Fadhlun Alwy Al-Beity

The World Health Organization proposed a clinical care bundle as a first response for postpartum haemorrhage (PPH), a leading cause of maternal deaths. A large trial was conducted to evaluate its effectiveness, with Tanzania among the participating countries. We explored the experiences of healthcare workers during the early implementation of this bundle within the broader trial. An exploratory qualitative study was conducted to understand the early implementation experiences of the PPH bundle. We held six focus group discussions (FGDs) with healthcare workers, clinical leads designated as champions, and research nurses from all six facilities that implemented the intervention in Tanzania. A d-eductive qualitative thematic analysis was performed using the Consolidated Framework for Implementation Research to structure our findings. We reported on four domains: the intervention and its implementation, individual attributes, and the inner and outer contexts. Healthcare workers reported positive experiences during implementation of the PPH first-response bundle. The innovation included several known components: calibrated drape for early detection, on-site training, facility audits, champions and the PPH care bundle comprising uterine massage, oxytocics, tranexamic acid and intravenous fluids. Individual participants appreciated the multi-component strategies that addressed chronic issues, including the lack of objective measurement of blood loss, inadequate skills, and supply shortages. Additionally, local clinical leads who served as champions increased local ownership and accountability. Facility-level challenges included staff rotation and a lack of clear communication, particularly when managing at-risk women. The availability of external support for training, supplies, and drugs required to administer the bundle, along with strong support from the districts and regional health management teams, enhanced the adoption and implementation process. The components of the bundle and the implementation strategies were well received and perceived as reducing the risk of severe postpartum haemorrhage and potentially saving lives. The perceived successes were contributed by the interconnectedness of the different strategies used. Facilities and countries aiming to scale need to harness these strategies that target the health system. In addition, there is a need to strengthen local facility audits, document and address chronic challenges affecting staff dynamics and supplies. District, regional and national leadership in adopting and integrating new clinical practices are key.

Background Vitamin B12 is an essential cofactor for two enzymes that have critical functions in pregnancy, both for maternal health and fetal development. However, the optimal supplemental dosage and its correlation with vitamin B12 status during pregnancy remain inadequately understood due to limited data. Methods This is a single-blinded, stratified, dose-ranging trial of vitamin B12 supplementation that will be conducted at the Ifakara Health Institute Bagamoyo Clinical Trial Unit in Bagamoyo, Tanzania. We will enroll 40 pregnant participants (gestational age 25–28 weeks) and 10 non-pregnant participants, stratified based on baseline vitamin B12 status (sufficient and insufficient). Pregnant participants are sequentially assigned to one of three doses: 2.6, 10, and 50 µg for four weeks. At the highest dose, pregnant participants are randomized to receive 50 µg once a day (Q24H) or 25 µg twice a day (Q12H). The two lower doses (2.6 and 10 µg) are given Q24H. Non-pregnant participants will receive 2.6 µg Q24H. The trial includes a four week in-patient phase for daily assessment and controlled feeding, with pregnant participants assessed once postpartum. Primary endpoints include serum B12 concentrations, holotranscobalamin concentrations, and their ratio after four weeks of daily supplementation. Discussion This study aims to deepen our understanding of nutrient requirements in pregnancy by generating high-quality, high dimensional data. We will answer questions about how pre supplementation vitamin B12 status and dosage impact vitamin B12 saturable absorption and steady-state over the course of four weeks. Limitations include our inability to assess pharmacokinetic changes across gestation, the impact of vitamin B12 status or supplementation on pregnancy and fetal/newborn health, comparing vitamin B12 effects between pregnant and non-pregnant individuals above the recommended dietary allowance (2.6 µg), and comparing Q12H and Q24H dosing at 50 µg. This is the first controlled feeding study to be conducted in sub-Saharan Africa. Registration ClinicalTrials.gov ( NCT05426395 , 16/06/2022).

