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Background: Globally, mobile health (mHealth) applications are known for their potential to improve healthcare providers’ access to relevant and reliable health information. Besides, electronic decision support tools, such as the Safe Delivery mHealth Application (SDA), may help to reduce clinical errors and to ensure quality care at the point of service delivery. The current study investigated the use of the SDA and its relationship to basic emergency obstetric and newborn care (BEmONC) outcomes for the most frequent complications in Rwanda; post-partum haemorrhage (PPH) and newborn asphyxia. Methods: The study adopted a pre–post intervention design. A pre-intervention record review of BEmONC outcomes: Apgar score and PPH progressions, was conducted for 6 months’ period (February 2019 – July 2019). The intervention took place in two district hospitals in Rwanda and entails the implementation of the SDA for 6 months (October 2019- March 2020), and included 54 nurses and midwives using the SDA to manage PPH and neonatal resuscitation. Six months’ post-SDA intervention, the effect of the SDA on BEmONC outcomes was evaluated. The study included 327 participants (114 cases of PPH and 213 cases of neonatal complications). The analysis compared the outcome variables between the baseline and the endline data. Fisher’s exact test was used to compare the proportions and test between-group differences and significance level set at p < 0.05. Results: Unstable newborn outcomes following neonatal resuscitation were recorded in 62% newborns cases at baseline and 28% newborns cases at endline, P-value = 0.000. Unstable maternal outcomes following PPH management were recorded in 19% maternal cases at baseline and 6% maternal cases at endline, P-value = 0.048. There was a significant association between the SDA intervention and newborns’ and maternal’ outcomes following neonatal resuscitation and PPH management, 6 months after baseline. Conclusion: The use of the SDA supported nurses and midwives in the management of PPH and neonatal resuscitation which may have contributed to improved maternal and neonatal outcomes during 6 months of the SDA intervention. The findings of this study are promising as they contribute to a broader knowledge about the effectiveness of SDA in low and middle income hospital settings.
This was a pre–post intervention study done over a 14-month period. The study was conducted in three phases. The first phase was the pre-SDA intervention baseline study over a period of 6 months (February 2019 – July 2019). During this phase, a record review was conducted to document maternal and neonatal outcomes, PPH and Apgar score progressions, at baseline. The second phase, the SDA intervention (August 2019 – September 2019) comprised of the capacity building of nurses and midwives on the usage of the SDA; the SDA provision; the SDA piloting, and the launch of the SDA which marked the start of the SDA implementation. More details on the SDA training are documented in the protocol paper for this study [34]. The last phase was the 6 months of post-SDA intervention (October 2019- March 2020). Phase three encompassed the implementation of the SDA and another record review was conducted to document maternal and neonatal outcomes, PPH and Apgar score progressions, at endline. The data were collected from the delivery registries using data extraction forms. The collected data included patients’ characteristics and information on maternal and newborn outcomes, Apgar scores and PPH progressions, following NR and PPH management. The data were collected by the researcher and four research assistants. Data accuracy and transcription were checked by the researcher before analysis. The study was conducted in two district hospitals in Rwanda: Masaka hospital in Kigali, an urban province; and Nyamata hospital located in the eastern rural province [26]. The two hospitals were chosen out of 12 district hospitals in the two provinces because both recorded a high number of deliveries per year [24]. Compared to other rural-based district hospitals, Nyamata reported the highest maternal and neonatal mortality rates [30]. The study participants included records on neonatal complication cases and PPH cases. The inclusion criteria for the cases of neonatal complications were set as babies born with asphyxia (Apgar score ≤ 7) and were subject to neonatal resuscitation. We excluded preterm births (≤ 36 completed weeks of gestation) and births with major congenital malformations because prematurity and congenital complications other than the newborn asphyxia could influence the newborn outcome after resuscitation [35]. We have also excluded records with missing data on Apgar scores and neonatal outcome. On the other hand, the inclusion criteria for PPH cases were set as women who had a recorded amount of blood loss more than or equal to 500 mls and were subjected to PPH management. The records with missing data on PPH progression and maternal outcomes were also excluded. The study was conducted in three phases. Phase one, pre-intervention, included 126 cases of newborns asphyxia and 67 cases of PPH. Phase two, intervention, involved 33 midwives and 21 nurses who used the SDA in both Masaka and Nyamata district hospitals. Nurses and midwives were chosen because they are the frontline healthcare providers in childbirth care in district hospitals of Rwanda. The inclusion criteria for nurses and midwives were set as follows: having a work experience of at least 6 months in obstetric care and willing to participate in the study. All nurses and midwives (n = 54) working in the maternity departments of the selected hospitals volunteered to participate in the study and they were trained on the use of SDA. Phase three, post-intervention, comprised 87 cases of newborns asphyxia and 47 