Mission Hospitals Research Articles

Catastrophic Healthcare Expenditure from Typhoid Perforation in Children in Nigeria.

Background: Out-of-pocket payments and catastrophic healthcare expenditures (CHE) are important barriers to achieving equity and access to emergency and essential surgical care in low- and middle-income countries (LMICs), with important implications for universal health coverage (UHC). However, data on CHE for surgical care in these settings are limited, especially with regard to infections. Methods: We performed a retrospective review of 32 children receiving laparotomy for typhoid intestinal perforation in a four-year period. Data on medical costs were reviewed. Because of the lack of reliable data on household incomes and average national incomes for Nigeria, gross domestic product per capita was used to calculate CHE. The GDP per capita for the country during the study period was $2,028.182. Expenditure >10% GDP per capita (or > $202.82) was considered CHE. Results: There were 15 boys and 17 girls aged 2-15 years (mean 7.72 years). Seventeen patients (53%) were referred from district/general hospitals or mission hospitals. After surgical treatment, 16 patients (50%) developed complications (intra-abdominal abscesses and incision complications), and nine (28.1%) required re-operation. Seven patients (21.9%) required intensive care (ICU) treatment and three (9.4%) died from overwhelming infection. The hospital stay was 3-93 days (mean 23 days). The average total medical cost was $452 (range $236-$1,700). The total medical costs exceeded 10% of GDP ($202.82) for all patients. Total expenditure for four patients requiring intensive care exceeded $202.82 for the ICU care alone. Conclusion: Surgical treatment of typhoid intestinal perforation in children is associated with a high rate of CHE if care is provided at tertiary hospitals. Investments in prevention and control of this and other surgical infections as well as scale up of capacity at district hospitals to provide such care are important in preventing CHE.

Effect of facility-based HIV self-testing on uptake of testing among outpatients in Malawi: a cluster-randomised trial

HIV self-testing increases testing uptake in sub-Saharan Africa but scale-up is challenging because of resource constraints. We evaluated an HIV self-testing intervention integrated into high-burden outpatient departments in Malawi. In this cluster-randomised trial, we recruited participants aged 15 years or older from 15 outpatient departments at high-burden health facilities (including health centres, mission hospitals, and district hospitals) in central and southern Malawi. The trial was clustered at the health facility level. We used constrained randomisation to allocate each cluster (1:1:1) to one of the following groups: standard provider-initiated testing and counselling with no intervention (provider offered during consultations), optimised provider-initiated testing and counselling (with additional provider training and morning HIV testing), and facility-based HIV self-testing (Oraquick HIV self-test, group demonstration and distribution, and private spaces for interpretation and counselling). The primary outcome was the proportion of outpatients tested for HIV on the day of enrolment, measured through exit surveys with a sample of outpatients. Analyses were on an intention-to-treat basis. The trial is registered with ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316. Between Sept 12, 2017, and Feb 23, 2018, 5885 outpatients completed an exit survey-2097 in the HIV self-testing group, 1951 in the standard provider-initiated testing and counselling group, and 1837 in the optimised provider-initiated testing and counselling group. 1063 (51%) of 2097 patients in the HIV self-testing group had HIV testing on the same day as enrolment, compared with 248 (13%) of 1951 in the standard provider-initiated testing and counselling group and 261 (14%) of 1837 in the optimised provider-initiated testing and counselling group. The odds of same-day HIV testing were significantly higher in the facility-based HIV self-testing group compared with either standard provider-initiated testing and counselling (adjusted odds ratio 8·52, 95% CI 3·98-18·24) or optimised provider-initiated testing and counselling (6·29, 2·96-13·38). Around 4% of those tested in the standard provider-initiated testing and counselling and optimised provider-initiated testing and counselling groups felt coerced to test, and around 1% felt coerced to share test results. No coercion was reported in the facility-based HIV self-testing group. Facility-based HIV self-testing increased HIV testing among outpatients in Malawi, with a minimal risk of adverse events. Facility-based HIV self-testing should be considered for scale-up in settings with a high unmet need for HIV testing. United States Agency for International Development.

