Periodic Reporting for period 4 - ALERT (Action Leveraging Evidence to Reduce perinatal morTality and morbidity in sub-Saharan Africa)
Reporting period: 2024-07-01 to 2024-12-31
Every year, five million children die before their second birthday globally. Approximately two million babies are stillborn, and just under 300,000 women die during pregnancy and childbirth - in all, nearly 7.5 million deaths occur in the first 1000 days of life. The few hours of the intrapartum period –from the onset of labour to the immediate postpartum¬– hold the greatest potential for saving lives. Evidence suggests that up to 2.5 million lives can be saved through evidence-based care in this critical intrapartum care period alone. There is compelling evidence outlining what needs to be done, as summarised in key guiding documents by the World Health Organization (WHO). However, research indicates two main barriers: i) insufficient provider competencies and substandard professional norms which are likely rooted in insufficient pre-service training, and ii) malfunctioning processes and operations that hinder the implementation of evidence-based guidelines for maternal and newborn health. Furthermore, mistreatment of women is increasingly recognised as a major issue in intrapartum care.
To address these challenges, we conceived the Action Leveraging Evidence to reduce perinatal Mortality and morbidity in Sub-Saharan Africa (ALERT) study. The overall objective of ALERT was to innovate, implement, and evaluate the effect, cost-effectiveness and implementation processes of a four-component ALERT intervention in hospitals. It was composed of co-design, competency-based training, quality improvement, and leadership mentoring.
To address these challenges, we conceived the Action Leveraging Evidence to reduce perinatal Mortality and morbidity in Sub-Saharan Africa (ALERT) study. The overall objective of ALERT was to innovate, implement, and evaluate the effect, cost-effectiveness and implementation processes of a four-component ALERT intervention in hospitals. It was composed of co-design, competency-based training, quality improvement, and leadership mentoring.
The implementation setting included three English-speaking East-African countries (Malawi, Tanzania and Uganda) and one French-speaking West-African country (Benin). These countries were purposively selected as they reflect different health system contexts and leveraged pre-existing research collaborations. ALERT was implemented in 16 district and referral hospitals in Benin, Malawi, Tanzania, and Uganda, including three public and one private-for-non-profit hospitals in each country.
We developed and successfully implemented an intervention composed of co-design, competency-based training, quality improvement and mentoring.
A total of 134,630 women were included in our stepped-wedge trial, with 60,403 during the comparison and 74,227 during the intervention period. More than 4,000 women were interviewed on their experiences with the care received in the hospitals after giving birth. Our preliminary results indicate that the intervention successfully reduced perinatal mortality by one-quarter (0.76 95% CI 0.63-0.91). Secondary indicators of maternal and perinatal morbidity also showed a reduction in morbidity, such as hypoxic-ischemic events (Apgar score <7). The intervention led to an increase in Caesarean sections. We observed no impact on the reduction of mistreatment during labour and birth, although the overall prevalence was low.
The study found that the total economic cost of implementing the intervention across four countries—Benin, Malawi, Tanzania, and Uganda—was approximately 130,000 USD, with significant variability due to local conditions such as travel distances and the frequency of the hospital visits by the in-country implementation teams. The Incremental Cost-Effectiveness Ratio (ICER) was calculated to compare the cost per perinatal death averted, showing costs around $800 per perinatal death averted in Benin and Uganda, while Malawi (around $2000) and Tanzania ($3200) had a higher ICER. In Tanzania, the ICER was especially high when based on pre-intervention perinatal mortality rates ($20,000). Preliminary results estimating a 24% reduction in perinatal mortality indicate that the intervention could improve health outcomes for newborns born in hospitals at a reasonable cost in typical high mortality and low resource settings in Sub-Saharan Africa, though further research is needed to explore country-specific dynamics.
The realist evaluation indicated improved hospital-level decision-making through the clinical training sessions in the training programme. Interviews supported the usefulness of the training as a refresher of previously obtained knowledge and a source of new knowledge, such as on ambulation during labour and birth position. The QI component contributed to improving care in all hospitals, with a focus on the improvement of the quality of care, and this contributed to better interactions between the different services related to emergency Caesarean sections. Departments such as the laboratory, pharmacy, and operating room improved their responsiveness, which facilitated emergency Caesarean sections. Tracking the QI component’s work helped facility managers in charge lobby for cleaning materials to improve infection prevention, foetal heart rate monitoring devices and drugs for emergency management of women, thus increased negotiating power.
The dissemination meetings in the four countries suggest that the ALERT team created a major momentum beyond the hospitals, with the intervention receiving traction by district health authorities and national policy makers. The two key innovations receiving the most interest was i) the perinatal e-registry and ii) the co-design component to better engage health care workers. The co-design process was emphasised as an empowering bottom-up approach that helped to identify and understand i) the critical problems as well as opportunities in the maternity wards, ii) the training needs to define the key priority areas for the competency-based training, and iii) prioritise the improvement work.
