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Working with lay midwives to improve the detection of neonatal complications in rural Guatemala

ABSTRACT: Background Globally most neonatal deaths occur within the first week of life and in low-income and middle-income countries. Strengthening health system linkages for frontline providers—such as lay midwives providing home-based obstetrical care—may improve neonatal outcomes in these settings. Here, we conducted a quality improvement study to increase the detection of neonatal complications by lay midwives in rural Guatemala, thereby increasing referrals to a higher level of care. Methods A quality improvement team in Guatemala reviewed drivers of neonatal health services provided by lay midwives. Improvement interventions included training on neonatal warning signs, optimised mobile health technology to standardise assessments and financial incentives for providers. The primary quality outcome was the rate of neonatal referral to a higher level of care. Results From September 2017 to September 2018, participating midwives attended 869 home deliveries and referred 80 neonates to a higher level of care. A proportion control chart, using the preintervention period from January to September 2017 as the baseline, showed an increase in the referral rate of all births from 1.5% to 9.9%. Special cause was obtained in January 2018 and sustained except for May 2018. The proportion of neonates receiving assessments by midwives in the first week of life increased to >90%. A trend toward an increasing number of days between neonatal deaths did not attain special cause. Conclusions Structured improvement interventions, including mobile health decision support and financial incentives, significantly increased the detection of neonatal complications and referral of neonates to higher levels of care by lay midwives operating in rural home-based settings in Guatemala. The results show the value of improving the integration of lay midwives and other first responders into neonatal systems of care in low-resource settings.

SUBMITTER: Juarez M

PROVIDER: S-EPMC7011902 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Project description:BackgroundThe global prevalence of diabetes has nearly doubled since 1980. Seventy-five percent of patients with diabetes live in low- and middle-income countries, such as Guatemala, where health care systems are often poorly equipped for chronic disease management. Community health workers (CHWs) and mobile health technology have increasingly been applied to the diabetes epidemic in these settings, although mostly in supportive rather than primary roles in diabetes management. We sought to improve diabetes care in rural Guatemala through the development of a CHW-led diabetes program and a smartphone application to provide CHWs with clinical decision support.MethodsWe worked with our local partners to develop a program model and the smartphone application (using the CommCare platform) and to train CHWs. We recruited patients with type 2 diabetes living in rural communities. Program evaluation used a single-group, pre-post design. Primary outcomes were hemoglobin A1c and the percentage of patients meeting A1c goals compared with baseline. We also followed a variety of process metrics, including application reliability.ResultsEighty-nine patients enrolled during the study period. The hemoglobin A1c percentage decreased significantly at 3 months (-1.0; 95% CI=-1.7, -0.6), 6 months (-1.5; 95% CI=-2.2, -0.8), 9 months (-1.3; 95% CI=-2.0, -0.6), and 12 months (-1.0; 95% CI=-1.7, -0.4). The percentage of patients with A1c ≤ 8% increased significantly at 3 months (23.6% to 44.4%, P=.007), 6 months (22.0% to 44.0%, P=.015), and 9 months (23.9% to 45.7%, P=.03). CHWs and supervising physicians agreed with application medication recommendations >90% of the time.ConclusionOur results suggest that CHWs can safely and effectively manage diabetes with the assistance of a smartphone application and remote physician supervision. This model should be evaluated versus other standards of care and could be adapted to other low-resource settings and chronic diseases.

Project description:BACKGROUND/OBJECTIVE:Guatemala's indigenous Maya population has one of the highest perinatal and maternal mortality rates in Latin America. In this population most births are delivered at home by traditional birth attendants (TBAs), who have limited support and linkages to public hospitals. The goal of this study was to characterize the detection of maternal and perinatal complications and rates of facility-level referral by TBAs, and to evaluate the impact of a mHealth decision support system on these rates. METHODS:A pragmatic one-year feasibility trial of an mHealth decisions support system was conducted in rural Maya communities in collaboration with TBAs. TBAs were individually randomized in an unblinded fashion to either early-access or later-access to the mHealth system. TBAs in the early-access arm used the mHealth system throughout the study. TBAs in the later-access arm provided usual care until crossing over uni-directionally to the mHealth system at the study midpoint. The primary study outcome was the monthly rate of referral to facility-level care, adjusted for birth volume. RESULTS:Forty-four TBAs were randomized, 23 to the early-access arm and 21 to the later-access arm. Outcomes were analyzed for 799 pregnancies (early-access 425, later-access 374). Monthly referral rates to facility-level care were significantly higher among the early-access arm (median 33 referrals per 100 births, IQR 22-58) compared to the later-access arm (median 20 per 100, IQR 0-30) (p?=?0.03). At the study midpoint, the later-access arm began using the mHealth platform and its referral rates increased (median 34 referrals per 100 births, IQR 5-50) with no significant difference from the early-access arm (p?=?0.58). Rates of complications were similar in both arms, except for hypertensive disorders of pregnancy, which were significantly higher among TBAs in the early-access arm (RR 3.3, 95% CI 1.10-9.86). CONCLUSIONS:Referral rates were higher when TBAs had access to the mHealth platform. The introduction of mHealth supportive technologies for TBAs is feasible and can improve detection of complications and timely referral to facility-care within challenging healthcare delivery contexts. TRIAL REGISTRATION:Clinicaltrials.gov NCT02348840 .