Choice of birth place among antenatal clinic attendees in rural mission hospitals in Ebonyi State, South-East Nigeria.

BackgroundLow utilization of health facilities for delivery by pregnant women poses a public health challenge in Nigeria.AimTo determine the factors that influence the choice of birth place among antenatal clinic attendees.MethodologyThis was a cross-sectional study of the eligible antenatal clinic attendees recruited at Mater Misericordiae Hospital, Afikpo and Saint Vincent Hospital, Ndubia in Ebonyi State from February 1, 2016 to June 30, 2016. Analysis was done using EPI Info 7.21 software (CDC Atlanta Georgia).ResultsA total of 397(99.3%) completely filled questionnaires were collated and analysed. Approximately 71% of the health facilities closest to the respondents had maternity services. It took at least 1 hour for 80.9% of the respondents to access health facilities with maternity services. Most (60.2%) of the respondents had at least one antenatal clinic attendance and majority of them did so at public hospitals. Approximately 43.8% of the respondents were delivered by the skilled birth attendants. The respondents’ age and the couple’s educational level, history of antenatal clinic attendance, distance of the health facility and availability of transport fare had a significant effect on delivery by skilled birth attendants. The common determinants of birth place were nearness of the health facilities, familiarity of healthcare providers, improved services, sudden labour onset and cost. Also 61.7% of the respondents chose to deliver in public health facilities due to favourable reasons but this could be hampered by the rudeness of some healthcare providers at such facilities. A significant proportion of private health facilities had unskilled manpower and shortage of drugs.ConclusionA greater proportion of women will prefer to deliver in health facilities. However there are barriers to utilization of these facilities hence the need to address such barriers.

Church and Poverty Alleviation Through Health Care Delivery in the Kumasi Metropolis

Health care has been the backbone of all developments across the globe. Its presence in every society has been possible due to the contributing role of religious institutions. The need for involvement of religious institutions in health care comes via global concern for the poor’s inability to access health care services. The main objective of this research is to assess what contributions the Church in Kumasi metropolis has made in reducing poverty among inhabitants. The study adds further insight into the range of investments required to achieve better health outcomes for the poor as an integral component of poverty reduction strategies, hence its significance. It indicates religious concerns and implications for good health and human advancement. This has grown to include a pro-poor approach and the strengthening of the delivery and quality of health services, reaching out to highly vulnerable groups, while developing more effective partnerships with the government and designing equitable health financing mechanisms. The research is cross-sectional involving interview with key respondents such as health administrators, health personnel, religious leaders and heads of mission hospitals, including a survey in the Kumasi metropolis. Inter alia, the study has revealed that achieving a better health for the poor requires going beyond the health sector to take action in related areas such as education, economics and spirituality. Keywords: church, poverty alleviation, health care delivery, development. DOI : 10.7176/DCS/9-10-08 Publication date :October 31 st 2019

Scaling up Maternal and Child Healthcare Delivery among Mission Hospitals in Southeast Nigeria: An Empirical Application of Data Envelopment Analysis for Setting Benchmarks and Targets.

The health system in many parts of Nigeria has been dysfunctional in several domains including financing, human resources, infrastructure, health management information system and hospital services. In an attempt to scale up Maternal and Child Health (MCH) services and ensure efficiency, Ebonyi State Government in Southeast Nigeria provided funding to mission hospitals across the State as a grant. This study used nonparametric method to assess the effect of this public financing on the efficiency of the mission hospitals. Operational cost and number of hospital beds were used as the input variables, while antenatal registrations, number of immunization doses and hospital deliveries were the output variables. The hospitals were disaggregated into 15 hospital-years. The mean overall technical efficiency of the mission hospitals was 84.05 22.45%. The mean pure technical efficiency was 95.56±6.9% and the scale efficiency was 88.05±22.20%. About 46.67% of all the hospital-years were technically and scale efficient. Although, 55.33% were generally inefficient, only 33.33% of hospital-years exhibited pure technical inefficiency. Low immunization coverage was the major cause of inefficiency. The study showed increased maternal health service output as result of public funding or intervention; however, the mission hospitals could have saved 16% of input resources if they had performed efficiently. It also shows that data envelopment analysis can be used in setting targets/benchmarks for relatively inefficient health facilities, and in monitoring impact of interventions on efficiency of hospitals over-time.

