Examining vulnerability and resilience in maternal, newborn and child health through a gender lens in low-income and middle-income countries : a scoping review

Funding This work was supported by the Bill & Melinda Gates Foundation under investment INV-015806 awarded to the Viable Helpers Development Organisation.Introduction Gender lens application is pertinent in addressing inequities that underlie morbidity and mortality in vulnerable populations, including mothers and children. While gender inequities may result in greater vulnerabilities for mothers and children, synthesising evidence on the constraints and opportunities is a step in accelerating reduction in poor outcomes and building resilience in individuals and across communities and health systems. Methods We conducted a scoping review that examined vulnerability and resilience in maternal, newborn and child health (MNCH) through a gender lens to characterise gender roles, relationships and differences in maternal and child health. We conducted a comprehensive search of peer-reviewed and grey literature in popular scholarly databases, including PubMed, ScienceDirect, EBSCOhost and Google Scholar. We identified and analysed 17 published studies that met the inclusion criteria for key gendered themes in maternal and child health vulnerability and resilience in low-income and middle-income countries. Results Six key gendered dimensions of vulnerability and resilience emerged from our analysis: (1) restricted maternal access to financial and economic resources; (2) limited economic contribution of women as a result of motherhood; (3) social norms, ideologies, beliefs and perceptions inhibiting women’s access to maternal healthcare services; (4) restricted maternal agency and contribution to reproductive decisions; (5) power dynamics and experience of intimate partner violence contributing to adverse health for women, children and their families; (6) partner emotional or affective support being crucial for maternal health and well-being prenatal and postnatal. Conclusion This review highlights six domains that merit attention in addressing maternal and child health vulnerabilities. Recognising and understanding the gendered dynamics of vulnerability and resilience can help develop meaningful strategies that will guide the design and implementation of MNCH programmes in low-income and middle-income countries.Publisher PDFPeer reviewe

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Associations between birth kit use and maternal and neonatal health outcomes in rural Jigawa state, Nigeria: A secondary analysis of data from a cluster randomized controlled trial.

BackgroundThe burden of maternal and neonatal mortality remains persistently high in Nigeria. Sepsis contributes significantly to both maternal and newborn mortality, and safe delivery kits have long been promoted as a cost-effective intervention to ensure hygienic delivery practices and reduce sepsis. However, there is limited evidence on the effectiveness of home birth kit distribution by community health workers, and particularly the impact of this intervention on health outcomes. This paper reports a secondary analysis of data from a cluster randomized trial in rural northern Nigeria in which birth kits were distributed by community health workers to pregnant women in their homes, analyzing non-experimental variation in receipt and use of birth kits. More specifically, associations between pregnant women's baseline characteristics and receipt and use of birth kits, and associations between birth kit use, care utilization and maternal and newborn outcomes were assessed.Methods and findingsBaseline, post-birth and endline data related to 3,317 births observed over a period of three years in 72 intervention communities in Jigawa state, Nigeria, were analyzed using hierarchical, logistic regression models. In total, 140 women received birth kits, and 72 women used the kits. There were no associations between baseline demographic characteristics, health history, and knowledge and attitudes and receipt of a kit, suggesting that community health workers did not systematically target the distribution of birth kits. However, women who used the kit reported reduced odds of past pregnancy complications (OR = 0.44, 95% CI: 0.19-1.00) as well as significantly higher odds of feeling generally healthy at baseline (OR = 2.00, 95% CI: 1.06-3.76), of exposure to radio media (OR = 1.97, 95% CI: 1.21-3.22), and of perceiving themselves as having a low-risk pregnancy (OR = 3.05, 95% CI:1.39-6.68). While there were no significant associations between birth kit use and facility based delivery, skilled birth attendance or post-natal care, women who used a kit exhibited significantly lower odds of completing four or more ANC visits (adjusted OR = 0.39, 95% CI: 0.18-0.85) and significantly higher odds of reporting prolonged labor (adjusted OR = 4.75, 95% CI: 1.36-16.59), and post-partum bleeding (adjusted OR = 3.25, 95% CI: 1.11-9.52).ConclusionsThis evidence suggests that use of birth kits is low in a rural population characterized by minimal baseline utilization of maternal and neonatal health services, and the use of birth kits was not associated with reductions in maternal or neonatal morbidity. While further research is required to understand how the effectiveness of birth kits may be shaped by the mechanism through which women access and utilize the kits, our findings suggest that the provision of kits to women outside of the formal health system may be associated with increased risk of adverse outcomes

