Förbättrad neonatal överlevnad och utveckling

Kortfattad beskrivning av forskningsområdet

Trots imponerande framsteg i för att öka barnöverlevnaden under de senaste decennierna har den neonatal överlevnaden (28 första dagarna i livet) inte minskat i samma takt, och står idag för en ökande andel av dödsfallen hos barn under fem år. Den högsta risken att dö är i samband med förlossning, och utöver de miljoner barn som dör under den första dagen i livet är lika barn dödfödda. Detta trots att interventionerna för att rädda dessa barn är kända och kostnadseffektiva. Innovativa lösningar för att ta itu med de samhälls- och hälsosystemsbarriärer som resulterar i neonatal dödlighet behövs

Projektbeskrivningar

Pågående projekt

  • NePeriQIP
    NePeriQIP-projektet fokuserar på att förbättra kvaliteten på förlossningsvården på distriktsnivå i Nepal. Detta uppskalningsprojekt äger rum på 12 distriktssjukhus och bygger på tidigare forskning som utförts av forskargruppen runt Helping Babies Breathe (HBB) konceptet. NePeriQIP-studien utgår från WHOs standard för förbättring av vårdkvaliteten för mammor och barn  genom ett omfattande satsning på att höja vårdkvaliteten och för kontinuiteten i den perinatala vård.

    Medarbetare
    UNICEF Nepal, hälsovårdsministeriet Nepal

    Finansiering
    Svenska forskningsrådet, UNICEF Nepal, Einhorn Foundation och STINT

    Ansvarig forskare/Kontaktperson
    Mats Målqvist, mats.malqvist@kbh.uu.se

  • NepCord
    NepCord-gruppen fokuserar på studier i samband med avnavling. I en serie randomiserade kontrollerade studier vid Paropakar Maternity och Women's Hospital i Katmandu, Nepal, har gruppen undersökt effekterna av att vänta med avnavling i tre minuter jämfört med en minut efter födseln, vilket är den rådande rekommendationen. Utfall som studerats är järnförråd och anemi vid 8 och 12 månaders ålder, bilirubin-nivåer under den första veckan och neurologisk utveckling vid en och två års ålder. Ytterligare undersökningar pågår för att undersöka effekterna av sen avnavling på hjärtfrekvens och perinatal överlevnad.

    Medarbetare
    UNICEF Nepal, Lifeline Nepal

    Finansiering
    STINT, SSMF, Svenska Forskningsrådet

    Ansvarig forskare/Kontaktperson
    Ola Andersson, ola.andersson@kbh.uu.se
     
  • Förbättrad kvalitetpå mödra- och nyföddhetsvård genom att mödravård i grupp i Tanzania
    Att ha väl fungerande mödravård är nödvändigt för hälsosamma mödrar och barn. Förlossningsvård är ett prioriterat område, men står inför många utmaningar då hälsosystem över hela världen och det finns lite resurser att möta dessa. Denna studie utförs i Tanzania och syftar till att bestämma effektiviteten hos mödravård i grupp som ett sätt att förbättra och bättre utnyttja de av begränsade resurserna där.

    Medarbetare
    Muhimbili University of Health and Applied Sciences (MUHAS), Tanzania

    Finansiering
    Swedish International Development Cooperation Agency (Sida)
    Ansvarig forskare/Kontaktperson
    Mats Målqvist, mats.malqvist@kbh.uu.se

Selected publications from the group

  • Rana N, Kc A, Målqvist M, Subedi K, Andersson O. Effect of Delayed Cord Clamping of Term Babies on Neurodevelopment at 12 Months: A Randomized Controlled Trial. Neonatology. 2018 Oct 2;115(1):36-42
  • Eriksson L, Nga NT, Hoa DTP, Duc DM, Bergström A, Wallin L, Målqvist M, Ewald U, Huy TQ, Thuy NT, Do TT, Lien PTL, Persson LÅ, Selling K. Secular trend, seasonality and effects of a community-based intervention on neonatal mortality. Follow-up of a cluster-randomized trial in Quang Ninh province, Vietnam. J Epidemiol Community Health. 2018 Sep;72(9):776-782
  • KC A, Bergström A, Chaulagain D, Brunell O, Ewald U, Gurung A, Eriksson L, Litorp H, Wrammert J, Grönqvist E, Edin PA, Le Grange C, Lamichhane B, Shrestha P, Pokharel A, Pun A, Singh C, Målqvist M. Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial. BMJ Glob Health. 2017 Sep 29;2(3):e000497.
  • Wrammet J, Zetterberg C, KC A, Ewald U, Målqvist M. Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings. Global Health Action 2017;10(1):1322372.
  • KC A, Wrammert J, Nelin V, Clark R, Ewald U, Peterson S, Målqvist M. Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal. BMC Pediatr. 2017 Apr 11;17(1):103.
  • Wrammert J, KC A, Ewald U, Målqvist M. Improved postnatal care needed to maintain gains in neonatal survival after Helping Babies Breathe implementation. Acta Paediatrica 2017 Mar 17.
  • KC A, Rana N, Målqvist M, Ranneberg LJ, Subedi K, Andersson O. Effects of delayed umbilical cord clamping on anemia at 8  and 12 months – A randomized clinical trial. JAMA Ped 2017;171(3):1-7.
  • Wrammert J, Sapkota S, Baral K, KC A, Målqvist M, Larsson M. Teamwork among midwives during neonatal resuscitation at a maternity hospital in Nepal. Women Birth, 2017 Feb 26. pii: S1871-5192(16)30120-2.
  • KC A, Wrammert J, Clark R, Ewald U, Vitrakoti R, Pun A, Raaijmakers H, Målqvist M. Reducing perinatal mortality in Nepal using Helping Babies Breathe. Pediatrics. 2016 Jun;137(6).

Sociala bestämmelsefaktorer för hälsa

Brief description of the research field

Equity in health is essential in order to reach the Sustainable Development Goals (SDGs). Social justice is not only a cross-cutting theme and a good intention, it is fundamental in order to achieve progress and sustainable living conditions for humanity. To have a fair and equal opportunity for all people to be able to harness their potential. The SDG agenda emphasizes Universal Health Coverage as the way forward to equity in health. This is however not enough, since in order to achieve true equity we also need to look at and understand not only structural barriers in society but also psychological and cultural limitations. The study of and struggle for equity in health is in its nature a transdisciplinary project.

To achieve equity in health, we need to improve and promote good health in the community. It has been stated that health begins at home! And all since Alma Ata conference 40 years ago, there has been a focus on how to promote community health and make sure that basic health services reach everyone. The commitment to primary care has fluctuated a bit over the decades, with a renewed effort in Ouagadougou in 2008. Today we talk about Universal Health Coverage (UHC) and the challenge is how to reach everyone. This is emphasized in the Sustainable Development Goals

Responsible researcher/contact person
Mats Målqvist, mats.malqvist@kbh.uu.se

Selected publications from the group

  1. KC A, Nelin V, Raaijmakers H, Kim HJ, Singh C, Målqvist M. Increased immunization coverage addresses the equity gap in Nepal. Bull World Health Organ. 2017 Apr 1;95(4):261-269.
  2. Målqvist M, Pun A, Raaijmakers H, Kc A. Persistent inequity in maternal health care utilization in Nepal despite impressive overall gains. Glob Health Action. 2017;10(1):1356083.
  3. Målqvist M, Singh C, KC A. Care seeking for childen with fever/cough or diarrhoea in Nepal, equity trends over the last 15 years. Scand J Public Health 2017 Mar;45(2):195-201.
  4. Målqvist M, Pun A, KC A. Essential newborn care after home delivery in Nepal, still a long way to go! Scand J Public Health, 2017 Mar;45(2):202-207.
  5. Målqvist M. Preserving misconception or a call to action? – a hermeneutical re-reading of the Nativity story. Glob Health Action 2015, 8:30386
  6. Binder P, Lien PT, Hoa DP, Målqvist M. Determinants of marginalization and inequitable maternal healthcare in North-Central Vietnam: A framework analysis. Global Health Action 2015, 8: 27554.
  7. Målqvist M, Yuan B, Trygg N, Selling K, Thomsen S. Targeted interventions for improved equity in maternal and child health in low- and middle-income settings: a systematic review and meta-analysis. PLoS One 2013 Jun 20;8(6).
  8. Bergman M, Nygren-Brunell O, Vilakati D, Målqvist M. Prolonged Exclusive Breastfeeding Through Peer Support: A Cohort Study From a Community Outreach Project in Swaziland. J Community Health, 2016 Oct;41(5):932-8.

