Every Newborn INDEPTH (EN-INDEPTH) Study - Additional Materials

The Every Newborn- International Network for the Demographic Evaluation of Populations and their Health (EN-INDEPTH) study was a cross-sectional, multi-site study conducted between July 2017 and August 2018, including a survey of 69,176 women aged 15-49 years in five Health and Demographic Surveillance Sites (HDSS) within the INDEPTH Network: Bandim in Guinea-Bissau, Dabat in Ethiopia, IgangaMayuge in Uganda, Matlab in Bangladesh and Kintampo in Ghana. The primary objective of the study was to compare two methods of retrospective recording of pregnancy outcomes in surveys: Full Birth History with additional questions on pregnancy losses (FBH+), and Full Pregnancy History (FPH). A secondary objective was to identify barriers and enablers to the reporting of pregnancy and adverse pregnancy outcomes during the survey and HDSS data collection, and particularly if these differ for the two survey questionnaire methods (FBH+ and FPH). The study also evaluated the use of existing/modified survey questions to capture the fertility intentions and selected pregnancy outcomes (Termination of Pregnancy, miscarriage, birthweight, gestational age), and birth and death certification

Linking data sources for measurement of effective coverage in maternal and newborn health: what do we learn from individual- vs ecological-linking methods?

BACKGROUND: Improving maternal and newborn health requires improvements in the quality of facility-based care. This is challenging to measure: routine data may be unreliable; respondents in population surveys may be unable to accurately report on quality indicators; and facility assessments lack population level denominators. We explored methods for linking access to skilled birth attendance (SBA) from household surveys to data on provision of care from facility surveys with the aim of estimating population level effective coverage reflecting access to quality care. METHODS: We used data from Mayuge District, Uganda. Data from household surveys on access to SBA were linked to health facility assessment census data on readiness to provide basic emergency obstetric and newborn care (BEmONC) in the same district. One individual- and two ecological-linking methods were applied. All methods used household survey reports on where care at birth was accessed. The individual-linking method linked this to data about facility readiness from the specific facility where each woman delivered. The first ecological-linking approach used a district-wide mean estimate of facility readiness. The second used an estimate of facility readiness adjusted by level of health facility accessed. Absolute differences between estimates derived from the different linking methods were calculated, and agreement examined using Lin's concordance correlation coefficient. RESULTS: A total of 1177 women resident in Mayuge reported a birth during 2012-13. Of these, 664 took place in facilities within Mayuge, and were eligible for linking to the census of the district's 38 facilities. 55% were assisted by a SBA in a facility. Using the individual-linking method, effective coverage of births that took place with an SBA in a facility ready to provide BEmONC was just 10% (95% confidence interval CI 3-17). The absolute difference between the individual- and ecological-level linking method adjusting for facility level was one percentage point (11%), and tests suggested good agreement. The ecological method using the district-wide estimate demonstrated poor agreement. CONCLUSIONS: The proportion of women accessing appropriately equipped facilities for care at birth is far lower than the coverage of facility delivery. To realise the life-saving potential of health services, countries need evidence to inform actions that address gaps in the provision of quality care. Linking household and facility-based information provides a simple but innovative method for estimating quality of care at the population level. These encouraging findings suggest that linking data sets can result in meaningful evidence even when the exact location of care seeking is not known

The 13 UN Life-saving Commodities for Maternal, Newborn and Child Health: Knowledge, Attitudes and Practices in Uganda