Vulnerability in maternal, new-born, and child health in low- and middle-income countries : findings from a scoping review

OBJECTIVES: To identify and synthesise prevailing definitions and indices of vulnerability in maternal, new-born and child health (MNCH) research and health programs in low- and middle-income countries. DESIGN AND SETTING: Scoping review using Arksey and O’Malley’s framework and a Delphi survey for consensus building. PARTICIPANTS: Mothers, new-borns, and children living in low- and middle-income countries were selected as participants. OUTCOMES: Vulnerability as defined by the authors was deduced from the studies. RESULTS: A total of 61 studies were included in this scoping review. Of this, 22 were publications on vulnerability in the context of maternal health and 40 were on new-born and child health. Definitions used in included studies can be broadly categorised into three domains: biological, socioeconomic, and environmental. Eleven studies defined vulnerability in the context of maternal health, five reported on the scales used to measure vulnerability in maternal health and only one study used a validated scale. Of the 40 included studies on vulnerability in child health, 19 defined vulnerability in the context of new-born and/or child health, 15 reported on the scales used to measure vulnerability in child health and nine reported on childhood vulnerability indices. As it was difficult to synthesise the definitions, their keywords were extracted to generate new candidate definitions for vulnerability in MNCH. CONCLUSION: Included studies paid greater attention to new-born/ child vulnerability than maternal vulnerability, with authors defining the terms differently. A definition which helps in improving the description of vulnerability in MNCH across various programs and researchers was arrived at. This will further help in streamlining research and interventions which can influence the design of high impact MNCH programs. SCOPING REVIEW REGISTRATION: The protocol for this review was registered in the open science framework at the registered address (https://osf.io/jt6nr)

Death registration in Nigeria: a systematic literature review of its performance and challenges

Background Death registration provides an opportunity for the legal documentation of death of persons. Documentation of deaths has several implications including its use in the recovery of inheritance and insurance benefits. It is also an important input for construction of life tables which are crucial for national planning. However, the registration of deaths is poor in several countries including Nigeria. Objective This paper describes the performance of death registration in Nigeria and factors that may affect its performance. Methods We conducted a systematic literature review of death registration completeness in Nigeria to identify, characterize issues as well as challenges associated with realizing completeness in death registration. Results Only 13.5% of deaths in Nigeria were registered in 2007 which regressed to 10% in 2017. There was no data reported for Nigeria in the World Health Organization database between 2008 and 2017. The country scored less than 0.1 (out of a maximum of 1) on the Vital Statistics Performance Index. There are multiple institutions with parallel constitutional and legal responsibilities for death registration in Nigeria including the National Population Commission, National Identity Management Commission and Local Government Authorities, which may be contributing to its overall poor performance. Conclusions We offer proposals to substantially improve death registration completeness in Nigeria including the streamlining and merger of the National Population Commission and the National Identity Management Commission into one commission, the revision of the legal mandate of the new agency to mainly coordination and establishment of standards. We recommend that Local Government authorities maintain the local registries given their proximity to households. This arrangement will be enhanced by increased utilization of information and communications technology in Civil Registration and Vital Statistics processes that ensure records are properly archived

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with $222 for low FiO2 leading to a −$6 (95% confidence interval [CI]: −$13 to −$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a −$11 (95$15 to −$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with $1257 for low FiO2 leading to a −$93 (95% CI: −$132 to −$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this

Use of Telemedicine for Post-discharge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review with Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardised assessment tools are needed. Summary background data: Surgical site infection is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. Methods: The primary outcome of this study was surgical site infection reported up to 30-days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analysed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30-days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs. 11.1%, P&lt;0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval 0.63-0.84, P&lt;0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In nine eligible non-randomised studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. Conclusions: Use of telemedicine to assess the surgical wound post-discharge is feasible, but risks underreporting of SSI. Standardised tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally