Postnatal infection surveillance by telephone in Dar es Salaam, Tanzania: An observational cohort study

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Study Justification:
– Maternal and newborn infections are significant causes of mortality and morbidity, particularly in low- and middle-income countries.
– Limited data exists on the incidence and risk factors of these infections in such settings.
– This study aimed to address this knowledge gap by using telephone surveillance to estimate infection rates and identify risk factors in women and newborns following hospital childbirth in Dar es Salaam, Tanzania.
Study Highlights:
– The study recruited 879 postnatal women from two tertiary hospitals and conducted telephone interviews 7 and 28 days after delivery.
– The incidence of infection was measured in both mothers and newborns, including specific types of infections such as endometritis, surgical site infections, urinary tract infections, and umbilical cord infections.
– The study found that the risk of infection was higher in women who had undergone caesarean section compared to those who had a vaginal delivery.
– Only 24% of women received pre-operative antibiotic prophylaxis before caesarean section, highlighting the need for improved implementation of this preventive measure.
– Newborns who required resuscitation at birth had a higher risk of infection compared to those who did not require resuscitation.
– The study also found that a significant proportion of women and newborns with possible infection sought care at health facilities, indicating the importance of timely healthcare-seeking behavior.
Recommendations:
– Improved implementation of pre-operative antibiotic prophylaxis for women undergoing caesarean section to reduce the risk of maternal infection.
– Strengthening infection prevention and control measures during childbirth, particularly for caesarean deliveries.
– Enhancing training and awareness among healthcare providers regarding the identification and management of postnatal infections.
– Promoting early recognition and prompt treatment of infection symptoms in women and newborns.
– Increasing access to healthcare facilities and ensuring appropriate care-seeking behavior for women and newborns with possible infection.
Key Role Players:
– Healthcare providers, including doctors, nurses, and midwives, involved in childbirth and postnatal care.
– Hospital administrators and policymakers responsible for implementing infection prevention and control measures.
– Public health officials and researchers involved in maternal and newborn health programs.
– Community health workers and outreach teams responsible for promoting healthcare-seeking behavior and providing education on postnatal infections.
Cost Items for Planning Recommendations:
– Training programs for healthcare providers on infection prevention and control measures.
– Provision of pre-operative antibiotic prophylaxis for women undergoing caesarean section.
– Development and dissemination of educational materials for healthcare providers and the community.
– Strengthening healthcare infrastructure and facilities to ensure access to timely and appropriate care.
– Monitoring and evaluation activities to assess the effectiveness of interventions and identify areas for improvement.
Please note that the above cost items are general suggestions and may vary depending on the specific context and resources available.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong as it presents clear findings and includes a large sample size. However, to improve the evidence, the abstract could include more details on the methodology, such as the specific criteria used to identify infections and the statistical analysis methods employed.

Introduction Maternal and newborn infections are important causes of mortality but morbidity data from low- and middle-income countries is limited. We used telephone surveillance to estimate infection incidence and risk factors in women and newborns following hospital childbirth in Dar es Salaam. Methods We recruited postnatal women from two tertiary hospitals and conducted telephone interviews 7 and 28 days after delivery. Maternal infection (endometritis, caesarean or perineal wound, or urinary tract infection) and newborn infection (umbilical cord or possible severe bacterial infection) were identified using hospital case-notes at the time of birth and self-reported symptoms. Adjusted Cox regression models were used to assess the association between potential risk-factors and infection. Results We recruited 879 women and interviewed 791 (90%). From day 0-7, 6.7% (49/791) women and 6.2% (51/762) newborns developed infection. Using full follow-up data, the infection rate was higher in women with caesarean childbirth versus women with a vaginal delivery (aHR 1.93, 95%CI 1.11-3.36). Only 24% of women received pre-operative antibiotic prophylaxis before caesarean section. Infection was higher in newborns resuscitated at birth versus newborns who were not resuscitated (aHR 4.45, 95%CI 2.10-9.44). At interview, 66% (37/56) of women and 88% (72/82) of newborns with possible infection had sought health-facility care. Conclusions Telephone surveillance identified a substantial risk of postnatal infection, including cases likely to have been missed by hospital-based data-collection alone. Risk of maternal endometritis and newborn possible severe bacterial infection were consistent with other studies. Caesarean section was the most important risk-factor for maternal infection. Improved implementation of pre-operative antibiotic prophylaxis is urgently required to mitigate this risk.