Career destination and reason for career destination preferences among medical graduates from Christian Medical College Vellore - Does rural service obligation increase retention of medical graduates in rural service?

Objectives:To find out the career destination of a cohort of doctors who have graduated from Christian Medical College (CMC) and to identify the reasons for their choice.Background:CMC is a training institution for medical graduates among a network of mission hospitals in India. After their graduation, most students complete a sponsorship obligation of 2 years in primary or secondary, rural and semi-urban hospitals.Methods: Study population:The study population was obtained from the electronic database of the medical graduates. The batches of medical graduates from 1966 to 1995 were analyzed. Quantitative data regarding the career destination were obtained from this database.Survey Instrument:A structured qualitative questionnaire was devised with both open and closed questions regarding their present area of work and the reason for their choice. This questionnaire was sent via email and posted to others who did not have email access; 17.5% responded to this questionnaire.Results:Data revealed that 57.4% of our alumni were working in India and 42.3% were working abroad. In India, 29% were working in the corporate sector, 21% in CMC, and 10% in rural hospitals. The pull factors for the doctors who stayed in India and in rural area were a felt need to serve. The pull factors for doctors to go abroad were pursuit of academic excellence and perceived better quality of life. The push factors against the pursuit of rural career were prior adverse experiences in the rural hospitals they had worked in.Conclusion:The career destinations depend mainly on satisfaction with work and familial expectations.

Living and Working at Oasis Hospital: Recollections of Missionary Nurses

Mission hospitals in postcolonial developing countries were often staffed by female nurses who cared for women during labor and birth. This article is a thematic analysis of narratives from nurses who served at Oasis Hospital, United Arab Emirates, during the years 1960 to 1980. Despite the challenges and sacrifices (both during their service and upon returning to their homelands), these nurses spoke fondly of community, friendships, and a sense of accomplishment.

Anesthesia for Cesarean Delivery: A Cross-sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe

(Anesth Analg. 2018;126:2056–2064) In low- and middle-income countries like Zimbabwe, cesarean delivery (CD) is the most common surgical procedure, and as such, can indicate overall surgical activity in a health care system. Recent studies have shown the highest risk of anesthesia-related maternal death occurring in sub-Saharan Africa. Using a questionnaire, the authors of the present study assessed the type of anesthesia used for CD, level of training of anesthesia providers, and availability of resources in provincial, district, and mission hospitals in Zimbabwe.

