Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an under‐resourced setting in Tanzania

Objective To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania, where audit results have been disappointing 2 years after its introduction. Methods Qualitative study involving participative observation of audit sessions, followed by 23 in‐depth interviews with health workers and managers. Knowledge and perceptions of audit were assessed and suggestions for improvement of the audit process explored. Results During the observational period, audit sessions were held irregularly and only when the head of department of obstetrics and gynaecology was available. Cases with evident substandard care factors were audited. In‐depth interviews revealed inadequate knowledge of the purpose of audit, despite the fact that participants regarded obstetric audit as a potentially useful tool. Insufficient staff commitment, managerial support and human and material resources were mentioned as reasons for weak involvement of health workers and poor implementation of recommendations resulting from audit. Suggestions for improvement included enhancing feedback to all staff and managers to attend sessions and assist with the effectuation of audit recommendations. Conclusion Obstetric staff in Ifakara see audit as an important tool for quality improvement. They recognise, however, that in their own situation, insufficient staff commitment and poor managerial support are barriers to successful implementation. They suggested training in concept and principles of audit as well as strengthening feedback of audit outcomes, to achieve structural health care improvements through audit.     

Moving from vertical to integrated child health programmes: experiences from a multi‐country assessment of the Child Health Days approach in Africa

Objectives To assess the effect of child health days (CHDs) on coverage of child survival interventions, to document country experiences with CHDs and to identify ways in which CHDs have strengthened or depleted primary health care (PHC) services. Methods Programme evaluation in six countries in sub‐Saharan Africa using both quantitative (review of routine child health indicators) and qualitative (key informant interviews) methods. Results We found that CHDs have raised the profile of child survival at different levels from central government to the community in all six countries. The approach has increased the coverage of vitamin A supplementation and immunizations, especially in previously poorly performing countries. However, similar improvements have not occurred in non‐CHD interventions, most notably exclusive breastfeeding. There were examples of duplication, especially in the capturing and use of health information. There was widespread evidence that PHC staff were being diverted from their usual PHC functions, and managers reported being distracted by the time required for the planning and execution of CHDs. Finally, there were examples of where the routine PHC system is becoming distorted through, for example, the payment of health worker incentives during CHD activities only. Conclusion Interventions such as CHDs can rapidly increase coverage of key child survival interventions; however, they need to do so in a manner that strengthens rather than depletes existing PHC services. Our findings suggest that stand alone child health day interventions may gradually need to be integrated with routine PHC through more general health system strengthening.     

Long‐term effects of malaria prevention with insecticide‐treated mosquito nets on morbidity and mortality in African children: randomised controlled trial

Objective The objective is to investigate the effect of malaria control with insecticide‐treated mosquito nets (ITNs) regarding possible higher mortality in children protected during early infancy, due to interference with immunity development, and to assess long‐term effects on malaria prevalence and morbidity. Methods Between 2000 and 2002, a birth cohort was enrolled in 41 villages of a malaria holoendemic area in north‐western Burkina Faso. All neonates (n = 3387) were individually randomised to ITN protection from birth (group A) vs. ITN protection from age 6 months (group B). Primary outcome was all‐cause mortality. In 2009, a survey took place in six sentinel villages, and in 2010, a census was conducted in all study villages. Results After a median follow‐up time of 8.3 years, 443/3387 (13.1%) children had migrated out of the area and 484/2944 (16.4%) had died, mostly at home. Long‐term compliance with ITN protection was good. There were no differences in mortality between study groups (248 deaths in group A, 236 deaths in group B; rate ratio 1.05, 95% CI: 0.889–1.237, P = 0.574). The survey conducted briefly after the rainy season in 2009 showed that more than 80% of study children carried asexual malaria parasites and up to 20% had clinical malaria. Conclusion Insecticide‐treated mosquito net protection in early infancy is not a risk factor for mortality. Individual ITN protection does not sufficiently reduce malaria prevalence in high‐transmission areas. Achieving universal ITN coverage remains a major challenge for malaria prevention in Africa.     

Health workers’ perceptions of obstetric critical incident audit in Thyolo District,Malawi

Objective To assess perceptions held by health workers in a Malawian district about obstetric critical incident audit. Insight into factors contributing to participation and endorsement may help to improve the audit process and reduce facility‐based maternal and neonatal mortality and morbidity. Methods This study involves semi‐structured interviews with 25 district health workers, a focus group discussion and observation of audit sessions in health facilities in Thyolo District, Malawi, between August 2009 and January 2010. Data were analysed with maxqda 2010. Results Findings were categorized into four major areas: (i) general knowledge of audit, (ii) participation in local audit and feedback sessions, (iii) the ability to reproduce the local audit cycle and (iv) effects and outcomes of audit and feedback. All health workers were familiar with the concept of audit and could reproduce the local cycle. Most health workers classified audit as an instructive and helpful tool to improve the quality of their work, provided that it is performed in a manner that enhances motivation and on‐the‐job learning. Conclusions Contradictory to recent reports from other African settings, which showed negative effects of audit on health workers’ motivation, staff in this district considered audit and feedback valuable tools to enhance the quality of the care they provide. Audit has become part of the professional routine in the district, and its educational value was considered its most important appeal.     

