternelle hospitalière est élevée et est liée en partie à la pratique médicale inadéquate. Cette recherche a été réalisée dans le cadre de l’étude QUARITE, un essai randomisé en grappe évaluant l’efficacité du programme GESTA International visant à réduire la mortalité maternelle hospitalière. GESTA a été mis en œuvre entre 2008 et 2010 et consistait en la formation des professionnels de santé et en la revue des cas de décès maternels. En parallèle de QUARITE, les programmes de prévention de la transmission du VIH de la mère à l’enfant (PTME) ont été mis à l’échelle à travers les pays. Ces derniers ayant également la capacité d’augmenter la qualité des soins obstétricaux, nous avons donc évalué les effets des deux programmes (GESTA et PTME) sur la qualité des soins. Dans un premier temps, à l’aide d’une recension des écrits nous avons évalué la capacité d’un audit clinique basé sur des critères à mesurer la qualité des soins obstétricaux. Cet audit vérifiait si l’offre des soins avait respecté les critères cliniques définissant la meilleure prise en charge selon l’évidence scientifique et l’avis des experts. Nous avons démontré que cet outil est largement utilisé dans les pays à faibles et moyens revenus, malgré le peu d’évidence sur sa validité (article 1). Dans un deuxième temps, nous avons développé un audit clinique basé sur des critères qui s’applique au contexte ouest-africain et qui a été approuvé par des experts-obstétriciens nationaux et internationaux. À partir des dossiers obstétricaux, les actes médicaux posés pendant le travail et l’accouchement ont été évalués à l‘aide de cet instrument. La qualité des soins a été estimée sous forme de pourcentage de critères atteints. Appliqué dans différents contextes et par différents auditeurs, nous avons démontré que notre instrument est fiable et valide (article 3). Néanmoins, l’expérience de l’audit nous a amenés à nous questionner sur le mauvais remplissage des dossiers médicaux et ses conséquences sur la qualité des soins (article 2). Dans un troisième temps, l’outil a été appliqué à large échelle pour évaluer les effets de l’intervention GESTA (article 4). Nous avons mené une révision de plus de 800 dossiers obstétricaux dans 32 hôpitaux de référence (16 bénéficiaires de l’intervention et 16 non-bénéficiaires). Grâce à cet audit clinique, nous avons démontré que le programme GESTA contribue à l’amélioration de la qualité des soins, spécifiquement l’examen clinique lors de l’admission et le suivi après l’accouchement. Dernièrement, nous avons utilisé cet instrument afin d’évaluer les effets des programmes de PTME sur la qualité des soins obstétricaux (article 5). Notre travail a documenté que seulement certaines composantes du programme de PTME améliorent la qualité des soins telles que la formation des professionnels et les services complémentaires en nutrition. En conclusion, cette recherche a identifié plusieurs pistes d’intervention pour améliorer la qualité des soins obstétricaux en Afrique de l’Ouest.In this thesis, we describe the results of a research project that aimed to measure and evaluate quality of care in referral hospitals in Mali and Senegal. In these countries, hospital maternal mortality is high and linked, in part, to inadequate medical practice. This research was conducted as part of the QUARITE cluster randomized trial that assessed whether the program, ALARM International, could reduce facility maternal mortality. ALARM was implemented from 2008 to 2010 and consisted of the training of local health professionals and the use of maternal death reviews. At the same time as QUARITE was ongoing, programs for the prevention of maternal to child transmission of HIV (PMTCT) were scaled- up; these can also improve obstetrical quality of care. Thus, we evaluated the effects of both programs (ALARM and PMTCT) on quality of care. We began with a systematic review of the literature to evaluate the capacity of a criterion-based clinical audit to measure the quality of obstetrical care (article 1). This type of audit verifies if the care provided meets criteria indicative of best clinical practices, according to the literature and expert opinion. Our review demonstrates that this tool has been used in a variety of low- and middle-income settings, but the way it has previously been employed leaves doubts as to its validity (article 1). We thus developed a criterion based clinical audit specific to the West African context and approved by national and international expert obstetricians. Using patient medical records, with this instrument we evaluated obstetrical care provided during labour and delivery. Quality of care was calculated based on the percentage of care criteria met. Applied to different sites and by different auditors, our instrument demonstrated concordant results and provided a valid image of the quality of obstetrical care provided at hospitals in the region (article 3). Nonetheless, the audit experience raised concerns about the implications of poor medical recordkeeping and archiving on quality of care (article 2). We used the criterion-based clinical audit to review over 800 medical records at 32 QUARITE hospitals (16 intervention and 16 control hospitals) in order to evaluate the effects of the ALARM intervention. We demonstrated that the ALARM program contributes to better obstetrical quality of care, especially during the first clinical examination and postpartum monitoring of women treated at intervention hospitals (article 4). Finally, we used this instrument to evaluate the effects of PMTCT programs on obstetrical quality of care (article 5). Our work demonstrated that certain components of a PMTCT program, specifically training of healthcare professionals and supplementary nutritional services, are associated with better obstetrical care. In all, this research identified several mechanisms that can be targeted by quality improvement interventions in West Africa

