BackgroundAlthough there are many evidence-based practices that reduce the risk of maternal and neonatal mortality around the time of birth, there remains a gap between what is known and the care received. This know-do gap is a source of preventable maternal and perinatal deaths and is the focus of improvement efforts in many countries. Following an increase in perinatal and maternal deaths, Gobabis District Hospital initiated a quality improvement (QI) initiative to increase adherence to these WHO Safe Childbirth Checklist (SCC)-targeted essential birth practices (EBPs).MethodsWe implemented the SCC with support from leadership, coaching and organisational redesign. Implementation was led by a facility champion supported by a QI team and adapted through a series of three 8-week Plan–Do–Study–Act (PDSA) cycles.ResultsDuring the 6-month period, we observed an improvement of average EBPs delivered from 68% to 95%. We also found reductions in perinatal mortality rates from 22 deaths/1000 deliveries to 13.8/1000 deliveries largely due to a drop in fresh stillbirths.ConclusionWe conclude that replicating the programme is feasible, acceptable and effective in areas where gaps exist, but it requires local leadership, ongoing coaching and adaptation through PDSA cycles.

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registration: NCT03044899.

Background : Namibia, a middle-income country in sub-Saharan Africa (SSA), plans to use the Maternal Near Miss (MNM) approach. Adaptations of the World Health Organization (WHO) MNM defining criteria (‘WHO MNM criteria’) were previously proposed for low-income settings in sub-Saharan Africa (‘SSA MNM criteria’), but whether these adaptations are required in middle-income settings is unknown. Objective : To establish MNM criteria suitable for use in Namibia, a middle-income country in SSA. Methods : Cross-sectional study from 1 March 2018 to 31 May 2018 in four Namibian hospitals. Pregnant women or within 42 days of termination of pregnancy or birth, fulfilling at least one WHO or SSA MNM criterion were included. Records of women identified by either only WHO criteria or only SSA criteria were assessed in detail. Results : 194 Women fulfilled any MNM criterion. WHO criteria identified 61 MNM, the SSA criteria 184 MNM. Of women who only fulfilled any of the unique SSA MNM criteria, 18 fulfilled the criterion ‘eclampsia’, one ‘uterine rupture’ and five ‘laparotomy’. These women were assessed to be MNM. Thresholds for blood transfusion to define MNM due to haemorrhage were two units in the SSA and five in WHO set. Two or three units were given to 95 women for mild/moderate haemorrhage or chronic anaemia who did not fulfil any WHO criterion and were not considered MNM. Fourteen women who were assessed to be MNM from severe haemorrhage received four units. Conclusions : WHO MNM criteria may underestimate and SSA MNM criteria overestimate the prevalence of MNM in a middle-income country such as Namibia, where MNM criteria ‘in between’ may be more appropriate. Namibia opts to apply a modification of the WHO criteria, including eclampsia, uterine rupture, laparotomy and a lower threshold of four units of blood to define MNM. We recommend that other middle-income countries validate our criteria for their setting.

Summary Background Risk of mortality following surgery in patients across Africa is twice as high as the global average. Most of these deaths occur on hospital wards after the surgery itself. We aimed to assess whether enhanced postoperative surveillance of adult surgical patients at high risk of postoperative morbidity or mortality in Africa could reduce 30-day in-hospital mortality. Methods We did a two-arm, open-label, cluster-randomised trial of hospitals (clusters) across Africa. Hospitals were eligible if they provided surgery with an overnight postoperative admission. Hospitals were randomly assigned through minimisation in recruitment blocks (1:1) to provide patients with either a package of enhanced postoperative surveillance interventions (admitting the patient to higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to stay in the ward, and placing a postoperative surveillance guide at the bedside) for those at high risk (ie, with African Surgical Outcomes Study Surgical Risk Calculator scores ≥10) and usual care for those at low risk (intervention group), or for all patients to receive usual postoperative care (control group). Health-care providers and participants were not masked, but data assessors were. The primary outcome was 30-day in-hospital mortality of patients at low and high risk, measured at the participant level. All analyses were done as allocated (by cluster) in all patients with available data. This trial is registered with ClinicalTrials.gov , NCT03853824 . Findings Between May 3, 2019, and July 27, 2020, 594 eligible hospitals indicated a desire to participate across 33 African countries; 332 (56%) were able to recruit participants and were included in analyses. We allocated 160 hospitals (13 275 patients) to provide enhanced postoperative surveillance and 172 hospitals (15 617 patients) to provide standard care. The mean age of participants was 37·1 years (SD 15·5) and 20 039 (69·4%) of 28 892 patients were women. 30-day in-hospital mortality occurred in 169 (1·3%) of 12 970 patients with mortality data in the intervention group and in 193 (1·3%) of 15 242 patients with mortality data in the control group (relative risk 0·96, 95% CI 0·69–1·33; p=0·79). 45 (0·2%) of 22 031 patients at low risk and 309 (5·6%) of 5500 patients at high risk died. No harms associated with either intervention were reported. Interpretation This intervention package did not decrease 30-day in-hospital mortality among surgical patients in Africa at high risk of postoperative morbidity or mortality. Further research is needed to develop interventions that prevent death from surgical complications in resource-limited hospitals across Africa. Funding Bill & Melinda Gates Foundation and the World Federati...

Introduction:During the past two decades, HIV and Sexual and Reproductive Health services in Namibia have been provided in silos, with high fragmentation. As a consequence of this, quality and efficiency of services in Primary Health Care has been compromised.Methods:We conducted an operational research (observational pre-post study) in a public health facility in Namibia. A health facility assessment was conducted before and after the integration of health services. A person-centred integrated model was implemented to integrate all health services provided at the health facility in addition to HIV and Sexual and Reproductive Health services. Comprehensive services are provided by each health worker to the same patients over time (longitudinality), on a daily basis (accessibility) and with a good external referral system (coordination). Prevalence rates of time flows and productivity were done.Results:Integrated services improved accessibility, stigma and quality of antenatal care services by improving the provider-patient communication, reducing the time that patients stay in the clinic in 16% and reducing the waiting times in 14%. In addition, nurse productivity improved 85% and the expected time in the health facility was reduced 24% without compromising the uptake of TB, HIV, outpatient, antenatal care or first visit family planning services. Given the success on many indicators resulting from integration of services, the goal of this paper was to describe “how” health services have been integrated, the “process” followed and presenting some “results” from the integrated clinic.Conclusions:Our study shows that HIV and SRH services can be effectively integrated by following the person-centred integrated model. Based on the Namibian experience on “how” to integrate health services and the “process” to achieve it, other African countries can replicate the model to move away from the silo approach and contribute to the achievement of Universal Health Coverage.