Objective: To compare the frequency and timing of postpartum haemorrhage (PPH) treatment initiation between hospitals implementing the MOTIVE treatment bundle (which consisted of uterine Massage, Oxytocic drugs, Tranexamic acid, IntraVenous fluids and Examination) and those following usual care. Design: Nested prospective observational study. Setting: Hospitals in Nigeria, Kenya, Tanzania and South Africa participating in the E‐MOTIVE trial. Population or Sample: Healthcare workers treating PPH. Methods: Between June and December 2022, we observed healthcare workers for 1–2 weeks in 39 E‐MOTIVE and 39 usual care hospitals across Nigeria, Kenya, Tanzania, and South Africa managing vaginal birth and treating PPH. We descriptively compared the frequency and timing from PPH detection to treatment initiation of individual treatments and the MOTIVE bundle, between E‐MOTIVE care and usual care. Results: Among 2578 observations in E‐MOTIVE care hospitals, 295 (11%) PPHs were treated, and among 2834 observations in usual care hospitals, 219 (8%) PPHs were treated. In E‐MOTIVE care hospitals, 97% (286/295) of women with PPH received the MOTIVE bundle, compared to 36% (79/219) in usual care. Median initiation times for the first component were similar (0 vs. 1 min), but E‐MOTIVE care hospitals achieved faster initiation of all components (13 min, IQR 6–18) compared to usual care (18 min, IQR 10–25). In total, 79% (233/295) of women in E‐MOTIVE care had all components initiated within 20 min, compared to 22% (48/219) in usual care. Conclusions: Timely and comprehensive management of PPH using the MOTIVE bundle, particularly initiating all components within 15–20 min, was commonly observed in the E‐MOTIVE care hospitals. Scaling up E‐MOTIVE care should emphasise timely bundle initiation to strengthen PPH treatment and improve maternal health outcomes in low‐and‐middle‐income countries.

Background Antenatal corticosteroids (ACS) utilization is disproportionately limited in low- and middle-income countries where most global preterm newborns who could benefit from this intervention are born. Understanding the factors affecting ACS use is crucial for improving its uptake. This study aimed to investigate facility-level factors associated with ACS use in low-resource countries. Methods We used data from ten Service Provision Assessment surveys across nine countries. We restricted the sample to facilities that provided delivery services. Our primary outcome was recent ACS use, defined as having administered ACS within the past three months before the survey. We conducted mixed-effect log binomial regressions, with country as a fixed effect and sub-national regions as random intercepts, to explore the association between recent ACS use and facility characteristics, injectable corticosteroids and ultrasound availability, facility structural readiness, and past performance of nine Comprehensive Emergency Obstetric and Newborn Care (CEmONC) signal functions. Results This study included 6183 facilities from nine countries. Across eight countries with nationally representative data, only 22.7% (median, range 4.0% to 27.4%) of facilities that provided delivery services had used ACS recently. Urban facilities had a 21% higher likelihood of recent ACS use (95% CI 6%–38%) than rural facilities. Corticosteroid availability was associated with a 14% higher likelihood of recent ACS use (95% CI 1%–29%). Facilities in the highest readiness tertile were more likely to have recent ACS use than those in the lowest (RR 1.91, 95% CI 1.58–2.30). Each CEmONC signal function, except for assisted vaginal deliveries, was significantly associated with recent ACS use, with neonatal resuscitation having the largest effect (RR 2.62, 95% CI 1.93–3.55). Conclusion Facilities that had performed CEmONC services were more likely to administer ACS, highlighting the importance of provider knowledge, skills, and competence in managing obstetric and newborn emergencies for effective ACS provision.

Background Vitamin B12 is an essential cofactor for two enzymes that have critical functions in pregnancy, both for maternal health and fetal development. However, the optimal supplemental dosage and its correlation with vitamin B12 status during pregnancy remain inadequately understood due to limited data. Methods This is a single-blinded, stratified, dose-ranging trial of vitamin B12 supplementation that will be conducted at the Ifakara Health Institute Bagamoyo Clinical Trial Unit in Bagamoyo, Tanzania. We will enroll 40 pregnant participants (gestational age 25–28 weeks) and 10 non-pregnant participants, stratified based on baseline vitamin B12 status (sufficient and insufficient). Pregnant participants are sequentially assigned to one of three doses: 2.6, 10, and 50 µg for four weeks. At the highest dose, pregnant participants are randomized to receive 50 µg once a day (Q24H) or 25 µg twice a day (Q12H). The two lower doses (2.6 and 10 µg) are given Q24H. Non-pregnant participants will receive 2.6 µg Q24H. The trial includes a four week in-patient phase for daily assessment and controlled feeding, with pregnant participants assessed once postpartum. Primary endpoints include serum B12 concentrations, holotranscobalamin concentrations, and their ratio after four weeks of daily supplementation. Discussion This study aims to deepen our understanding of nutrient requirements in pregnancy by generating high-quality, high-dimensional data. We will answer questions about how pre-supplementation vitamin B12 status and dosage impact vitamin B12 saturable absorption and steady-state over the course of four weeks. Limitations include our inability to assess pharmacokinetic changes across gestation, the impact of vitamin B12 status or supplementation on pregnancy and fetal/newborn health, comparing vitamin B12 effects between pregnant and non-pregnant individuals above the recommended dietary allowance (2.6 µg), and comparing Q12H and Q24H dosing at 50 µg. This is the first controlled feeding study to be conducted in sub-Saharan Africa. Registration ClinicalTrials.gov (NCT05426395, 16/06/2022).