Hälsosystem och implementeringsforskning

Brief description of the research field

The importance of Health Systems Research (HSR) is increasingly acknowledged within the field of Global Health. To understand how health systems cope with their mandate and respond to changes and challenges is paramount in the efforts to improve health. Most low and middle-income countries suffer under weak health systems, not capable of delivering the appropriate and timely services to the population. To enhance understanding of these process a systems thinking approach is needed, expanding the idea of health systems from administrative bodies to encompassing the whole of society. Functioning and implementation need to be strengthened and new methods and policies need to be developed for more efficient service delivery.

It has been stated that health begins at home! Therefore, a wider definition and view on what encompass the health system is needed. And all since Alma Ata conference 40 years ago, there has been a focus on how to promote community health and make sure that basic health services reach everyone. The commitment to primary care has fluctuated a bit over the decades, with a renewed effort in Ouagadougou in 2008. Today we talk about Universal Health Coverage (UHC) and the challenge is how to reach everyone. This is emphasized in the Sustainable Development Goals

The community health worker (CHW) has received a lot of attention and a lot of responsibility has been placed on this cadre. Many times, the CHW has become the answer to all preventive work challenges, the easy solution when health care planners feel the need to reach outside the medicalized health facility. There are however many testimonies of CHWs being over-burdened, over-stretched and under-paid. The importance of CHWs as the link between community and healthcare system has been established, but lack of resources hampers the possibilities to professionalize this element.

To strengthen health system and make use of accumulated evidence on best practice the Health systems and implementation science sub-group also generates evidence of how to enable successful implementation of well-researched interventions. Health system weaknesses, such as lack of resources (medicines, equipment and staff with adequate knowledge and skills), dysfunctional referral systems and a culture of informal payment and lack of trust in health services. Implementation research is ‘the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health’.

Project descriptions

Ongoing projects

Reorientation of the Health System towards Primary Diabetes Care in Sudan
In 2015, 415 million individuals were living with diabetes, 75% of them in low- and middle-income countries. Estimates suggest that the burden of diabetes will increase to 642 million by 2040. The majority of health systems in low resources settings are organised for the treatment of acute rather than chronic conditions and face an immense challenge to tackle an increasing number of patients with life-long conditions. Diabetes educators has been a successful strategy adopted in several high-income countries and has been put forward as the most cost-effective intervention for low- and middle-income countries. The project aim to investigate diabetes care in Sudan and to evaluate the effect of diabetes educators in governmental primary health care centers in Khartoum towards quality and efficiency of diabetes care.

Collaborators
Ahfad University for Women (Sudan) and Diabetes Prevention Promotion Organization (Sudan)

Funding
Diabetes Prevention Promotion Organization (Sudan)

Responsible researcher/contact person
Mats Målqvist, mats.malqvist@kbh.uu.se

Strengthening Maternal and Perinatal Death Review Systems

Maternal and Perinatal Death Surveillance and Response (MPDSR) system has been proposed as a quality improvement strategy to tackle maternal and perinatal mortality in weak health systems. The approach builds on the notion that through evaluation and learning from mistakes system failures can be corrected and service delivery improved. Together with Muhimbili University of Health and Applied Sciences (MUHAS) in Tanzania, a project is currently ongoing to further understand the barriers and enablers of the MPDSR and how the development of action plans can facilitate improvement at community level.

Collaborators
Muhimbili University of Health and Applied Sciences (MUHAS), Tanzania

Funding
Swedish International Development Cooperation Agency (Sida)

Responsible researcher/contact person
Mats Målqvist, mats.malqvist@kbh.uu.se

Exploring the Under Reporting of Pregnancy and Adverse Pregnancy Outcomes in Population and Health Surveys in Uganda

Under reporting of Adverse Pregnancy Outcomes (APOs) results in data that indicates a lower prevalence of these events, and yet this information feeds into national and local statistics. These will be used for planning, priority setting and are potentially important for monitoring progress to achieving the sustainable development goals and the Every Newborn Action Plan (ENAP). Therefore, planning will be based on incomplete data and misinformation, resulting in difficulty in identifying the causes of these deaths, the context around their occurrence, and how to potentially avoid them in the future. Knowledge is still lacking of the barriers and enablers to reporting of pregnancy and APOs within the African setting, more so in Uganda. Not much information is available on reporting from the perspective of mothers who have suffered pregnancy losses, from men, and from the interviewers who conduct the surveys. There is also limited information on context specific definitions of pregnancy and the role of gender. This study seeks to investigate these barriers and enablers, with specific focus on population and health surveys in Iganga-Mayuge HDSS, Uganda.