Background: Life Saving Commodities (LSC) are medicines, medical devices and health supplies that effectively address leading avoidable causes of death during pregnancy, childbirth and childhood. In 2012 the United Nations put priority on globally promoting 13 priority LSC across the reproductive, maternal, newborn and child health (RMNCH) continuum of care. We assessed barriers to demand, access and utilization of these 13 LSC. Methods: This was a mixed methods cross-sectional study using both quantitative and qualitative approaches. The quantitative component was a health facility survey while the qualitative one was community-based. A blend of simple random and purposive sampling was undertaken to recruit study participants in four regions of Uganda. A total of 125 health facilities were surveyed and 513 people interviewed. Descriptive and bivariate analysis was done for quantitative data while the qualitative strand employed thematic analysis. This paper presents descriptive findings on knowledge, attitudes and practices (KAP) pertaining to the 13 LSC. Results: There was a variation in knowledge of LSC. Knowledge on child health commodities (ORS and Zinc) was higher among community members compared to the other commodities which are largely hospital-based (injectable antibiotics, antenatal corticosteroids, chlorhexidine, oxytocin, misoprostol and magnesium sulphate). Although health workers were knowledgeable on most LSC they also demonstrated limited comprehensive knowledge some, particularly those relating to reproductive and newborn health (48% and 42.4% respectively). For instance only 37.6% had comprehensive knowledge on management of preterm labour; only 44.8% health facilities had health workers knowledgeable on use of antenatal corticosteroids for preterm labour and only 30.4% reported to give antibiotics. Perceptions on some commodities, particularly the female condom and emergency contraception, were largely negative and health workers practiced selective recommendation or use. Explanatory factors for this could be traced at individual, household, community, facility and macro levels. Constrained by system-related issues like medicine stock-outs, majority of health workers were improvising and using available alternatives to LSC. Conclusion: The concept “lifesaving commodities” for maternal, newborn and child health was not well understood by both health workers as caregivers and community as service users. As a result they have not been demanded for, made available or utilized as originally intended. Alongside improved LSC availability, their overlooked, complementary nature and efficacy should continuously be emphasized to the various stakeholders for optimum results

Using research priority-setting to guide bridging the implementation gap in countries - a case study of the Uganda newborn research priorities in the SDG era.

BACKGROUND: One of the greatest challenges that countries face regarding the achievement of the Sustainable Development Goal (SDG) targets for child health regard the actions required to improve neonatal health; these interventions have to be informed by evidence. In view of the persisting high numbers of newborn deaths in Uganda, we aimed to define a locally contextualised national research agenda for newborn health to guide national investments towards SDG targets. METHODS: We adopted a systematic approach for priority-setting adapted from the Child Health and Nutrition Research Initiative. We identified and listed local newborn researchers and experts in Uganda by reviewing the PubMed database, through a snowballing technique, and engaged the Ministry of Health. Participants were requested to generate at least three research questions. The collated questions were sent to the same expert group to be rated using five criteria, including answerability, scalability, impact, generalisability and speed. FINDINGS: Of the 300 researchers and stakeholders contacted, 104 responded (36%) and generated 304 questions. These questions were collated and duplicates removed giving a condensed list of 41 research questions. These questions were then rated by 82 experts. Of the top 15 research questions, 86.7% (13/15) were in the service delivery and 6.7% (1/15) in the development domain, while only 6.7% (1/15) was in the group 'other'. None of the leading 15 questions was in the discovery domain. Strategies to improve quality of intrapartum care featured high in the responses, while research around care for premature babies was not a perceived focus of research. CONCLUSIONS: The focus of improved evidence to guide and innovate service delivery, foremost intrapartum care, reflects the importance of this area as accelerated improvement is likely to yield fast and sustained survival gains in the neonatal period and beyond in Uganda. We recommend that other countries adapt a similar approach in defining priority reproductive, maternal, newborn and child health areas for investment in order to accelerate progress towards achieving the SDGs

The use of continuous surveys to generate and continuously report high quality timely maternal and newborn health data at the district level in Tanzania and Uganda.