Project description:BackgroundIn Tanzania, birth asphyxia is a leading cause of neonatal death. The aim of this study was to identify factors that influence successful neonatal resuscitation to inform clinical practice and reduce the incidence of very early neonatal death (death within 24 h of delivery).MethodsThis was a qualitative narrative inquiry study utilizing the 32 consolidated criteria for reporting qualitative research (COREQ). Audio-recorded, semistructured, individual interviews with midwives were conducted. Thematic analysis was applied to identify themes.ResultsThematic analysis of the midwives' responses revealed three factors that influence successful resuscitation: 1. Hands-on training ("HOT") with clinical support during live emergency neonatal resuscitation events, which decreases fear and enables the transfer of clinical skills; 2. Unequivocal commitment to the Golden Minute® and the mindset of the midwife; and. 3. Strategies that reduce barriers. Immediately after birth, live resuscitation can commence at the mother's bedside, with actively guided clinical instruction. Confidence and mastery of resuscitation competencies are reinforced as the physiological changes in neonates are immediately visible with bag and mask ventilation. The proclivity to perform suction initially delays ventilation, and suction is rarely clinically indicated. Keeping skilled midwives in labor wards is important and impacts clinical practice. The midwives interviewed articulated a mindset of unequivocal commitment to the baby for one Golden Minute®. Heavy workload, frequent staff rotation and lack of clean working equipment were other barriers identified that are worthy of future research.ConclusionsTraining in resuscitation skills in a simulated environment alone is not enough to change clinical practice. Active guidance of "HOT" real-life emergency resuscitation events builds confidence, as the visible signs of successful resuscitation impact the midwife's beliefs and behaviors. Furthermore, a focused commitment by midwives working together to reduce birth asphyxia-related deaths builds hope and collective self-efficacy.

Project description:BackgroundSchizophrenia is a severe and disabling condition that presents a dire health equity challenge. Our initial 6-month trial (previously reported) using mobile texting and lay health supporters, called LEAN, significantly improved medication adherence from 0.48 to 0.61 (adjusted mean 0.11, 95% CI 0.03 to 0.20, P=.007) for adults with schizophrenia living in a resource-poor village in rural China.ObjectiveWe explored the effectiveness of our texting program in improving participants' medication adherence, functioning, and symptoms in an extended implementation of the intervention after its initial phase.MethodsIn an approximated stepped-wedge wait-list design randomized controlled trial, 277 community-dwelling villagers with schizophrenia were assigned 1:1 in phase 1 into intervention and wait-list control groups. The intervention group received (1) lay health supporters (medication or care supervisors), (2) e-platform (mobile-texting reminders and education message) access, (3) a token gift for positive behavioral changes, and (4) integration with the existing government community-mental health program (the 686 Program) while the wait-listed control group initially only received the 686 Program. Subsequently (in the extended period), both groups received the LEAN intervention plus the 686 Program. The primary outcome was antipsychotic medication adherence (percentage of dosages taken over the past month assessed by unannounced home-based pill counts). The secondary outcomes were symptoms measured during visits to 686 Program psychiatrists using the Clinical Global Impression scale for schizophrenia and functioning measured by trained student assessors using the World Health Organization Disability Assessment Schedule 2.0. Other outcomes included data routinely collected in the 686 Program system (refill records, rehospitalization due to schizophrenia, death for any reason, suicide, wandering, and violent behaviors). We used intention-to-treat analysis and missing data were imputed. A generalized estimating equation model was used to assess program effects on antipsychotics medication adherence, symptoms, and functioning.ResultsAntipsychotics medication adherence improved from 0.48 in the control period to 0.58 in the extended intervention period (adjusted mean difference 0.11, 95% CI 0.04 to 0.19; P=.004). We also noted an improvement in symptoms (adjusted mean difference -0.26, 95% CI -0.50 to -0.02; P=.04; Cohen d effect size 0.20) and a reduction in rehospitalization (0.37, 95% CI 0.18 to 0.76; P=.007; number-needed-to-treat 8.05, 95% CI 4.61 to 21.41). There was no improvement in functioning (adjusted mean difference 0.02, 95% CI -0.01 to 0.06; P=.18; Cohen d effect size 0.04).ConclusionsIn an extended implementation, our intervention featuring mobile texting messages and lay health workers in a resource-poor community setting was more effective than the 686 Program alone in improving medication adherence, improving symptoms, and reducing rehospitalization.Trial registrationChinese Clinical Trial Registry; ChiCTR-ICR-15006053 https://tinyurl.com/y5hk8vng.

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Working with lay midwives to improve the detection of neonatal complications in rural Guatemala

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