NGO-provided free HIV treatment and services in Burkina Faso: scarcity, therapeutic rationality and unfair process

Until 2010, Burkina Faso was an exception to the international trend of abolishing user fees for antiretroviral treatment (ART). Patients were still expected to pay 1,500F CFA (2 Euros) per month for ART. Nevertheless, many non-governmental organizations (NGOs) exempted patients from payment. The objective of this study was to investigate how NGOs selected the beneficiaries of payment exemptions for government-provided ART and rationed out complementary medical and psychosocial services

Childhood adversity and leisure time physical and sports activity in older adults: A cross-sectional analysis from the International Mobility in Aging Study

Aim: The purpose is to examine the relationship between childhood adversity and leisure time physical activity (LTPA) among community-dwelling older adults from high and middle-income sites. Methods: Cross-sectional analysis of 2012 data from older adult ages 64-75 years old from King-ston, Canada; St. Hyacinthe, Canada; Tirana, Albania; Manizales, Colombia; and Natal, Brazil. Principal exposure variables were childhood social and economic adversity. Covariates included participant age, sex, income, and educational attainment. Outcome variables were LTPA and lei-sure time sports activity (LTSA). Results: High-income sites had higher LTPA prevalence than middle-income sites. Females were less likely to engage in LTPA compared to males in Tirana (OR:0.53, 95%CI:0.30-0.94), but were more likely to engage in LTPA in Manizales (OR:2.54, 95%CI:1.54-4.18). Low education was less likely than high education to engage in LTPA in Kingston (OR:0.38, 95%CI:0.19-0.73) and Natal (OR: 0.52, 95%CI:0.28-0.97). Low income was less likely than high income to engage in LTPA in St. Hyacinthe (OR: 0.42, 95%CI:0.20-0.89) and Manizales (OR:0.33, 95%CI:0.16-0.55). In Tirana, low income was more likely than high income to engage in LTPA (OR:5.27, 95%CI:2.06-13.51). Conclusions: Childhood economic and social adversity were not significantly associated with LTPA. Sex, income, and education were associated with older adult PA engagement, however the direction of the association varied by site location. This suggests that the paradigms surrounding PA behavior may vary from city to city. Understanding the site-specific risk factors to PA engage-ment may better inform clinical recommendations and public health approaches to increase PA engagement among older adults across the globe

Disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the International Mobility in Aging Study

Introduction:The relationships between falls, fear of falling, poor mobility, and PA avoidance occur in a cyclic, multi-directional fashion. Aim: This study investigates the concomitant associations of fall history, fear of falling, and physical performance (SPPB) on physical activity using a cross-national sample of community-dwelling older adults from middle and high-income countries.Methods:Linear mixed-effects models looking at the influence of individual and environmental factors were used and participants were nested within each study site.Results:Estimated walking minutes was 52% lower for those with low SPPB compared to high SPPB, 20% lower for those with medium level fear of falling compared to low levels, and 50% lower for those with high level fear of falling compared to low levels.Conclusion:An individual’s fear of falling and physical performance may be important to consider when making PA recommendations to older adults regardless of sex, age, and environment

Local country food sources of methylmercury, selenium and omega-3 fatty acids in Nunavik, Northern Quebec

Country foods are central to Inuit culture and replete in selenium (Se) and long-chain omega-3 polyunsaturated fatty acids (n-3 PUFA). However, some marine country foods bioaccumulate high concentrations of methylmercury (MeHg). Se and n-3 are associated with several health benefits in Nunavik, Northern Quebec, but, recent studies show that prenatal MeHg exposure is associated with visual, cognitive and behavioral deficit later in childhood. The study objectives are to identify contemporary country food sources of MeHg, Se and long-chain n-3 PUFA in Nunavik, particularly among childbearing-age women, taking into account regional differences in consumption profiles. The contribution of different country foods to daily MeHg, Se, long-chain n-3 PUFA intake (μg/kg body weight/day) was estimated using: (i) country food consumption and blood biomarkers data from the 2004 Nunavik Health Survey (387 women, 315 men), and (ii) data on MeHg, Se, long-chain n-3 PUFA concentrations found in Nunavik wildlife species. In the region where most traditional beluga hunting takes place in Nunavik, the prevalence of at-risk blood Hg (≥ 8 μg/L) in childbearing-age women was 78.4%. While most country foods presently consumed contain low MeHg, beluga meat, not a staple of the Inuit diet, is the most important contributor to MeHg: up to two-thirds of MeHg intake in the beluga-hunting region (0.66 of MeHg intake) and to about one-third in other regions. In contrast, seal liver and beluga mattaaq - beluga skin and blubber - only mildly contributed to MeHg (between 0.06 and 0.15 of MeHg intake), depending on the region. Beluga mattaaq also highly contributed to Se intake (0.30 of Se intake). Arctic char, beluga blubber and mattaaq, and seal blubber contributed to most long-chain n-3 PUFA intake. This study highlights the importance of considering interconnections between local ecosystems and dietary habits to develop recommendations and interventions promoting country foods' benefits, while minimizing the risk of MeHg from beluga meat, especially for childbearing-age women