중국 근대 프로테스탄트 의료선교사(史) 연구의 흐름

The aim of this paper is to suggest the future direction of research on the history of medical missionary works by taking a general view of performances of research on the history of Chinese modern protestant medical missionary works in three Eastern Asian countries and considering insufficiencies of the previous studies.BR The history of protestant medical missionary works is a very important research topic to understand the Chinese modern medical history, since those works introduced modern medicine to China in earnest. Besides, this research is required to comprehend the history of Chinese modern Christianity, since medical practice has been regarded as a kind of missionary work.BR Until the 70s, most studies were to criticized medical missionary works, considering them as cultural invasion of imperialism. But after the 80s, studies focusing on positive aspects of medical missionary works began to emerge. Since the 90s, the scope of research has expanded and research topics and regions have diversified.BR The first study on Chinese medical missionary works is a record that a medical missionary in China wrote and left himself. This is valuable as a historical record to show how missionaries thought about China at that time. The second is a study on figures, who were involved in medical missionary works. There are studies focusing on the identities of medical missionaries, who had to perform two roles as a doctor and as a missionary and focusing on lives and activities of medical activities of named medical missionaries. The third is a study on the indigenization discourse. This study is to examine the process in which the leading role of medical missionary activity switched from foreign missionaries to Chinese people. Fourthly, the studies on hospitals and medical schools occupy the biggest proportion of research from the perspective of the medical history, since hospitals and medical schools are where medical mission is realized directly. Fifthly the majority of studies on activities and influences of medical missionary groups are concentrated on the establishment of Medical Missionary Society in Guangzhou and the China Medical Missionary Association, their activities, and influences on Chinese society. Lastly, there are studies on translation of medical terms and publication of medical books of medical missionaries.BR After the 1980s, there was an increase in concern about the history of medical missionary works and a lot of research findings were announced. But it is hard to say that research on medical missionary works is a mainstream in the history of Christianity and in the history of medicine. For active future research on this field, following studies would be needed.BR First, there should be a study to compare and consider the histories of Korean, Chinese and Japanese medical missionary works, since medical missionaries worked in Korea and Japan as well as in China and they highly influenced modern medical development in Korea, China and Japan. This comparative study would help in figuring out the reasons why medical missionary works could develop in modern East Asia. Second, the studies on figures are mostly focused on specific regions or specific figures. Thus, microhistorical research focusing on more diverse figures and missionary groups should be conducted. Third, research on indigenization needs to consider both missionaries and Chinese people. It is also necessary to pay attention to “self-propagating”, in mission hospitals and medical schools. Fourth, research on the medical history lacks a consideration of specificity of church medical works represented by religiosity. On the contrary, research on the history of Christianity lacks an understanding of professional medical fields. There is a need to consider these two aspects comprehensively. Fifth, it is required to do comparative research, which includes activities of Catholicism, in addition to protestant medical missionary works.

Implementation of the 'Test and Treat' policy for newly diagnosed people living with HIV in Zimbabwe in 2017.

Setting: Sixteen mission hospitals in Zimbabwe that are implementing the 'Test and Treat' programme for people living with the human immunodeficiency virus (HIV). Objectives: To assess linkages of HIV diagnosis to care and treatment, time taken from being diagnosed with HIV infection to initiation of antiretroviral therapy (ART) and 3-month programmatic outcomes for those starting ART. Design: Cross-sectional study using secondary data. Results: Among 972 people newly diagnosed with HIV, 915 (94%) enrolled for HIV care and 771 (79%) were initiated on ART. Enrolment in care and initiation on ART on the same day as testing occurred in respectively 864 (89%) and 628 (65%) newly diagnosed patients. Over 80% of those who underwent HIV testing in maternal and child health departments initiated ART on the same day. Of the 144 (16%) people in care who were not initiated on ART, the principal reason in 102 (71%) was being transferred out. Most patients (90%) on ART were retained in care at 3 months, with transfer out accounting for most of the remainder. Conclusion: The 'Test and Treat' approach was feasible and successful in getting newly HIV-infected people initiated early on ART. More research is needed to better understand the processes, benefits and potential risks.

Anesthesia for Cesarean Delivery: A Cross-Sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe.

