Early neonatal mortality is modulated by gestational age, birthweight and fetal heart rate abnormalities in the low resource setting in Tanzania – a five year review 2015–2019

Background: Early Neonatal mortality (ENM) (\u3c7days) remains a signifcant problem in low resource settings. Birth asphyxia (BA), prematurity and presumed infection contribute signifcantly to ENM. The study objectives were to determine: frst, the overall ENM rate as well as yearly ENM rate (ENMR) from 2015 to 2019; second, the infuence of decreasing GA (\u3c37weeks) and BW (\u3c2500g) on ENM; third, the contribution of intrapartum and delivery room factors and in particular fetal heart rate abnormalities (FHRT) to ENM; and fourth, the Fresh Still Birth Rates (FSB) rates over the same time period. Methods: Retrospective cohort study undertaken in a zonal referral teaching hospital located in Northern Tanzania. Labor and delivery room data were obtained from 2015 to 2019 and included BW, GA, fetal heart rate (FHRT) abnormalities, bag mask ventilation (BMV) during resuscitation, initial temperature, and antenatal steroids use. Abnormal outcome was ENM\u3c7days. Analysis included t tests, odds ratios (OR), and multivariate regression analysis. Results: The overall early neonatal mortality rate (ENMR) was 18/1000 livebirths over the 5 years and did not change signifcantly comparing 2015 to 2019. Comparing year 2018 to 2019, the overall ENMR decreased signifcantly (OR 0.62; 95% confdence interval (CI) 0.45–0.85) as well as infants ≥37weeks (OR 0.45) (CI 0.23–0.87) and infants \u3c37weeks (OR 0.57) (CI 0.39–0.84). ENMR was signifcantly higher for newborns \u3c37 versus ≥37weeks, OR 10.5 (p\u3c0.0001) and BW \u3c2500 versus ≥2500g OR 9.9. For infants \u3c1000g / \u3c28weeks, the ENMR was ~588/1000 livebirths. Variables associated with ENM included BW - odds of death decreased by 0.55 for every 500g increase in weight, by 0.89 for every week increase in GA, ENMR increased 6.8-fold with BMV, 2.6-fold with abnormal FHRT, 2.2-fold with no antenatal steroids (ANS), 2.6-fold with moderate hypothermia (all \u3c0.0001). The overall FSB rate was 14.7/1000 births and decreased signifcantly in 2019 when compared to 2015 i.e., 11.3 versus 17.3/1000 live births respectively (p=0.02). Conclusion: ENM rates were predominantly modulated by decreasing BW and GA, with smaller/ less mature newborns 10-fold more likely to die. ENM in term newborns was strongly associated with FHRT abnormalities and when coupled with respiratory depression and BMV suggests BA. In smaller newborns, lack of ACS exposure and moderate hypothermia were additional associated factors. A composite perinatal approach is essential to achieve a sustained reduction in ENMR

Expanding access to rehabilitation using mobile health to address musculoskeletal pain and disability

Introduction Musculoskeletal (MSK) disorders such as low back pain and osteoarthritis are a leading cause of disability and the leading contributor to the need for rehabilitation services globally. This need has surpassed the availability of trained clinicians; even in urban areas where services and providers are thought to be more abundant, access can be challenged by transportation options and financial costs associated with travel, care and lost time from work. However, continuing standard of fully in-person rehabilitation care for MSK-associated pain and disability may no longer be necessary. With increased ownership or access to even a basic mobile phone device, and evidence for remote management by trained clinicians, some individuals with MSK disorders may be able to continue their rehabilitation regimen predominantly from home after initial evaluation in primary care or an outpatient clinic. Methods This manuscript describes application of a framework we used to culturally and contextually adapt an evidence-based approach for leveraging digital health technology using a mobile phone (mHealth) to expand access to rehabilitation services for MSK-associated pain and disability. We then conducted a multi-level analysis of policies related to the adapted approach for rehabilitation service delivery to identify opportunities to support sustainability. Results Our study was conducted in Tanzania, a lower-middle income country with their first National Rehabilitation Strategic Plan released in 2021. Lessons learned can be applied even to countries with greater infrastructure or fewer barriers. The seven-step adaptation framework used can be applied in other regions to improve the likelihood of local mHealth adoption and implementation. Our practice and policy assessment for Tanzania can be applied in other regions and used collaboratively with government officials in support of building or implementing a national rehabilitation strategic plan. Conclusion The work described, lessons learned and components of the plan are generalizable globally and can improve access to rehabilitation services using mHealth to address the significant and increasing burden of disability