BACKGROUND: The lack of high quality timely data for evidence-informed decision making at the district level presents a challenge to improving maternal and newborn survival in low income settings. To address this problem, the EQUIP project (Expanded Quality Management using Information Power) implemented a continuous household and health facility survey for continuous feedback of data in two districts each in Tanzania and Uganda as part of a quality improvement innovation for mothers and newborns. METHODS: Within EQUIP, continuous survey data were used for quality improvement (intervention districts) and for effect evaluation (intervention and comparison districts). Over 30 months of intervention (November 2011 to April 2014), EQUIP conducted continuous cross-sectional household and health facility surveys using 24 independent probability samples of household clusters to represent each district each month, and repeat censuses of all government health facilities. Using repeat samples in this way allowed data to be aggregated at six four-monthly intervals to track progress over time for evaluation, and for continuous feedback to quality improvement teams in intervention districts.In both countries, one continuous survey team of eight people was employed to complete approximately 7,200 household and 200 facility interviews in year one. Data were collected using personal digital assistants. After every four months, routine tabulations of indicators were produced and synthesized to report cards for use by the quality improvement teams. RESULTS: The first 12 months were implemented as planned. Completion of household interviews was 96% in Tanzania and 91% in Uganda. Indicators across the continuum of care were tabulated every four months, results discussed by quality improvement teams, and report cards generated to support their work. CONCLUSIONS: The EQUIP continuous surveys were feasible to implement as a method to continuously generate and report on demand and supply side indicators for maternal and newborn health; they have potential to be expanded to include other health topics. Documenting the design and implementation of a continuous data collection and feedback mechanism for prospective description, quality improvement, and evaluation in a low-income setting potentially represents a new paradigm that places equal weight on data systems for course correction, as well as evaluation

Status of birth and pregnancy outcome capture in Health Demographic Surveillance Sites in 13 countries.

OBJECTIVES: We compared pregnancy identification methods and outcome capture across 31 Health Demographic Surveillance System (HDSS) sites in 14 countries in sub-Saharan Africa and Asia. METHODS: From 2009 to 2014, details on the sites and surveillance systems including frequency of update rounds, characteristics of enumerators and interviewers, acceptable respondents were collected and compared across sites. RESULTS: The 31 HDSS had a combined population of over 2,905,602 with 165,820 births for the period. Stillbirth rate ranged from 1.9 to 42.6 deaths per 1000 total births and the neonatal mortality rate from 2.6 to 41.6 per 1000 live births. Three quarters (75.3%) of recorded neonatal deaths occurred in the first week of life. The proportion of infant deaths that occurred in the neonatal period ranged from 8 to 83%, with a median of 53%. Sites that registered pregnancies upon locating a live baby in the routine household surveillance round had lower recorded mortality rates. CONCLUSIONS: Increased attention and standardization of pregnancy surveillance and the time of birth will improve data collection and provide platforms for evaluations and availability of data for decision-making with implications for national planning

Stillbirth maternity care measurement and associated factors in population-based surveys: EN-INDEPTH study.

BACKGROUND: Household surveys remain important sources of maternal and child health data, but until now, standard surveys such as Demographic and Health Surveys (DHS) have not collected information on maternity care for women who have experienced a stillbirth. Thus, nationally representative data are lacking to inform programmes to address the millions of stillbirths which occur annually. METHODS: The EN-INDEPTH population-based survey of women of reproductive age was undertaken in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017-2018). All women answered a full birth history with additional questions on pregnancy losses (FBH+) or full pregnancy history (FPH). A sub-sample, including all women reporting a recent stillbirth or neonatal death, was asked additional maternity care questions. These were evaluated using descriptive measures. Associations between stillbirth and maternal socio-demographic characteristics, babies' characteristics and maternity care use were assessed using a weighted logistic regression model for women in the FBH+ group. RESULTS: A total of 15,591 women reporting a birth since 1 January 2012 answered maternity care questions. Completeness was very high (> 99%), with similar proportions of responses for both live and stillbirths. Amongst the 14,991 births in the FBH+ group, poorer wealth status, higher parity, large perceived baby size-at-birth, preterm or post-term birth, birth in a government hospital compared to other locations and vaginal birth were associated with increased risk of stillbirth after adjusting for potential confounding factors. Regarding association with reported postnatal care, women with a stillbirth were more likely to report hospital stays of > 1 day. However, women with a stillbirth were less likely to report having received a postnatal check compared to those with a live birth. CONCLUSIONS: Women who had experienced stillbirth were able to respond to questions about pregnancy and birth, and we found no reason to omit questions to these women in household surveys. Our analysis identified several potentially modifiable factors associated with stillbirth, adding to the evidence-base for policy and action in low- and middle-income contexts. Including these questions in DHS-8 would lead to increased availability of population-level data to inform action to end preventable stillbirths