Cesarean delivery is the most common surgical procedure in low- and middle-income countries, so provision of anesthesia services can be measured in relation to it. This study aimed to assess the type of anesthesia used for cesarean delivery, the level of training of anesthesia providers, and to document the availability of essential anesthetic drugs and equipment in provincial, district, and mission hospitals in Zimbabwe. In this cross-sectional survey of 8 provincial, 21 district, and 13 mission hospitals, anesthetic providers were interviewed on site using a structured questionnaire adapted from standard instruments developed by the World Federation of Societies of Anaesthesiologists and the World Health Organization. The anesthetic workforce for the hospitals in this survey constituted 22% who were medical officers and 77% nurse anesthetists (NAs); 55% of NAs were recognized independent anesthetic providers, while 26% were qualified as assistants to anesthetic providers and 19% had no formal training in anesthesia. The only specialist physician anesthetist was part time in a provincial hospital. Spinal anesthesia was the most commonly used method for cesarean delivery (81%) in the 3 months before interview, with 19% general anesthesia of which 4% was ketamine without airway intubation. The mean institutional cesarean delivery rate was 13.6% of live births, although 5 district hospitals were <5%. The estimated institutional maternal mortality ratio was 573 (provincial), 251 (district), and 211 (mission hospitals) per 100,000 live births. Basic monitoring equipment (oximeters, electrocardiograms, sphygmomanometers) was reported available in theatres. Several unsafe practices continue: general anesthesia without a secure airway, shortage of essential drugs for spinal anesthesia, inconsistent use of recovery area or use of table tilt or wedge, and insufficient blood supplies. Postoperative analgesia management was reported inadequate. This study identified areas where anesthetic provision and care could be improved. Provincial hospitals, where district/mission hospitals refer difficult cases, did not have the higher level anesthesia expertise required to manage these cases. More intensive mentorship and supervision from senior clinicians is essential to address the shortcomings identified in this survey, such as the implementation of evidence-based safe practices, supply chain failures, high maternal morbidity, and mortality. Training of medical officers and NAs should be strengthened in leadership, team work, and management of complications.

Comparative Assessment of Clients Satisfaction with Doctors Services in Teaching and Mission Hospitals in South East Nigeria

Comparative Assessment of Clients Satisfaction with Doctors Services in Teaching and Mission Hospitals in South East Nigeria

PROSES PENINGKATAN KETERLIBATAN KARYAWAN MELALUI GAYA KEPEMIMPINAN DAN MOTIVASI KERJA

The aims of this study was to determine the process of increasing the employee engagement of the nurse children’s unit in the Balai Klinik Ibu & Anak RKZ Malang. This study used a qualitative approach with phenomenology design to explain the application of the leadership model hospital of directors and motivation of nurse children’s unit in an effort to increase their engagement. Data were collected by interviewing 7 informants who are senior, intermediate and junior nursing staff. Data were analyzed using the Interactive Model of Analysis. The results showed that the application leadership model of hospital director for senior and intermediate nurses through the delegation of authority and involvement in decision-making; and for junior nurses through leading by example and description of vision and mission hospitals. Intrinsic motivation of nurses in the works are a live call and pride in their work, while extrinsic motivation is the incentive, salary, promotion, exchange office space, conducive working environment and good relationship between colleagues. The existence of unresolved conflicts between the hospital director with the senior nursing staff related to dissatisfaction in the distribution of incentives encouraging the increased desire to resign from the job and is more suited completed transactional leadership models. DOI : https://doi.org/10.26905/jbm.v5i1.2322

Influence of Hospital Capabilities on Organizational Performance of Mission Hospitals in Kenya

Modern healthcare is characterized by new disease patterns; advanced technologies; unpredictable patients’ needs; physical infrastructure and diverse workforce requirements. A hospital is mainly the first point of health care service delivery; and is indispensable in fostering a healthy population. The health sector in Kenya has allowed a diverse non-governmental healthcare sector to develop. Mission hospitals belong to this sector and can significantly improve their service delivery with proper application of strategic management practices. The field of strategic management has undergone a major shift in focus over the last two decades regarding organizational performance variation: from industry's specific to organization-specific factors. Since the inception of strategic management studies in the 1950s; scholars have sought to know determinants that make some organizations more successful than others. This quest has created a bifurcated view, one on industry structure and the other on specific organizational resources.