Collaborators
Makerere University, Kampala, Uganda

Responsible researcher/contact person
Mats Målqvist, mats.malqvist@kbh.uu.se

Context Assessment for Community Health (COACH) project

The COACH project initially aimed to develop a tool that focused on modifiable aspects of local health care context in low- and middle-income settings, i.e. aspects of context that could be intervened upon to enhance health system strengthening. The development of the COACH tool was undertaken with partners in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua. The application and continued psychometric evaluation of the COACH tool (© Bergström and Estabrooks 2015) is still ongoing.

Collaborators (during the development to the tool)
ICDDR,B (Bangladesh), Hanoi University of Public Health (Vietnam), Makerere University College of Health Sciences (Uganda), Stellenbosch University (South Africa), Fundacion Coordinación de Hermanamientos e Iniciativas de Cooperación (Nicaragua), University of Alberta (Canada) and Dalarna University (Sweden).

Funding (during the development to the tool)
The Swedish International Development Cooperation Agency

Responsible researcher/contact person
Anna Bergström, anna.bergstrom@kbh.uu.se

NePeriQIP

The NePeriQIP project is focusing on improving the quality of maternal and new-born care at district level in Nepal. This scale-up project is taking place in 12 district hospitals and builds on previous research conducted by the research group evaluating the introduction of Helping Babies Breathe with a Quality Improvement strategy at a tertiary hospital in Kathmandu. The NePeriQIP trial departs from the WHO standards for improving maternal and new-born quality of care and intends to deliver a comprehensive Quality Improvement package for the continuum of perinatal care.

Collaborators
UNICEF Nepal, Ministry of Health Nepal

Funding
Swedish Research Council, UNICEF Nepal, Einhorn Foundation and STINT

Responsible researcher/contact person
Mats Målqvist, mats.malqvist@kbh.uu.se

Selected publications from the group

  1. Trimmer C, Målqvist M. Clinical communication and caregivers’ satisfaction with child healthcare in Nepal; results from Nepal Health Facility Survey 2015. BMC Health Serv Res (2019) 19:17.
  2. Målqvist M. Community agency and empowerment - a need for new perspectives and deepened understanding. Ups J Med Sci. 2018 Jun;123(2):123-130.
  3. Eltom MA, Babiker Mohamed AH, Elrayah-Eliadarous H, Yassin K, Noor SK, Elmadhoun WM, Ahmed MH. Increasing prevalence of type 2 diabetes mellitus and impact of ethnicity in north Sudan. Diabetes Res Clin Pract. 2018 Feb;136:93-99. doi: 10.1016/j.diabres.2017.11.034. Epub 2017 Dec 2.
  4. Almblad AC, Målqvist M, Engvall G. From skepticism to assurance and control; Implementation of a patient safety system at a pediatric hospital in Sweden. PLoS One. 2018 Nov 26;13(11):e0207744.
  5. Almblad AC, Målqvist M, Engvall G. Caring for the Acutely, Severely Ill Child-A Multifaceted Situation with Paradoxical Elements: Swedish Healthcare Professionals' Experiences. J Pediatr Nurs. 2016 Sep-Oct;31(5):e293-300.
  6. Bergström A, Skeen S, Duc DM, Blandon E., Estabrooks C, Gustavsson P, Hoa DT, Kallestal C, Malqvist M, Nga NT, Persson L-A, Pervin J, Peterson S, Rahman A, Selling K, Squires JE, Tomlinson M, Waiswa P, Wallin L. Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings. Implement Sci, 2015. 10(1): p. 120.
  7. Baker U, Petro A, Marchant T, Peterson S, Manzi F, Hanson C†, Bergström A†. Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities: A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework. PLoS One (2018), 13(12), e0209092. doi:10.1371/journal.pone.0209092
  8. Mocumbi S, McKee K, Munguambe K, Chiau R, Högberg U, Hanson C, Wallin L, Sevene E, Bergström A. Ready to deliver maternal and newborn care? Health providers’ perceptions of their work context in rural Mozambique. Global Health Action (2018), 11:1, 1532631,
  9. Pallangyo E, Mbekenga C, Olsson P, Eriksson L†, Bergström A†. Implementation of a facilitation intervention to improve postpartum care in a low-resource suburb of Dar es Salaam, Tanzania. Implement Sci (2018) 13:102.
  10. Eriksson L, Bergström A, Hoa DP, Nguyen NT, Eldh AC. Sustainability of knowledge implementation in a low- and middle- income context: Experiences from a facilitation project in Vietnam targeting maternal and neonatal health. PLoS ONE, 2016, 12(8): e0182626.