Background: The majority of women experience pain during childbirth. Offering and supporting women to use different methods for coping with pain is an essential competency for maternity care providers globally. Research suggests a gap between what women desire for pain management and what is available and provided in many low-and middle-income settings. The study aimed to understand how pain management is perceived by those involved: women experiencing childbirth and maternity care providers. Methods: Individual semi-structured interviews with women (n = 23), maternity care providers (n = 17) and focus group discussions (n = 4) with both providers and women were conducted in two hospitals in Southern Tanzania in 2021. Transcribed interviews were analysed using reflexive thematic analysis. Coding and analysis were supported by the software MAXQDA. Results: Three main themes were generated from the data. The first, ‘pain management is multifaceted’, describes how some providers and women perceived pain management as entailing various methods to manage pain. Providers perceived themselves as having a role in utilization of pain management to varying degree. The second theme ‘pain management is primarily a woman’s task’ highlights a perception of pain management as unnecessary, which appeared to link with some providers’ perceptions of pain as natural and necessary for successful childbirth. Few women explicitly shared this perception. The third theme ‘practice of pain management can be improved’ illustrates how women and maternity care providers perceived current practices of pain management as suboptimal. According to providers, this is primarily due to contextual factors such as shortage of staff and poor ward infrastructure. Conclusion: Women’s and maternity care providers’ perceptions ranged from perceiving pain management as involving a combination of physiological, psychological and social aspects to perceive it as related with limited to no pain relief and/or support. While some women and providers had similar perceptions about pain management, other women also reported a dissonance between what they experienced and what they would have preferred. Efforts should be made to increase women’s access to respectful pain management in Tanzania.

Timely detection and treatment of postpartum hemorrhage (PPH) are crucial to prevent complications or death. A calibrated blood-collection drape can help provide objective, accurate and early diagnosis of PPH, and a treatment bundle can address delays or inconsistencies in the use of effective interventions. Here we conducted an economic evaluation alongside the E-MOTIVE trial, an international, parallel cluster-randomized trial with a baseline control phase involving 210,132 women undergoing vaginal delivery across 78 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania. We aimed to assess the cost-effectiveness of the E-MOTIVE intervention, which included a calibrated blood-collection drape for early detection of PPH and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination and escalation), compared with usual care. We used multilevel modeling to estimate incremental cost-effectiveness ratios from the perspective of the public healthcare system for outcomes of cost per severe PPH (blood loss ≥1,000 ml) avoided and cost per disability-adjusted life-year averted. Our findings suggest that the use of a calibrated blood-collection drape for early detection of PPH and bundled first-response treatment is cost-effective and should be perceived by decision-makers as a worthwhile use of healthcare budgets. ClinicalTrials.gov identifier: NCT04341662.