A Descriptive Study to Evaluate the level of Knowledge regarding Biomedical Waste Management among Nurses in Christian Mission Hospitals at Madurai

A Descriptive Study to Evaluate the level of Knowledge regarding Biomedical Waste Management among Nurses in Christian Mission Hospitals at Madurai

A Distance Blended Learning Program to Upgrade the Clinical Competence of District Non-doctor Anesthesia Providers in Nepal.

Across Nepal, anesthesia at a district level is provided mostly by non-doctor anesthesia providers (anesthesia assistants-AAs). Nepal's Government recognized the need to sustain competence with continuous professional development and to upgrade 6-month trained working AAs to professional equivalence with the new national standard of 12-month training. As they are essential district health workers and AA clinical training sites are full, an innovative distance blended learning, competency-based, upgrade 1-year course was developed and conducted in 2014-2017 for two batches. The course content was developed over 18months by a team of Nepali and overseas AA training experts. The 1-year course started with a refresher course, continued with tablet-based 12-month self-learning modules and clinical case logs, regular educational mentor communication, midcourse 2-week contact time in an AA training site, regular text messaging and ended with clinical examination and multiple-choice questions. Tablet content included 168 new case studies, pre- and posttests, video lectures, matching exercises and a resource library. All module work and logged clinical cases were uploaded centrally, where clinical mentors were able to review work. Clinical skills were upgraded, as needed, through direct clinical contact midway through the course. Quantitative and qualitative course assessments were included. Fourteen working AAs in first batch and eight working AAs in second batch from district, zonal and mission hospitals across Nepal were enrolled. All remained working at their hospitals throughout the course, and there were no significant tablet problems inhibiting course completion. Twenty-one AAs completed all modules successfully with time required for module completion averaging 19.2h (range 11.2-32). One AA left the course after 3 months with a personal problem. Subjectively, AAs felt that the obstetric and pediatric modules were more difficult; lowest marks were objectively seen in the airway module. Clinical mentors averaged 8.2h mentoring review work per module with direct student communication of 2.9h per module per month. Participants logged a total of 5473 clinical cases, ranging between 50 and 788 cases each. Complications were recorded; outcomes were good. Challenges were the national IT infrastructure making data synchronization difficult and the lack of clinical exposure at some AA's hospitals. Nineteen AAs attended the final examination, and all passed. Two AAs withdrew before the final examination period due to personal and logistic reasons. This is the first use of distance blended learning to upgrade district health workers in Nepal and perhaps for non-doctor anesthesia providers globally. Key success factors were motivated students, cultural and contextualized clinical content, good educational mentoring relationships with regular communication, central IT and motivational support, and face-to-face midcourse clinical contact time.

Tablet e-Logbooks: Four Thousand Clinical Cases and Complications e-Logged by 14 Nondoctor Anesthesia Providers in Nepal.

To meet the need for essential surgery across rural Nepal, anesthesia at district level is delivered by nondoctor anesthetists. They require support to maintain confidence and competence, and upgraded professional registration to secure their status. To meet these needs, a distance-blended learning course was pioneered and delivered. A core course requirement was to log all clinical cases; these were logged on a new e-logbook. Fourteen nondoctor anesthesia providers working in 12 different districts across Nepal were enrolled in the 1-year course. The course is based on self-completion on a tablet loaded with new learning modules, a resource library, and a case logbook. Continuous educational mentoring was provided by anesthesiologists by phone and email. The logbook included preanesthesia assessment and interventions, American Society of Anesthesiologists (ASA) grading, types of cases and anesthesia given, monitors used, complications, outcomes and free text remarks. Cases were uploaded monthly to a database, and mentors reviewed all logbook entries. The 14 nondoctor anesthesia providers were widely distributed across the country in district, zonal, community, and mission hospitals, and had different levels of clinical experience and caseloads. Logbooks and uploads were regularly completed without difficulty; 1% cases were entered incompletely with no case details provided. A total of 4143 cases were recorded. Annual caseload per nondoctor anesthesia provider ranged from 50 to 788, the majority of which were under spinal anesthesia; 34% of the total cases were cesarean deliveries, of which 99% received spinal anesthesia. Fifty gastrointestinal laparotomies (1% total) were recorded. Ninety-one percent of cases were ASA I, 0.8% ASA III/IV. Pulse oximetry was used in 98% of cases. Complications were recorded in 6% of cases; the most common were circulation problems (69%) including hypotension and occasional bradycardia after spinal anesthesia. Airway complications were usually under ketamine anesthesia requiring basic airway maneuvers; 4 difficult intubations were recorded under general anesthesia. Anesthesia outcomes were good with overall mortality of 0.1% (total 4 cases). Causes of death included severe preeclampsia, sepsis postlaparotomy, and patients with multiorgan failure for minor procedure. The tablet-based electronic anesthesia logbook was successfully used to record cases, complications, and outcomes across rural Nepal. The nondoctor anesthesia providers had trust and confidence in recording outcomes. It remains to be tested whether an e-logbook would be routinely completed outside of a specific training course. Such a logbook could be incorporated into all continuous professional development programs for rural nondoctor anesthetists.