This study was a collaboration between London School of Hygiene and Tropical Medicine (LSHTM) and Ifakara Health Institute (IHI) and based at two of the three public Regional Referral Hospitals in Dar es Salaam; Amana (Ilala district) and Temeke (Temeke district). Each hospital conducts approximately 1,000 births per month. It was a sub-study of a pilot evaluation of training in environmental cleaning [15]. Two research nurses per hospital recruited eligible women from postnatal wards every Monday to Thursday. They sampled from all women who gave birth in the previous 24 hours using a random number application [16] with probability proportional to delivery mode (caesarean or vaginal). Eligible women were aged 18 years or older with access to at least one mobile telephone and providing signed or witnessed thumbprint consent. Women admitted to the intensive care unit were ineligible. Women provided up to three mobile telephone numbers; one or two of their own and one for a relative or neighbour. Replacements were sampled in the same way when potential participants were unavailable or ineligible. Two research nurses at IHI offices in Dar es Salaam interviewed each woman twice by telephone in Kiswahili, starting seven and 28 days after recruitment. Nurses made four telephone call attempts, over seven days, to reach each woman. The primary outcomes were 1) possible maternal postnatal infection (one or more of caesarean surgical site infection, urinary tract infection, perineal wound infection or endometritis) and 2) possible newborn infection (either of pSBI or umbilical cord infection). Each outcome was measured as a rate, and as the day 7 (early infection) and day 8–28 cumulative risk. Infections were identified from women’s hospital case-notes around the time of childbirth or from self-reported symptoms during telephone interview using standard definitions [7, 17, 18]. These definitions were adapted by the first author to include only symptoms and signs easily reported by the women (Table 1). Secondary outcomes were each individual infection listed above, plus mastitis. a)Centres for Disease Control [18] b) Scottish Intercollegiate Guidelines Network [17] c)Young Infants Clinical Signs Study [7]. Potential risk factors were extracted from hospital case-notes; maternal age, gestational age, parity, HIV, diabetes, hypertensive disorder, haemorrhage, prelabour rupture of membranes (PROM), induction of labour, delivery mode, postpartum haemorrhage (PPH) and infection during labour. Possible consequences of infection collected during telephone interview were self-reported readmission, depression assessed using a validated 5-question modified Edinburgh Postnatal Depression Scale (EPDS) and functionality according to five common postpartum activities (S1 Appendix). Data was entered on tablets with Open Data Kit (ODK), using unique identification (ID) numbers to maintain confidentiality. Data was extracted from maternal paper case-notes after hospital discharge, including demographics, pregnancy and childbirth history, infection diagnosed during admission and antibiotics prescribed (S2 Appendix). Telephone interviews with women consisted of pre-coded closed questions on the history of specific symptoms of infection, day of symptom onset, care-seeking behaviour, and readmission to hospital. At day-28, women were also asked questions on depression and function (S1 Appendix). Women with infection symptoms were advised to attend a health-facility if they hadn’t already. In cases of maternal depression or neonatal death, women were offered referral to social welfare liaison for counselling and support. Research nurses received six days training in recruitment and data collection, including two days at the hospitals when they piloted the tools on 24 women. Telephone interview nurses additionally conducted pilot interviews with the same 24 women over two days. With 900 women and an estimated 10% loss to follow-up at day-28, we would have 95% confidence to estimate a maternal infection risk of 3%±1.2% with 80% power. Our daily recruitment target was 12–20 women per hospital. Data was cleaned and analysed using STATA 16. Gestational age was grouped as preterm (<37 weeks) or term (37–42 weeks). The depression score was grouped as no depression (0–5) or possible depression (6–30). Maternal function questions were analysed individually as “any” or “no difficulty” in performing the function. Duplicate ID numbers and data entry errors were corrected where possible using hospital case-notes or comparing with other study data. Any remaining discordant data was dropped. There was inconsistency in the occurrence of stillbirths between data sources, therefore stillbirths were not analysed. Data on twin and triplet newborns was also inconsistent and in addition an error in ODK programming meant only data from the first baby was useable. Women’s demographic and pregnancy data was described by delivery mode. Rates of infection were calculated from delivery until the day-28 telephone call using reported days from delivery to start of symptoms. Symptoms reported at both day-7 and day-28 were counted as distinct infection events if they started over 14 days apart, or if they met criteria for different infection types and started over seven days apart, or if initial symptoms had resolved by the day-7 interview. Date of death and infection data were not collected from babies who died before the day-7 interview, therefore these babies were excluded from infection outcome analyses. Babies who died after the day-7 interview contributed to infection analyses up to day 7. Using Cox regression with robust standard errors to account for clustering by person, we explored associations between potential risk factors and the rate of maternal postnatal infection or possible newborn infection. Proportional hazards assumptions were checked using tests based on Schoenfeld Residuals. Factors showing evidence of association in the crude analysis (p<0.1) were explored further in multivariable models. Maternal age and delivery hospital were considered a priori confounders for risk of maternal postnatal infection. We restricted the parameters in the final models to 10% of the number of outcomes. For missing risk-factor data, we carried out multiple imputation using chained equations (MICE) because most variables were categorical, creating 10 imputed datasets. Delivery mode and hospital were included as auxiliary variables. Women whose case-notes were missing were excluded from risk-factor analysis. We report the highest level of care sought by women and newborns with possible infection and the percentage readmission to hospital for those with and without infection. We describe maternal depression and function at day-28 and explore associations with early postnatal infection using chi-squared tests and logistic regression. The study was approved by the Tanzanian National Institute for Medical Research, IHI Institutional Research Board and LSHTM Research Ethics Committee. Written informed consent was obtained from women on the postnatal wards. Willingness to continue in the study was confirmed at the start of each telephone interview. There was no public or patient involvement in the study design or interpretation of results. The Soapbox Collaborative supported the study following external peer review of the study proposal.