Socioecological Factors Associated with Hypertension Awareness and Control Among Older Adults in Brazil and Colombia: Correlational Analysis from the International Mobility in Aging Study

Background: Hypertension awareness and control are understudied among older adults in middle-income countries, with limited work contextualizing awareness and control across layers of influence (individual to the community). Research on hypertension in Latin America is acknowledged as insufficient. Objectives: This study applies the socioecological model (SEM) to examine individual, interpersonal, institutional, and community factors related to hypertension awareness and control in older adults residing in Brazil and Colombia. It identifies groups of older adults more likely to be unaware of their condition and/or to have challenges achieving hypertension control. Methods: We analyzed International Mobility in Aging Study data of 803 community-dwelling adults 65–74 years from study sites in the two most populous countries in South America. The study framework was the socioecological model. Logistic regression models identified factors associated with hypertension awareness and control. Conclusions: Hypertension was prevalent in both samples (>70%), and awareness was high (>80%). Blood pressure control among diagnosed respondents was low: 30% in Brazil and 51% in Colombia. Factors across the socioecological model were associated with awareness and control, with notable differences across countries. Those with diabetes (OR 4.19, 95%CI 1.64–10.71) and insufficient incomes (OR: 1.85, 95%CI 1.03–3.31) were more likely to be aware of their hypertension. In Colombia, those reporting no community activity engagement were less likely to be aware compared to those reporting community activities. In Brazil, it was the opposite. Women (OR 1.66, 95%CI 1.12–2.46) and those reporting strolling shops and stores (OR 1.80, 95% CI 1.09–3.00) were significantly more likely to have their hypertension under control. In Brazil, those 70–75 were significantly less likely to have their hypertension under control compared to their younger counterparts. In Colombia, this was not observed. This paper highlights the importance of theory-based studies within unique Latin American contexts on hypertension and suggests novel opportunities for intervention

Data gaps in adolescent fertility surveillance in middle-income countries in Latin America and South Eastern Europe: Barriers to evidence-based health promotion

Adolescent health is a major global priority. Yet, as recently described by the World Health Organization (WHO), increased recognition of the importance of adolescent health rarely transforms into action. One challenge is lack of data, particularly on adolescent fertility. Adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families. Other important components of adolescent fertility include abortion, miscarriage, and stillbirth. Access to reliable, consistently-collected data to understand the scope and complexity of adolescent fertility is critical for designing strong research, developing meaningful policies, building effective programs, and evaluating success in these domains. Vital surveillance data can be challenging to obtain in general, and particularly in low- and middle-income countries and other under-resourced settings (including rural and indigenous communities in high-income countries). Definitions also vary, making comparisons over time and across locations challenging. Informed by the Adolescence and Motherhood Research project in Brazil and considering relevance to the Southern Eastern European (SEE) context, this article focuses on challenges in surveillance data for adolescent fertility for middle-income countries. Specifically, we review the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then we (3) consider implications of data gaps on this topic for selected middle-income countries in Latin America and SEE, and (4) propose next steps to improve adolescent fertility data for evidence-based health promotion in the middle-income country context

Data gaps in adolescent fertility surveillance in middle-income countries in Latin America and South Eastern Europe: Barriers to evidence-based health promotion

Adolescent health is a major global priority. Yet, as recently described by the World Health Organization (WHO), increased recognition of the importance of adolescent health rarely transforms into action. One challenge is lack of data, particularly on adolescent fertility. Adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families. Other important components of adolescent fertility include abortion, miscarriage, and stillbirth. Access to reliable, consistently-collected data to understand the scope and complexity of adolescent fertility is critical for designing strong research, developing meaningful policies, building effective programs, and evaluating success in these domains. Vital surveillance data can be challenging to obtain in general, and particularly in low- and middle-income countries and other under-resourced settings (including rural and indigenous communities in high-income countries). Definitions also vary, making comparisons over time and across locations challenging. Informed by the Adolescence and Motherhood Research project in Brazil and considering relevance to the Southern Eastern European (SEE) context, this article focuses on challenges in surveillance data for adolescent fertility for middle-income countries. Specifically, we review the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then we (3) consider implications of data gaps on this topic for selected middle-income countries in Latin America and SEE, and (4) propose next steps to improve adolescent fertility data for evidence-based health promotion in the middle-income country context.Conflicts of interest: None