Background: Women’s childbirth experiences provide a unique understanding of care received in health facilities from their voices as they describe their needs, what they consider good and what should be changed. Quality Improvement interventions in healthcare are often designed without inputs from women as end-users, leading to a lack of consideration for their needs and expectations. Recently, quality improvement interventions that incorporate women’s childbirth experiences are thought to result in healthcare services that are more responsive and grounded in the end-user’s needs. Aim: This study aimed to explore women’s childbirth experiences to inform a co-designed quality improvement intervention in Southern Tanzania. Methods: This exploratory qualitative study used semi-structured interviews with women after childbirth (n = 25) in two hospitals in Southern Tanzania. Reflexive thematic analysis was applied using the World Health Organization’s Quality of Care framework on experiences of care domains. Results: Three themes emerged from the data: (1) Women’s experiences of communication with providers varied (2) Respect and dignity during intrapartum care is not guaranteed; (3) Women had varying experience of support during labour. Verbal mistreatment and threatening language for adverse birthing outcomes were common. Women appreciated physical or emotional support through human interaction. Some women would have wished for more support, but most accepted the current practices as they were. Conclusion: The experiences of care described by women during childbirth varied from one woman to the other. Expectations towards empathic care seemed low, and the little interaction women had during labour and birth was therefore often appreciated and mistreatment normalized. Potential co-designed interventions should include strategies to (i) empower women to voice their needs during childbirth and (ii) support healthcare providers to have competencies to be more responsive to women’s needs.

Background Timely detection and treatment of postpartum haemorrhage (PPH) are crucial to prevent complications or death. A calibrated blood-collection drape can help provide objective, accurate, and early diagnosis of PPH and a treatment bundle can address delays or inconsistencies in the use of effective interventions. Methods We conducted an incremental cost-effectiveness analysis alongside the E-MOTIVE trial, an international, parallel cluster-randomised trial with a baseline control phase, designed to assess a multi-component intervention for PPH in patients having vaginal delivery. We compared the E-MOTIVE intervention, which included a calibrated blood-collection drape for early detection of PPH and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), with usual care. We used multilevel modelling to estimate incremental cost-effectiveness ratios from the perspective of the public healthcare system for outcomes of cost per case of severe PPH (blood loss ≥1000 mL) prevented and cost per disability-adjusted life-year (DALY) averted. Results A total of 80 secondary-level hospitals across Kenya, Nigeria, South Africa, and Tanzania, in which 210,132 patients underwent vaginal delivery, were randomly assigned to the E-MOTIVE group or the usual-care group. Among hospitals and patients with data, severe PPH was diagnosed in 1.6% of patients in the E-MOTIVE group and 4.3% of patients in the usual-care group (risk difference, -2.6%; 95% CI -3.1% to -2.1%). Mean DALYs per patient were lower for the E-MOTIVE group (-0.0027; 95% CI -0.0081 to 0.0029) whilst mean costs per patient were slightly higher compared with the usual-care group (0.30 USD; 95% CI -2.31 to 2.78). The E-MOTIVE intervention was deemed cost-effective at contemporary willingness-to-pay thresholds and remained cost-effective across the full range of sensitivity and country-level analyses. Interpretation Use of a calibrated blood-collection drape for early detection of PPH and bundled first-response treatment is cost-effective and should be perceived by decision makers as a worthwhile use of healthcare budgets. Funding Bill & Melinda Gates Foundation (NCT04341662).

BackgroundPreterm birth contributes to significant neonatal and under-five mortality and morbidities. This study assessed the risk factors associated with preterm births at a tertiary teaching hospital in Dar es Salaam, Tanzania. MethodsCase-control study to compare risk factors of preterm birth amongst 140 women with preterm deliveries as cases and 280 women with term deliveries as controls. A structured interviewer-administered questionnaire was used. Univariate and multivariable logistic regression analyses were done using STATA version 17 software. ResultsThe proportion of preterm deliveries was 17.9%. Women with less than four antenatal visits were three times more likely to have a preterm birth than those with four or more attendances (aOR 3.6, 95% CI 1.95–6.57, P < 0.001). The odds of preterm birth increased among women who experienced antepartum haemorrhage (aOR 25.7, 95% CI 12.72–52.03, P < 0.001), pre-eclampsia/eclampsia (aOR 29.9, 95% CI 7.78–115.41, P < 0.001) and preterm membrane rupture (aOR 62.8; 95% CI 23.51–168.21, P < 0.001). Among multiparous women, short interpregnancy intervals, prior preterm birth, or stillbirth increased the odds of preterm birth.ConclusionPoor antenatal attendance, obstetric complications, and premature rupture of membranes were among the identified risk factors. All could be addressed by quality antenatal care. Rwanda J Med Health Sci 2023;6(3):335-345