Infant hydrocephalus in sub-Saharan Africa: the reality on the Tanzanian side of the lake.

OBJECTIVE Infant hydrocephalus is estimated to affect more than 100,000 new infants each year in sub-Saharan Africa (SSA). Bugando Medical Centre (BMC), a government-funded and patient cost-shared referral center, serves over 13 million people in the Lake and Western regions of Tanzania. The goals of this study were to characterize the infant population affected by hydrocephalus who presented to BMC and were treated with a ventriculoperitoneal shunt (VPS) to determine the rate of early complications associated with this surgical procedure and to assess its potential risk factors. METHODS Data were prospectively collected from all patients less than 1 year of age who, over a period of 7 months, were diagnosed with hydrocephalus and admitted to BMC for insertion of a primary VPS. Demographic data, maternal history, preoperative studies, surgical procedure, and surgical complications developing by the time of the first follow-up visit were analyzed. Risk factors associated with the surgical complications were determined. RESULTS During the 7-month study period, 125 infants eligible for the study were included in the analysis. Overall, 75% were younger than 6 months of age, and 56% were males. Only 7% of mothers had a gestational ultrasound, 98% did not receive preconception folic acid, and 25% delivered their child at home. In most patients with hydrocephalus the etiology was uncertain (56%), and other patients had postinfectious (22.4%) or myelomeningocele-associated (16%) hydrocephalus. Patients' mean head circumference on admission was 51.4 ± 6.3 cm. Their median age at shunt surgery was 137 days, and 22.4% of the patients were operated on without having undergone radiological assessment. The majority of shunts were placed in a right parietooccipital location. Thirteen patients had undergone a previous intraventricular endoscopic procedure. Overall, at least one surgical complication was found in 33.6% of patients up to the first follow-up assessment (median follow-up time of 70 days); shunt infection was the most common complication. The postoperative mortality rate was 9%. The risk factors associated with early surgical complications were tumor-related etiology, larger head circumference, and postoperative hospital stays of greater duration. CONCLUSIONS In a region of the continent where most infant hydrocephalus cases had an uncertain etiology, most patients presented to the hospital in a late stage, with no prenatal diagnosis and with large head circumferences. Standard preoperative investigations were not uniformly performed, and the surgical complications, led by VPS infection, were disturbingly high. Younger patient age, previous endoscopic procedure, surgeon involved, and cranial location of the VPS had no statistical relation to the surgical complications. This study shows that the positive results previously reported by SSA mission hospitals, subspecialized in pediatric neurosurgery, are still not generalizable to every hospital in East Africa. To improve maternal and neonatal care in the Lake region of Tanzania, the development of a fluxogram to determine hydrocephalus etiology, a strict perioperative protocol for VPS insertion, and an increase in the number of endoscopic procedures are recommended to BMC.