Based on the provided description, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can allow healthcare providers to remotely monitor and provide care for postnatal women and newborns. This can help identify and address potential infections early on, reducing the need for in-person visits and improving access to healthcare.

2. Mobile health (mHealth) applications: Developing mobile applications that provide educational resources, symptom tracking, and appointment reminders can empower women to take control of their own health and seek appropriate care when needed. These applications can also facilitate communication between healthcare providers and patients, ensuring timely access to information and support.

3. Community health workers: Training and deploying community health workers who can conduct home visits and provide basic healthcare services can improve access to maternal health, especially in remote or underserved areas. These workers can educate women on infection prevention, monitor their health, and refer them to healthcare facilities when necessary.

4. Improved pre-operative antibiotic prophylaxis: Strengthening the implementation of pre-operative antibiotic prophylaxis for women undergoing caesarean sections can significantly reduce the risk of postnatal infections. This can be achieved through training healthcare providers, ensuring the availability of antibiotics, and implementing standardized protocols.

5. Health education and awareness campaigns: Conducting targeted health education campaigns to raise awareness about the importance of seeking timely care for postnatal infections can help reduce delays in seeking healthcare and improve access to treatment. These campaigns can be conducted through various channels, including community meetings, radio broadcasts, and social media.

6. Strengthening healthcare infrastructure: Investing in the improvement of healthcare facilities, including staffing, equipment, and supplies, can enhance the capacity to provide quality maternal healthcare services. This can help ensure that women have access to appropriate care and treatment for postnatal infections.

It is important to note that these recommendations are based on the specific context of the study mentioned in the description. The implementation of these innovations should be tailored to the local healthcare system and resources available in each setting.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the study is the implementation of postnatal infection surveillance by telephone. This innovative approach involves conducting telephone interviews with postnatal women to identify and monitor maternal and newborn infections following hospital childbirth.

