Who delivers where? The effect of obstetric risk on facility delivery in East Africa.

OBJECTIVES: Skilled attendance at birth is key for the survival of pregnant women. This study investigates whether women at increased risk of maternal and newborn complications in four East African countries are more likely to deliver in a health facility than those at lower risk. METHODS: Demographic and Health Survey data for Kenya 2014, Rwanda 2014-15, Tanzania 2015-16 and Uganda 2011 were used to study women with a live birth in the three years preceding the survey. A three-level obstetric risk index was created using known risk factors. Generalised linear Poisson regression was used to investigate the association between obstetric risk and facility delivery. RESULTS: We analysed data from 13 119 women across the four countries of whom 42-45% were considered at medium risk and 12-17% at high risk, and the remainder were at low risk. In Rwanda, 93% of all women delivered in facilities but this was lower (59-66%) in the other three countries. There was no association between a woman's obstetric risk level and her place of delivery in any country; greater wealth and more education were, however, independently strongly associated with facility delivery. CONCLUSIONS: In four East African countries, women at higher obstetric risk were not more likely to deliver in a facility than those with lower risk. This calls for a renewed focus on antenatal risk screening and improved communication on birth planning to ensure women with an increased chance of maternal and newborn complications are supported to deliver in facilities with skilled care

Evangelical Christianity and Women’s Changing Lives

Women have outnumbered men as followers of Christianity at least since the transition to industrial capitalist modernity in the West. Yet developments in women's lives in relation to employment, family and feminist values are challenging their Christian religiosity. Building on a new strand of gender analysis in the sociology of religion, this article argues that gender is central to patterns of religiosity and secularization in the West. It then offers a case study of evangelical Christianity in England to illustrate how changes in women's lives are affecting their religiosity. Specifically, it argues that evangelical Christianity continues to be important among women occupying more traditional social positions (as wives and mothers), but adherence is declining among the growing number whose lives do not fit this older model

Hands washing, glove use, and avoiding recontamination before aseptic procedures at birth: A multicenter time-and-motion study conducted in Zanzibar.

BACKGROUND: Our primary objective was to assess hand hygiene (HH) compliance before aseptic procedures among birth attendants in the 10 highest-volume facilities in Zanzibar. We also examined the extent to which recontamination contributes to poor HH. Recording exact recontamination occurrences is not possible using the existing World Health Organization HH audit tool. METHODS: In this time-and-motion study, 3 trained coders used WOMBATv2 software to record the hand actions of all birth attendants present in the study sites. The percentage compliance and 95% confidence intervals (CIs) for individual behaviors (hand washing/rubbing, avoiding recontamination and glove use) and for behavioral sequences during labor and delivery were calculated. RESULTS: We observed 104 birth attendants and 781 HH opportunities before aseptic procedures. Compliance with hand rubbing/washing was 24.6% (95% CI, 21.6-27.8). Only 9.6% (95% CI, 7.6-11.9) of birth attendants also donned gloves and avoided recontamination. Half of the time when rubbing/washing or glove donning was performed, hands were recontaminated prior to the aseptic procedure. CONCLUSIONS: In this study, HH compliance by birth attendants before aseptic procedures was poor. To our knowledge, this is the first study in a low- to middle-income country to show the large contribution to poor HH compliance from hand and glove recontamination before the procedure. Recontamination is an important driver of infection risk from poor HH. It should be understood for the purposes of improvement and therefore included in HH monitoring and interventions

The Clean pilot study: evaluation of an environmental hygiene intervention bundle in three Tanzanian hospitals.

BACKGROUND: Healthcare associated infections (HAI) are estimated to affect up to 15% of hospital inpatients in low-income countries (LICs). A critical but often neglected aspect of HAI prevention is basic environmental hygiene, particularly surface cleaning and linen management. TEACH CLEAN is an educational intervention aimed at improving environmental hygiene. We evaluated the effectiveness of this intervention in a pilot study in three high-volume maternity and newborn units in Dar es Salaam, Tanzania. METHODS: This study design prospectively evaluated the intervention as a whole, and offered a before-and-after comparison of the impact of the main training. We measured changes in microbiological cleanliness [Aerobic Colony Counts (ACC) and presence of Staphylococcus aureus] using dipslides, and physical cleaning action using gel dots. These were analysed with descriptive statistics and logistic regression models. We used qualitative (focus group discussions, in-depth interviews, and semi-structured observation) and quantitative (observation checklist) tools to measure why and how the intervention worked. We describe these findings across the themes of adaptation, fidelity, dose, reach and context. RESULTS: Microbiological cleanliness improved during the study period (ACC pre-training: 19%; post-training: 41%). The odds of cleanliness increased on average by 1.33 weekly during the pre-training period (CI = 1.11-1.60), and by 1.08 (CI = 1.03-1.13) during the post-training period. Cleaning action improved only in the pre-training period. Detection of S. aureus on hospital surfaces did not change substantially. The intervention was well received and considered feasible in this context. The major pitfalls in the implementation were the limited number of training sessions at the hospital level and the lack of supportive supervision. A systems barrier to implementation was lack of regular cleaning supplies. CONCLUSIONS: The evaluation suggests that improvements in microbiological cleanliness are possible using this intervention and can be sustained. Improved microbiological cleanliness is a key step on the pathway to infection prevention in hospitals. Future research should assess whether this bundle is cost-effective in reducing bacterial and viral transmission and infection using a rigorous study design

Diversity and divergence: the dynamic burden of poor maternal health.

Maternal health is a big issue and is central to sustainable development. Each year, about 210 million women become pregnant and about 140 million newborn babies are delivered-the sheer scale of maternal health alone makes maternal well being and survival vital concerns. In this Series paper, we adopt primarily a numerical lens to illuminate patterns and trends in outcomes, but recognise that understanding of poor maternal health also warrants other perspectives, such as human rights. Our use of the best available evidence highlights the dynamic burden of maternal health problems. Increased diversity in the magnitude and causes of maternal mortality and morbidity between and within populations presents a major challenge to policies and programmes aiming to match varying needs with diverse types of care across different settings. This diversity, in turn, contributes to a widening gap or differences in levels of maternal mortality, seen most acutely in vulnerable populations, predominantly in sub-Saharan Africa. Strong political and technical commitment to improve equity-sensitive information systems is required to monitor the gap in maternal mortality, and robust research is needed to elucidate major interactions between the broad range of health problems. Diversity and divergence are defining characteristics of poor maternal health in the 21st century. Progress on this issue will be an ultimate judge of sustainable development

Hand washing glove use, and avoiding recontamination before aseptic procedures at birth : A multicenter time-and-motion study conducted in Zanzibar

The project was funded by the Medical Research Council – PHIND scheme. Award number MR/N015975/1. The Soapbox Collaborative also contributed by funding staff involved in this project. The writing up of this paper provided part of the background needed for the CLEAN Study funded by the UK Joint Global Health Trials (Wellcome, MRC, DFID and DOH) Award number: MR/R019274/1. We thank the Ministry of Health of Zanzibar for their participation and engagement in the study. A special thanks to Rukaiya M Said, Mwanafatima Ali Mohammed, Bijuma Mkubwa Abdallah, and Asya Hati Vuai who collected all the data. We also thank Marina Daniele for participating in the consultation exercise aimed at refining the definition of opportunity. Finally, we thank Daniel Powell and David Macleod for the support in data management. Data sharing Anonymized data at the opportunity level are available in Appendix F, from https://doi.org/10.17037/DATA.00000778.Peer reviewedPublisher PD