Outreach Training and Supportive Supervision for Quality Malaria Service Delivery: A Qualitative Evaluation in 11 Sub-Saharan African Countries.

Quality improvement of malaria services aims to ensure that more patients receive accurate diagnosis, appropriate treatment, and referral. The Outreach Training and Supportive Supervision Plus (OTSS+) approach seeks to improve health facility readiness and provider competency through onsite supportive supervision, troubleshooting, and on-the-job training. As part of a multicomponent evaluation, qualitative research was conducted to understand the value of the OTSS+ approach for malaria quality improvement. Semistructured key informant interviews, focus group discussions, and structured health facility-based interviews were used to gather stakeholder perspectives at subnational, national, and global levels. Data were collected globally and in 11 countries implementing OTSS+; in-depth data collection was done in four: Cameroon, Ghana, Niger, and Zambia. Study sites and participants were selected purposively. Verbatim transcripts were analyzed thematically, following the Framework approach. A total of 262 participants were included in the analysis; 98 (37.4%) were supervisees, 99 (37.8%) were supervisors, and 65 (24.8%) were other stakeholders. The OTSS+ approach was perceived to improve provider knowledge and skills in malaria service delivery and to improve data and supply management indirectly. Improvements were attributed to a combination of factors. Participants valued the relevance, adaptation, and digitization of supervision checklists; the quality and amount of contact with problem-solving supervisors; and the joint identification of problems and solutions, and development of action plans. Opportunities for improvement were digitized checklist refinement, assurance of a sufficient pool of supervisors, prioritization of health facilities, action plan dissemination and follow-up, and data review and use. The OTSS+ approach was perceived to be a useful quality improvement approach for malaria services.

Case fatality and factors associated with Maternal mortality in patients with eclampsia: A retrospective review of 761 cases in a tertiary institution in Nigeria.

To determine the case fatality and factors associated with maternal mortality in patients with eclampsia in UMTH, we conducted a retrospective review of 761 consecutive cases of eclampsia managed UMTH, Nigeria, from 2005 to 2020. Case fatality was 7.6%, most being unbooked primigravidae with no formal education. Common causes of death identified were aspiration, cerebrovascular accident, and haemorrhage. Admission delayed >10 hours was found to be independently associated with maternal death, and Caesarean delivery.

Health systems readiness and quality of inpatient malaria case-management in Kano State, Nigeria.

BACKGROUND: Nigeria was among the first African countries to adopt and implement change of treatment policy for severe malaria from quinine to artesunate. Seven years after the policy change health systems readiness and quality of inpatient malaria case-management practices were evaluated in Kano State of Nigeria. METHODS: A cross-sectional survey was undertaken in May 2019 at all public hospitals. Data collection comprised hospital assessments, interviews with inpatient health workers and data extraction from medical files for all suspected malaria patients admitted to the paediatric and medical wards in April 2019. Descriptive analyses included 22 hospitals, 154 health workers and 1,807 suspected malaria admissions analysed from malaria test and treat case-management perspective. RESULTS: 73% of hospitals provided malaria microscopy, 27% had rapid diagnostic tests and 23% were unable to perform any parasitological malaria diagnosis. Artemisinin-based combination therapy (ACT) was available at 96% of hospitals, artemether vials at 68% while injectable quinine and artesunate were equally stocked at 59% of hospitals. 32%, 21% and 15% of health workers had been exposed to relevant trainings, guidelines and supervision respectively. 47% of suspected malaria patients were tested while repeat testing was rare (7%). 60% of confirmed severe malaria patients were prescribed artesunate. Only 4% of admitted non-severe test positive cases were treated with ACT, while 76% of test negative patients were prescribed an anti-malarial. Artemether was the most common anti-malarial treatment for non-severe test positive (55%), test negative (43%) and patients not tested for malaria (45%). In all categories of the patients, except for confirmed severe cases, artemether was more commonly prescribed for adults compared to children. 44% of artesunate-treated patients were prescribed ACT follow-on treatment. Overall compliance with test and treat policy for malaria was 13%. CONCLUSIONS: Translation of new treatment policy for severe malaria into inpatient practice is compromised by lack of malaria diagnostics, stock-outs of artesunate and suboptimal health workers' practices. Establishment of the effective supply chain and on-going supportive interventions for health workers accompanied with regular monitoring of the systems readiness and clinical practices are urgently needed.

Provider and patient perceptions of malaria rapid diagnostic test use in Nigeria: a cross-sectional evaluation.

BACKGROUND: Nigeria commenced a phased programmatic deployment of rapid diagnostic tests (RDT) at the primary health care (PHC) facility levels since 2011. Despite various efforts, the national testing rate for malaria is still very low. The uptake of RDT has been variable. This study was undertaken to determine the provider and patient perceptions to RDT use at the PHC level in Nigeria with their implications for improving uptake and compliance. METHODS: A cross-sectional survey was conducted in 120 randomly selected PHCs across six states, across the six-geopolitical zones of Nigeria in January 2013. Health facility staff interviews were conducted to assess health workers (HW) perception, prescription practices and determinants of RDT use. Patient exit interviews were conducted to assess patient perception of RDT from ten patients/caregivers who met the eligibility criterion and were consecutively selected in each PHC, and to determine HW's compliance with RDT test results indirectly. Community members, each selected by their ward development committees in each Local Government Area were recruited for focus group discussion on their perceptions to RDT use. RESULTS: Health workers would use RDT results because of confidence in RDT results (95.4%) and its reduction in irrational use of artemisinin-based combination therapy (ACT) (87.2%). However, in Enugu state, RDT was not used by health workers because of the pervasive notion RDT that results were inaccurate. Among the 1207 exit interviews conducted, 549 (45.5%) had received RDT test. Compliance rate (administering ACT to positive patients and withholding ACT from negative patients) from patient exit interviews was 90.2%. Among caregivers/patients who had RDT done, over 95% knew that RDT tested for malaria, felt it was necessary and liked the test. Age of patients less than 5 years (p = 0.04) and "high" educational status (p = 0.0006) were factors influencing HW's prescription of ACT to RDT negative patients. CONCLUSION: The study demonstrated positive perception to RDT use by HW and among community members with good compliance rate among health workers at the PHC level. This positive perception should be explored in improving the current low level of malaria testing in Nigeria while addressing the influence of age on HW administration of ACT to RDT negative cases.