The study conducted in Dar es Salaam, Tanzania, used telephone surveillance to estimate infection incidence and risk factors in women and newborns. The results showed that telephone surveillance identified a substantial risk of postnatal infection, including cases that may have been missed by hospital-based data collection alone. The study also found that caesarean section was the most important risk factor for maternal infection.

By implementing postnatal infection surveillance by telephone, healthcare providers can proactively monitor and identify infections in postnatal women and newborns. This approach allows for early detection and timely intervention, which can significantly improve maternal and newborn health outcomes.

To implement this innovation, healthcare facilities can establish a system where postnatal women are contacted via telephone at specific intervals following childbirth. Trained healthcare professionals can conduct interviews to assess for symptoms of infection and provide guidance on seeking appropriate care if needed. This approach can help bridge the gap in accessing healthcare services by reaching out to women who may not be able to return to the hospital for follow-up care.

Furthermore, the use of telephone surveillance can also help collect valuable data on infection rates and risk factors, which can inform future interventions and improve overall maternal health outcomes. This data can be used to identify areas of improvement, such as the implementation of pre-operative antibiotic prophylaxis for women undergoing caesarean sections.

Overall, implementing postnatal infection surveillance by telephone can be an innovative solution to improve access to maternal health by proactively identifying and addressing infections in postnatal women and newborns. This approach can help reduce morbidity and mortality rates associated with maternal and newborn infections, ultimately improving maternal and newborn health outcomes.
AI Innovations Methodology
The study titled “Postnatal infection surveillance by telephone in Dar es Salaam, Tanzania: An observational cohort study” aimed to estimate the incidence of maternal and newborn infections following hospital childbirth in Dar es Salaam, Tanzania, using telephone surveillance. The study recruited postnatal women from two tertiary hospitals and conducted telephone interviews 7 and 28 days after delivery. Maternal and newborn infections were identified using hospital case-notes and self-reported symptoms. The study found a substantial risk of postnatal infection, including cases that may have been missed by hospital-based data collection alone. The risk of maternal endometritis and newborn possible severe bacterial infection was consistent with other studies. Caesarean section was identified as the most important risk factor for maternal infection.

To simulate the impact of recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Identify the recommendations: Based on the findings of the study and other relevant research, identify specific recommendations that could improve access to maternal health. For example, one recommendation could be to improve the implementation of pre-operative antibiotic prophylaxis for women undergoing caesarean section.

2. Define the simulation parameters: Determine the key parameters that will be used to simulate the impact of the recommendations. This could include factors such as the current rate of pre-operative antibiotic prophylaxis, the expected increase in the rate of prophylaxis after implementing the recommendation, and the estimated reduction in maternal infection rates associated with improved prophylaxis.

3. Develop a simulation model: Create a simulation model that incorporates the identified parameters and simulates the impact of the recommendations on improving access to maternal health. The model could use mathematical equations or statistical methods to estimate the potential reduction in maternal infection rates based on the expected increase in the rate of pre-operative antibiotic prophylaxis.

4. Validate the simulation model: Validate the simulation model by comparing its predictions with real-world data or other validated models. This step is important to ensure the accuracy and reliability of the simulation results.

5. Conduct sensitivity analysis: Perform sensitivity analysis to assess the robustness of the simulation results to variations in the input parameters. This will help identify the key factors that influence the impact of the recommendations and provide insights into the potential uncertainties associated with the simulation.

6. Interpret the simulation results: Analyze and interpret the simulation results to understand the potential impact of the recommendations on improving access to maternal health. This could include estimating the reduction in maternal infection rates, assessing the cost-effectiveness of implementing the recommendations, and identifying any potential barriers or challenges to implementation.

By following this methodology, policymakers and healthcare providers can gain valuable insights into the potential impact of recommendations on improving access to maternal health and make informed decisions about implementing interventions to address maternal health challenges.

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