Using vital registration data to update mortality among patients lost to follow‐up from ART programmes: evidence from the Themba Lethu Clinic,South Africa

Objective To estimate the rates of mortality in patients lost to follow‐up (LTFU) from a large urban public sector HIV clinic in South Africa. Methods We compared vital status using the clinic’s database to vital status verified against the Vital Registration system at the South African Department of Home Affairs. We compared rates of mortality before and after updating mortality data. Predictors of mortality were estimated using Kaplan–Meier curves and proportional hazard regression. Results Of the 7097 total patients who initiated highly active antiretroviral therapy at Themba Lethu Clinic by October 1st, 2008 and had an ID number, 6205 were included. 2453 patients (21%) were LTFU, of whom 1037 (42.3%) could be included in the analysis. After matching to the vital registration system, mortality more than doubled from 4.2% (258/6205) to 10.9% (676/6205). Overall 37% of those LTFU died by life‐table analysis the probability of survival amongst those LTFU was 69% (95% CI: 66–72%), 64% (95% CI: 61–67%) and 59% (95% CI: 55–62%) by years 1, 2 and 3 since being lost, respectively. Those at highest risk of death after being lost were patients with a history of tuberculosis, CD4 count < 100 cells/μl, BMI < 17.5, haemoglobin < 10 and on <6 months of treatment. Conclusion Mortality was substantially underestimated among patients lost from a South African HIV treatment programme despite limited active tracing. Linking to vital registration systems can provide more accurate assessments of programme effectiveness and target lost patients most at risk for mortality.     

Mortality measurement in transition: proof of principle for standardised multi‐country comparisons

Objective To demonstrate the viability and value of comparing cause‐specific mortality across four socioeconomically and culturally diverse settings using a completely standardised approach to VA interpretation. Methods Deaths occurring between 1999 and 2004 in Butajira (Ethiopia), Agincourt (South Africa), FilaBavi (Vietnam) and Purworejo (Indonesia) health and socio‐demographic surveillance sites were identified. VA interviews were successfully conducted with the caregivers of the deceased to elicit information on signs and symptoms preceding death. The information gathered was interpreted using the InterVA method to derive population cause‐specific mortality fractions for each of the four settings. Results The mortality profiles derived from 4784 deaths using InterVA illustrate the potential of the method to characterise sub‐national profiles well. The derived mortality patterns illustrate four populations with plausible, markedly different disease profiles, apparently at different stages of health transition. Conclusions Given the standardised method of VA interpretation, the observed differences in mortality cannot be because of local differences in assigning cause of death. Standardised, fit‐for‐purpose methods are needed to measure population health and changes in mortality patterns so that appropriate health policy and programmes can be designed, implemented and evaluated over time and place. The InterVA approach overcomes several longstanding limitations of existing methods and represents a valuable tool for health planners and researchers in resource‐poor settings.     

Adult deaths and the future: a cause‐specific analysis of adult deaths from a longitudinal study in rural Tanzania 2003–2007

Objectives To determine patterns and risk factors for cause‐specific adult mortality in rural southern Tanzania. Methods The study was a longitudinal open cohort and focused on adults aged 15–59 years between 2003 and 2007. Causes of deaths were ascertained by verbal autopsy (VA). Cox proportion hazards regression model was used to determine factors associated with cause‐specific mortality over the 5‐year period. Results Thousand three hundred and fifty‐two of 65 548 adults died, representing a crude adult mortality rate (AMR) of 7.3 per 1000 person years of observation (PYO). VA was performed for 1132 (84%) deaths. HIV/AIDS [231 (20.4%)] was the leading cause of death followed by malaria [150 (13.2%)]. AMR for communicable disease (CD) causes was 2.49 per 1000 PYO, 1.21 per 1000 PYO for non‐communicable diseases (NCD) and 0.53 per 1000 PYO for accidents/injury causes. NCD deaths increased from 16% in 2003 to 24% in 2007. High level of education was associated with a reduction in the risk of dying from NCDs. Those with primary education (HR = 0.67, 95% CI: 0.49, 0.92) and with education beyond primary school (HR = 0.11, 95% CI: 0.02, 0.40) had lower mortality than those who had no formal education. Compared with local residents, in‐migrants were 1.7 (95% CI: 1.37, 2.11) times more likely to die from communicable disease causes. Conclusion NCDs are increasing as a result of demographic and epidemiological transitions taking place in most African countries including Tanzania and require attention to prevent increased triple disease burden of CD, NCD and accident/injuries.