Using verbal and social autopsy approaches to understand why neonates die in rural settings: a case study of a remote rural district in Uganda

Introduction Neonatal mortality remains a formidable challenge in low-resource settings, such as Uganda, despite global health initiatives. This study employs a social and verbal autopsy approach to identify the causes, settings and health accessibility challenges surrounding neonatal deaths in the Luuka district from 1 January 2017 to 31 December 2019.Methods We analysed data from 172 neonatal verbal and social autopsies (VASA) conducted over 3 years, as part of a maternal and neonatal demand and supply health system strengthening intervention. Cause-of-death coding was done by two independent medical officers using WHO-ICD-10 guidelines to ascertain the causes of death. VASA-coded data analysis of the causes of death was done in STATA V.14.0. In addition, 16 key informant interviews were conducted, including 2 community health workers,6 household members and 8 health workers, with qualitative data analysed through thematic content analysis.Results Among the 172 neonate deaths, 95.9% occurred in the early neonatal period (0–6 days) and 4.1% in the late neonatal period (7–27 days). The primary causes of death were birth asphyxia (42.4%), low birth weight/prematurity (18.6%), other perinatal causes (12.8%) and neonatal sepsis (9.3%). Delays in getting appropriate care at the facility (delay 3) and delays in seeking care (delay 1) (51.2% and 44.2%, respectively) were linked to newborn mortality. Qualitative insights underscored inadequate awareness of neonatal danger signs, deficient referral systems, drug shortages, reliance on unskilled traditional birth attendants and insufficient neonatal care facilities as significant contributors.Conclusion Addressing delays in both home-based care (delay 1) and timely access to appropriate care in healthcare facilities (delays 2 and 3) is pivotal in mitigating neonatal mortality. Comprehensive interventions targeting improved access to maternal services and enhanced quality of care in health facilities are imperative for advancing newborn survival in rural settings

Differences in essential newborn care at birth between private and public health facilities in eastern Uganda

Background: In Uganda and elsewhere, the private sector provides an increasing and significant proportion of maternal and child health services. However, little is known whether private care results in better quality services and improved outcomes compared to the public sector, especially regarding care at the time of birth. Objective: To describe the characteristics of care-seekers and assess newborn care practices and services received at public and private facilities in rural eastern Uganda. Design: Within a community-based maternal and newborn care intervention with health systems strengthening, we collected data from mothers with infants at baseline and endline using a structured questionnaire. Descriptive, bivariate, and multivariate data analysis comparing nine newborn care practices and three composite newborn care indicators among private and public health facilities was conducted. Results: The proportion of women giving birth at private facilities decreased from 25% at baseline to 17% at endline, whereas overall facility births increased. Private health facilities did not perform significantly better than public health facilities in terms of coverage of any essential newborn care interventions, and babies were more likely to receive thermal care practices in public facilities compared to private (68% compared to 60%, p=0.007). Babies born at public health facilities received an average of 7.0 essential newborn care interventions compared to 6.2 at private facilities (p<0.001). Women delivering in private facilities were more likely to have higher parity, lower socio-economic status, less education, to seek antenatal care later in pregnancy, and to have a normal delivery compared to women delivering in public facilities. Conclusions: In this setting, private health facilities serve a vulnerable population and provide access to service for those who might not otherwise have it. However, provision of essential newborn care practices was slightly lower in private compared to public facilities, calling for quality improvement in both private and public sector facilities, and a greater emphasis on tracking access to and quality of care in private sector facilities