Search

Abstract Background A disproportionate burden of maternal deaths occurs in low- and middle-income countries (LMICs), and obstetric hemorrhage (OH) is a leading cause of excess mortality. In Zambia, most of maternal deaths are directly caused by OH. The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that uses compression to the abdomen and lower body to stop and reverse hypovolemic shock secondary to OH. We describe the process and experiences introducing the NASG into the Zambia public health system to encourage the development of national policies, clinical guidelines, and implementation plans that feature the NASG. Methods We conducted an observational study of NASG introduction to 143 public health facilities in Northern Province, Zambia, organizing observations into the five dimensions of the RE-AIM evaluation framework: reach, effectiveness, adoption, implementation, and maintenance. The NASG was introduced in August 2019, and the introduction was evaluated for 18 months. Data on healthcare worker training and mentorship, cases where NASG was used, and NASG availability and use during the study period were collected and analyzed. Results The NASG was successfully introduced and integrated into the Zambia public health system, and appropriately used by healthcare workers when responding to cases of OH. Sixteen months after NASG introduction, NASGs were available and functional at 99% of study sites and 88% reported ever using a NASG. Of the 68 cases of recorded OH where a NASG was applied, 66 were confirmed as clinically appropriate, and among cases where shock index (SI) could be calculated, 59% had SI ≥ 0.9. Feedback from healthcare providers revealed that 97% thought introducing the NASG was a good decision, and 92% felt confident in their ability to apply the NASG after initial training. The RE-AIM average for this study was 0.65, suggesting a public health impact that is not equivocal, and that NASG introduction had a positive population-based effect. Conclusions A successful NASG demonstration took place over the course of 18 months in the existing health system of Northern Province, Zambia, suggesting that incorporation of NASG into the standard of care for obstetric emergency in the Zambia public sector is feasible and can be maintained without external support.

Abstract Background Public health systems in resource-constrained settings have a critical role to play in the elimination of HIV transmission but are often financially constrained. This study is an evaluation of a mother-infant-pair model called “Umoyo,” which was designed to be low cost and scalable in a public health system. Facilities with the Umoyo model dedicate a clinic day to provide services to only HIV-exposed infants (HEIs) and their mothers. Such models are in operation with reported success in Zambia but have not been rigorously tested. This work establishes whether the Umoyo model would improve 12-month retention of HEIs. Methods A cluster randomized trial including 28 facilities was conducted across two provinces of Zambia to investigate the impact on 12-month retention of HEIs in care. These facilities were offering Prevention of Mother-to-Child-Transmission (PMTCT) services and supported by the same implementing partner. Randomization was achieved by use of the covariate-constrained optimization technique. Secondary outcomes included the impact of Umoyo clinics on social support and perceived HIV stigma among mothers. For each of the outcomes, a difference-in-difference analysis was conducted at the facility level using the unweighted t test. Results From 13 control (12-month retention at endline: 45%) and 11 intervention facilities (12-month retention at endline: 33%), it was found that Umoyo clinics had no impact on 12-month retention of HEIs in the t test (− 11%; 99% CI − 40.1%, 17.2%). Regarding social support and stigma, the un-weighted t test showed no impact though sensitivity tests showed that Umoyo had an impact on increasing social support (0.31; 99% CI 0.08, 0.54) and reducing perceived stigma from health care workers (− 0.27; 99% CI − 0.46, − 0.08). Conclusion The Umoyo approach of having a dedicated clinic day for HEIs and their mothers did not improve retention of HEIs though there are indications that it can increase social support among mothers and reduce stigma. Without further support to the underlying health system, based on the evidence generated through this evaluation, the Umoyo clinic day approach on its own is not considered an effective intervention to increase retention of HIV-exposed infants. Trial registration Pan African Clinical Trial Registry, ID: PACTR201702001970148. Prospectively registered on 13 January 2017.

Abstract Background Road Traffic Crashes (RTCs) are the third highest cause of death in Zambia, claiming about 2000 lives annually, with pedestrians and cyclists being the most vulnerable. Human error accounts for 87.3% of RTCs. Minibus and big bus public service vehicles (PSVs) are among the common vehicle types involved in these crashes. Given the alarmingly high rate of road traffic crashes involving PSV minibuses and big buses within Zambia, there is a need to mitigate this through innovative solutions. In other settings, it has been shown that stickers in PSVs encouraging passengers to speak out against reckless driving can reduce RTCs, but it is unclear whether such an intervention could work in Zambia. Based on this evidence, the Zambia Road Transport and Safety Agency (RTSA) has developed a road safety bus sticker campaign for PSVs and before national scale-up, RTSA is interested in evidence of the impact of these stickers. Methods This evaluation will be a stratified two-arm randomized controlled trial with a one-to-one ratio. The sample will be stratified by vehicle type, thus creating a two-arm trial for minibuses and a separate two-arm trial for big buses. The sample will include 2110 minibuses and 300 big buses from four towns in Zambia. The primary outcome of interest will be the difference in the rate of RTCs over a 14-month period (7-months before the intervention and 7 months after) between buses with and without the new RTSA road safety bus stickers. Discussion This study will provide evidence on the impact of the Zambian sticker program on road traffic crashes as implemented through minibuses and big buses, that can help inform the scale up of a national ‘Zambia road safety bus sticker campaign’. Trial registration PACT-R, PACTR201711002758216. Registered 13 November 2017-Retrospectively registered.

Abstract Background A strong evidence base exists regarding routine and emergency services that can effectively prevent or reduce maternal and new-born mortality. However, even when skilled providers care for women in labour, many of the recommended services are not provided, despite being available. Barriers to the provision of appropriate childbirth services may include lack of availability of supplies, limited health worker knowledge and confidence, or inadequate time. The WHO Safe Childbirth Checklist (SCC) includes reminders for evidenced-based practices at specific points in the childbirth process. Zambia is currently considering nation-wide adoption of the SCC, but there is a need for context-specific evidence. Beginning in September 2017, a program is being implemented in Nchelenge District to pilot use of the SCC, along with coaching that focuses on strengthening the systems that allow the essential practices in childbirth to be performed. Methods This study will use a pre-post study design to measure health worker adherence to the essential practices for delivery care outlined in the SCC. Data will be collected through observations of health workers as they care for mothers during childbirth at four facilities. Data collection will take place before the start of the intervention, at 3 months, and at 6 months post-intervention. The primary outcome interest is the change in the average proportion of essential childbirth practices completed. A health worker questionnaire will be administered at the time that the SCC is introduced and 6 months later to gather their perspectives on incorporating the SCC into clinical practice in Zambia. Discussion Findings are expected to inform plans for introducing the SCC in Zambia. This evaluation will aim to understand uptake and impact of the SCC and associated coaching in the context of a basic level of mentorship that the government could feasibly provide at a national scale. Trial registration Clinical Trials.gov (NCT03263182) Registered August 28, 2017.