We developed and successfully implemented an intervention composed of co-design, competency-based training, quality improvement and mentoring.
A total of 134,630 women were included in our stepped-wedge trial, with 60,403 during the comparison and 74,227 during the intervention period. More than 4,000 women were interviewed on their experiences with the care received in the hospitals after giving birth. Our preliminary results indicate that the intervention successfully reduced perinatal mortality by one-quarter (0.76 95% CI 0.63-0.91). Secondary indicators of maternal and perinatal morbidity also showed a reduction in morbidity, such as hypoxic-ischemic events (Apgar score <7). The intervention led to an increase in Caesarean sections. We observed no impact on the reduction of mistreatment during labour and birth, although the overall prevalence was low.
The study found that the total economic cost of implementing the intervention across four countries—Benin, Malawi, Tanzania, and Uganda—was approximately 130,000 USD, with significant variability due to local conditions such as travel distances and the frequency of the hospital visits by the in-country implementation teams. The Incremental Cost-Effectiveness Ratio (ICER) was calculated to compare the cost per perinatal death averted, showing costs around $800 per perinatal death averted in Benin and Uganda, while Malawi (around $2000) and Tanzania ($3200) had a higher ICER. In Tanzania, the ICER was especially high when based on pre-intervention perinatal mortality rates ($20,000). Preliminary results estimating a 24% reduction in perinatal mortality indicate that the intervention could improve health outcomes for newborns born in hospitals at a reasonable cost in typical high mortality and low resource settings in Sub-Saharan Africa, though further research is needed to explore country-specific dynamics.
The realist evaluation indicated improved hospital-level decision-making through the clinical training sessions in the training programme. Interviews supported the usefulness of the training as a refresher of previously obtained knowledge and a source of new knowledge, such as on ambulation during labour and birth position. The QI component contributed to improving care in all hospitals, with a focus on the improvement of the quality of care, and this contributed to better interactions between the different services related to emergency Caesarean sections. Departments such as the laboratory, pharmacy, and operating room improved their responsiveness, which facilitated emergency Caesarean sections. Tracking the QI component’s work helped facility managers in charge lobby for cleaning materials to improve infection prevention, foetal heart rate monitoring devices and drugs for emergency management of women, thus increased negotiating power.
The dissemination meetings in the four countries suggest that the ALERT team created a major momentum beyond the hospitals, with the intervention receiving traction by district health authorities and national policy makers. The two key innovations receiving the most interest was i) the perinatal e-registry and ii) the co-design component to better engage health care workers. The co-design process was emphasised as an empowering bottom-up approach that helped to identify and understand i) the critical problems as well as opportunities in the maternity wards, ii) the training needs to define the key priority areas for the competency-based training, and iii) prioritise the improvement work.
Reducing perinatal mortality is of major importance towards achieving the Sustainable Development Goals (SDGs). Our project is relevant to SDG 3, explicitly on improving maternal and perinatal health. In addition, our project had an important impact on SDG 4, “Ensure inclusive and equitable quality education”, by innovating a novel bottom-up approach to capacity building. Our co-design work has improved knowledge of teamwork, decision-making, and improvement work in gender-mixed and multidisciplinary teams. We blended the co-design approach, training, and quality improvement and supported the identification of neglected areas such as pain relief. The empowering influence of the bottom-up components also helped female midwifery providers to increase their confidence in their profession. Thus, we saw an impact on gender issues. Finally, our work supported the strengthening of hospital processes and had an impact on strengthening these institutions, thus contributing to SDG 16: “Peace, justice and strong institution”.
Further, we substantially improved knowledge on current issues in maternal and perinatal health, including i) which groups are most affected, iii) interaction between vulnerabilities, iii) heat and perinatal mortality, iv) hidden issues within labour and childbirth, v) implementation constraints to scale companionship, vi) the effect of health systems on mortality in hospitals.
We included nine PhD students in the project, allowing them to learn within a vibrant consortium, earn a PhD, and generate new knowledge. Three post-doctoral researchers expanded their expertise and understanding, and numerous MSc students contributed to the data, leading to greater academic output.
Further, we substantially improved knowledge on current issues in maternal and perinatal health, including i) which groups are most affected, iii) interaction between vulnerabilities, iii) heat and perinatal mortality, iv) hidden issues within labour and childbirth, v) implementation constraints to scale companionship, vi) the effect of health systems on mortality in hospitals.
We included nine PhD students in the project, allowing them to learn within a vibrant consortium, earn a PhD, and generate new knowledge. Three post-doctoral researchers expanded their expertise and understanding, and numerous MSc students contributed to the data, leading to greater academic output.