Surgical Care Capacity in Uganda: Government Versus Private Sector Investment

Background: Uganda is a low-income country with blended, tiered government health care facilities and private/non-governmental (NGO)/mission hospitals. The population is 84% rural; 100% of referral hospitals and majority of specialist physicians are urban. Summary of background data: This project compared various levels of government hospitals with private/NGO hospitals to determine adequacy to deliver emergency and essential surgical care (EESC) and anesthesia. Methods: Using the WHO Situational Analysis Tool, a representative selection of 38 hospitals (25% of Ugandan hospitals) was assessed for capacity to deliver surgical, anesthetic and obstetric care in 4 domains: infrastructure, human resources, surgeries performed or referred, and equipment. Results: In all facilities, laboratory availability was 86%; anesthesia machines, 66%; generators, 55%; and continuous running water, 42%; oxygen, 32%; and electricity, 26%. Resuscitator bags and mask/tubing were present less than 50% of health facilities. Only 84% of all health facilities had a stethoscope; sterilizers only at 50%. This situation was much more dismal in district hospitals. Surgeons were found at 71% of public hospitals and 63% of NGO/mission hospitals; 60% surgeons, and over 50% of anesthesiologists were only in teaching hospitals; obstetricians almost exclusively in higher-level hospitals. Conclusions: The infrastructure for surgical services and anesthesia were noticeably absent at district hospital level and below, yet were readily available at the tertiary care center level. Overall national and regional referral hospitals were better equipped than NGO facilities, suggesting the government is capable of fully equipping hospitals to provide surgical care. These surveys highlight potential for improvement in surgical care at all levels.

Baseline characteristics of study sites and women enrolled in a three-arm cluster randomized controlled trial: PMTCT uptake and retention (pure) Malawi

BackgroundMalawi introduced an ambitious public health program known as “Option B+” which provides all HIV-infected pregnant and breastfeeding women with lifelong combination antiretroviral therapy, regardless of WHO clinical stage or CD4 cell count. The PMTCT Uptake and REtention (PURE) study aimed at evaluating the effect of peer-support on care-seeking and retention in care.Methods/designPURE Malawi was a three-arm cluster randomized controlled trial that compared facility-based and community-based models of peer support to standard of care under Option B+ strategy. Each arm was expected to enroll a minimum of 360 women with a total minimum sample size of 1080 participants. 21 sites (clusters) were selected for inclusion in the study. This paper describes the site selection, recruitment, enrollment process and baseline characteristics of study sites and women enrolled in the trial.ResultsStudy implementation was managed by 3 partner organizations; each responsible for 7 study sites. The trial was conducted in the South East, South West, and Central West zones of Malawi, the zones where the implementing partners operate. Study sites included 2 district hospitals, 2 mission hospitals, 2 rural hospitals, 13 health centers and 1 private clinic. Enrollment occurred from November 2013 to November 2014, over a median period of 31 weeks (range 17–51) by site. A total of 1269 HIV-infected pregnant (1094) and breastfeeding (175) women, who were eligible to initiate ART under Option B+, were enrolled. Each site reached or surpassed the minimum sample size. Comparing the number of women enrolled versus antenatal cohort reports, sites recruited a median of 90% (IQR 75–100) of eligible reported women. In the majority of sites the ratio of pregnant and lactating women enrolled in the study was similar to the ratio of reported pregnant and lactating women starting ART in the same sites. The median age of all women was 27 (IQR 22–31) years. All women have ≥20 months of possible follow-up time; 96% ≥ 2 years (24–32 months).ConclusionThe PURE Malawi study showed that 3 implementing partner organizations could successfully recruit a complex cohort of pregnant and lactating women across 3 geographical zones in Malawi within a reasonable timeline.Trial registrationThis study is registered at clinicaltrials.gov - ID Number NCT02005835. Registered 4 December, 2013.