Risk factors and microbial isolates of puerperal sepsis at the University of Maiduguri Teaching Hospital, Maiduguri, North-eastern Nigeria.

PURPOSE: To determine the risk factors and microbial isolates of puerperal sepsis. METHODS: A 12 year retrospective review of patients with puerperal sepsis from January 1999 to December 2010 at the University of Maiduguri Teaching Hospital (UMTH) was conducted. Information on socio-demographic characteristics, clinical presentations, place and mode of delivery and microorganism isolated from the endocervical swabs was collected and analysed. Comparison was also made with the other women that delivered during the period of study. RESULTS: The incidence of puerperal sepsis was 0.78%. Majority (88.0%) of the patients were unbooked, 59.1% delivered at home and 23.1% delivered in other peripheral hospitals. The major risk factors for developing puerperal sepsis were unbooked status, home delivery, perineal trauma, caesarean section (C/S) and maternal age <24 years with OR of 56.60, 39.25, 8.52, 4.99 and 1.32, respectively. The commonest microorganism isolated were Staphylococcus aureus and Escherichia coli seen in 35.4 and 20.9%, respectively. Streptococcus species was found in 6.9%, while 20.3% had polymicrobials isolated. CONCLUSION: Puerperal sepsis continues to present a significant risk of maternal mortality in developing countries. The risk factors are unbooked women, home delivery, perineal trauma, caesarean section and maternal age <24 years. S. aureus and E. coli are the commonest isolated organisms. There is a need to enlighten the populace on the need for booking, skilled attendant at delivery and hospital delivery under aseptic conditions.

Is routine antenatal screening for syphilis in Nigeria still justified clinically and economically?

OBJECTIVE: To determine the seroprevalence and cost effectiveness of antenatal syphilis screening at the University of Maiduguri Teaching Hospital (UMTH), Maiduguri, Nigeria. METHODS: A retrospective chart analysis of venereal disease research laboratory (VDRL) results among pregnant women at the UMTH, Maiduguri, Nigeria, during a 10-year period (from 1st January 1999 to 31st December 2008) was undertaken. RESULTS: A total of 18,712 women registered for antenatal care during the study period. Of these, 18,101 had serological screening for syphilis. Only 12 of the 18,101 screened were seropositive by VDRL, 9 (75%) were confirmed by Treponema pallidum hemagglutination assay (TPHA), giving a seroprevalence rate of 0.05%. Three (25%) were biological false-positive. The peak age-specific incidence of 0.02% was in the 20-24 year-age group. There was zero prevalence in the age groups 15-19 and >40 years. There was no case of congenital syphilis seen. The cost for VDRL testing per patient in UMTH is US$2. The total amount of money spent on VDRL tests over the study period was US$37,424. CONCLUSION: The seroprevalence rate of syphilis is extremely low in this study. This calls for a review of the policy of routine antenatal serology screening for syphilis in Maiduguri, Nigeria.

Rising trend and indications of caesarean section at the university of Maiduguri teaching hospital, Nigeria.

OBJECTIVE: To determine the trend and indications for the use of caesarean delivery in our environment. METHOD: A retrospective review of the caesarean sections performed at University of Maiduguri Teaching Hospital from January 2000 to December 2005 inclusive. RESULTS: During the study period, there were 10,097 deliveries and 1192 caesarean sections giving a caesarean section rate of 11.8%. The major maternal indications were cephalopelvic disproportion (15.5%), previous caesarean section (14.7%), eclampsia (7.2%), failed induction of labor (5.5%), and placenta previa (5.1%). Fetal distress (9.6%), breech presentation (4.7%), fetal macrosomia (4.3%), and pregnancy complicated by multiple fetuses (4.2%) were the major fetal indications. The caesarean section rate showed a steady increase over the years (7.20% in 2000-13.95% in 2005), but yearly analysis of the demographic characteristics, type of caesarean section, and the major indications did not reveal any consistent changes to account for the rising trend except for the increasing frequency of fetal distress as an indication of caesarean section over the years, which was also not statistically significant (c[2] =8.08; P=0.12). The overall perinatal mortality in the study population was found to be 72.7/1000 birth and despite the rising rate of caesarean section, the perinatal outcomes did not improve over the years. CONCLUSION: Trial of vaginal birth after caesarean section in appropriate cases and use of cardiotocography for continuous fetal heart rate monitoring in labor with confirmation of suspected fetal distress through fetal blood acid--base study are recommended. A prospective study may reveal some of the other reasons for the increasing caesarean section rate.