Neonatal Mortality is Modulated by Gestational Age, Birthweight and Fetal Heart Rate Abnormalities in the Low Resource Setting in Tanzania – a Five Year Review 2015-2019

Background Neonatal mortality (NM) remains a significant problem in low resource settings. Birth asphyxia (BA) and prematurity contribute significantly to NM. The study objectives were to determine first, the overall NM as well as yearly neonatal mortality rate from 2015 to 2019. Second, the impact of decreasing GA (\u3c37 weeks) and BW (\u3c2500 grams) on NM. Third, the contribution of intrapartum and delivery room (DR) factors and in particular fetal heart rate abnormalities (FHRT) on NM \u3c7 days. Methods Retrospective cohort study. Labor and delivery room data were obtained from 2015 to 2019 and included BW, GA, fetal heart rate (FHRT) abnormalities, bag mask ventilation (BMV) during resuscitation, initial temperature, antenatal steroids use. Outcome was binary i.e. either death \u3c 7 days or survival. Analysis included t tests, odds ratios (OR) and multiple logistic regression Results The overall neonatal mortality rate was 18/1000 livebirths over the five years. NM was significantly higher for newborns \u3c37 versus ≥37 weeks, OR 10.5 (p\u3c0.0001) and BW \u3c2500 versus ≥2500g OR 9.9 (p\u3c0.0001). For infants \u3c1000g / \u3c28 weeks, the neonatal mortality rate was ~ 588/1000 livebirths. Variables associated with NM included BW - odds of death decreased by 0.55 for every 500g increase in weight, by 0.89 for every week increase in GA, NM increased 6.8-fold with BMV, 2.6-fold with abnormal FHRT, 2.2 fold with no antenatal corticosteroid (ACS), 2.6-fold with moderate hypothermia (all \u3c0.0001). Conclusion NM rates was predominantly modulated by decreasing BW and GA, with smaller/ less mature newborns 10-fold more likely to die. NM in term newborns is strongly associated with FHRT abnormalities and when coupled with respiratory depression suggests BA. In smaller newborns, lack of ACS and moderate hypothermia were additional contributing factors. A composite perinatal approach is essential to achieve a sustained reduction in NM

Where can Tanzania health system integrate clinical management of patients with dual tuberculosis and diabetes mellitus?:A cross-sectional survey at varying levels of health facilities

OBJECTIVE: To assess the current Tanzania health facilities readiness in integrating clinical management of dual Tuberculosis (TB) and Diabetes Mellitus (DM) by using the Service Availability and Readiness Assessment (SARA) manual of the World Health Organization prior to implementing an integrated service model. STUDY DESIGN: Cross-sectional study. METHODS: A needs assessment survey was conducted at varying levels of health care facilities. The SARA manual evaluated the service delivery outcomes in terms of availability of guidelines, medicines and diagnostic equipment, training of healthcare workers in providing TB and DM care, and patient record review. Data were analyzed using Statistical Package for Social Science version 26. RESULTS: Among 29 health facilities selected, three were regional referral hospitals, eight were district hospitals and eighteen were health centers. Baseline investigations revealed that GeneXpert MTB/RIF machines were present in 10 (34.5%) facilities, and glycated hemoglobin devices were present in two (6.9%) facilities, while all health facilities had a glucometer. The presence of an attending medical doctor in 19 (65.5%) facilities and the presence of operating biochemistry analyzers in 15 (51.7%) facilities were two mandatory variables used to assess readiness. Among the various guidelines observed, none of the facilities had the 2016 DM guidelines. Overall, 15 (51.7%) health facilities were ready to integrate dual TB and DM services. CONCLUSION: Integrative TB/DM screening and management activities can be achieved only if integration initiatives are prioritized at all levels of health facilities and among health policy makers in Tanzania. At least half of the health facilities were prepared to integrate the management of dual TB/DM. However, there is an urgent need to mobilize significant resources to improve the integration in these facilities, such as management guidelines and diagnostics.