cases of PPH. The flowchart in Fig. 1 shows the number of neonatal complication cases and PPH cases considered in the pre-intervention group (before the introduction of SDA) and the post-intervention group (after SDA). Records review flow chart The SDA is a smartphone application developed by the Maternity Foundation, Copenhagen University, and the University of Southern Denmark. It is designed to support nurses and midwives in clinical decision making, by providing them with instant access to evidence-based BEmONC clinical guidelines and a selection of essential preventive protocols in a user-friendly format. The content of the SDA is primarily based on WHO (World health organization) clinical BEmONC guidelines and has been validated by an international group of global health experts [36]. The SDA contains easy to understand animated instruction videos, action cards with validated clinical guidelines, essential drugs lists with their indications, practical procedures guidelines, and a learning platform [32]. All features and functions in the SDA are designed for low-literacy and low-income settings and work offline once downloaded. The SDA can be used as a job aid and as an instructive aid in emergencies. While practicing, the skilled birth attendant (SBA) can consult action cards and drug lists to be helped in his/her clinical decision making. In the free time, the SBA can again play animated instruction videos, consult procedures descriptions and use the learning platform to update his/her knowledge and skills. The SDA can be downloaded free of charge for iPhone at https://itunes.apple.com/dk/app/safe-delivery/id985603707?mt=8 and for Android at https://play.google.com/store/apps/details?id=dk.maternity.safedelivery&hl=en. The nurses and midwives in both hospitals received an explanation of the nature and purpose of the research and half-day training session on the use of the SDA. The majority of participants have downloaded the SDA on their personal smartphones during the training. The training session encompassed: an introduction to the research project; an overview of the SDA development and global outreach; description of the SDA features and modules; and hands-on practice on using the SDA as a job-aid and as a learning tool. Each of the study settings (Masaka and Nyamata) received three smartphones, with pre-installed English and French versions of the SDA. This was followed by the 6 months’ intervention period, during which nurses and midwives provided BEmONC services with the assistance of the SDA installed on their personal smartphones or the smartphones provided by the researcher. During this period, the provided six smartphones were made available to the team on duty (three staffs per shift per hospital) at all times for use as a backup in case the participants experienced problems with their own smartphones. Nurses and midwives were expected to use the SDA as often as they wished. The intervention also entailed two visits per week by two research assistants to each of the study hospitals. During the visits, the research assistants monitored the SDA use by nurses and midwives. Data extraction forms were used to retrieve information on all cases of PPH and neonatal complications recorded in delivery registers. These were extracted and reviewed 6 months’ pre-SDA intervention and 6 months’ post-SDA intervention. The delivery registers contain information on obstetric and neonatal care including the Apgar scores and PPH progressions following neonatal resuscitation and PPH management. Newborn deaths or admission to the neonatal intensive care unit (NICU) or to neonatologist’s service due to an unstable outcome (Apgar score < 7) after neonatal resuscitation was used as the primary outcome measure to determine the failure of neonatal resuscitation. The mothers’ referral to a higher-level facility (referral hospital) following an unstable outcome (persistent bleeding) after PPH management was considered as the primary outcome to measure the failure of PPH management at the district hospital. On the newborn side, we obtained data on Apgar scores progression and neonatal outcome following 10 min’ neonatal resuscitation before and after the use of the SDA. While on the mother’s side, we obtained data on maternal outcomes following PPH management before and after the use of the SDA. This study has been approved by the Human Research Ethics Committee of the University of the Witwatersrand (M190258) and the University of Rwanda, College of Medicine and Health Sciences’ Institutional Review Board (No.377/CMHS IRB/2018). Permission to collect data has been granted by the hospitals which have authorization of using aggregated patient data in research. Consents to track the SDA usage were obtained from nurses and midwives. This study was carried out in accordance with relevant guidelines and regulations in the Ethical Declarations. The data were checked for errors and exported from Microsoft Excel (Microsoft Corporation) to Stata version 16 (StataCorp LLC) for cleaning and analysis. Descriptive summary statistics were computed on data including the hospital, age of the mother at childbirth, the weight of the newborn at birth, sex of the newborn, mode of delivery, the leading clinician during delivery, Apgar scores at 1, 5 and 10 min and the resuscitation action taken for the newborns. For the maternal outcome, descriptive statistics included the hospital, age of the mother at delivery, gestational age in weeks, Mode of delivery, the leading clinician during delivery, Blood loss in milliliters, causes of PPH, the resuscitation action taken, mother outcome and cause of maternal death if dead. Further, the neonatal outcomes and maternal outcomes were compared at baseline and endline using Fisher’s exact test. Significance level was set at p < 0.05.
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