Preventability and delayed care seeking in stillbirths and neonatal deaths in the Child Health and Mortality Prevention Surveillance (CHAMPS) South Africa site Open Access
Ramakrishna, Namrata (Spring 2024)
Abstract
Previous studies in the Child Health and Mortality Prevention Surveillance (CHAMPS) network have described that many deaths among infants and children, including in South Africa, could have been averted through improved health-seeking behaviors and access to high-quality care. However, such efforts have excluded stillbirths and neonates, despite these two populations comprising nearly half of all deaths among children aged <5 years in low- and middle-income countries in regions with high rates of mortality among children aged <5 years. Our objective was to document the frequency of delays in the “Three Delays-in-Healthcare” framework and to describe factors associated with delays among stillbirths and deceased neonates who enrolled in CHAMPS in South Africa. We conducted a retrospective, descriptive study using data collected in Soweto, South Africa on stillbirths and deceased neonates. According to the “Three Delays-in-Healthcare” framework, we categorized delays in (1) deciding to seek clinical care, (2) reaching healthcare facilities, and (3) receiving optimal clinical care in healthcare facilities. Comparisons between factors associated with delays were made using Chi-square testing.
Overall, 396/847 (47%) stillbirths and neonates had at least one delay according to the “Three Delays-in-Healthcare” framework. Delays in deciding to seek care were present in 13% of cases (n=117), delays in reaching a healthcare facility were present in 8% of cases (n=71), and delays in receiving optimal clinical care at healthcare facilities were present in 36% of cases (n=303). Among delays in receiving optimal clinical care, inter-facility transfer related delays were the most common delay and occurred in 15% (n=130) of cases. A higher proportion of mothers who were HIV negative (n=205/422, 49%) experienced at least one delay compared to those who tested HIV positive (n=77/191, 40%). More female cases had documented delays (51%) than male cases (43%, P=0.03). A greater proportion of stillbirths and neonates who died outside healthcare facilities experienced a delay in the decision to seek clinical care compared to those who died in a healthcare facility (34% vs 13%, P<0.001). From 2017-2019, 32% of all cases had at least one documented delay, which increased to 58% among cases that enrolled from 2020-2022 (P<0.001). Further study to compare the frequency of delays in seeking clinical care and its provision among live neonates in Soweto, South Africa, may elucidate the contributory role of these delays in stillbirths and neonatal deaths.
Table of Contents
Literature Review 1
Global Burden of Stillbirth and Neonatal Deaths 1
Gaps in Quality Clinical Care Contribute to Stillbirths and Neonatal Deaths 1
“Three Delays-in-Healthcare” Model 2
Delays in Deciding to Seek Clinical Care (Delay 1) 3
Delays in Reaching Healthcare Facilities (Delay 2) 4
Delays in Receiving Optimal Clinical Care in Healthcare Facilities (Delay 3) 5
“Three Delays-in-Healthcare” Change over Time 6
Applications of the “Three Delays-in-Healthcare” Model to Stillbirths and Neonatal Deaths 7
The South African Context 10
Purpose of Our Study 13
Introduction 15
Methods 16
Study Design 16
Study Setting 17
Data Sources 18
Inclusion and Exclusion Criteria 20
Data Extraction 20
Definitions 21
Analyses 21
Results 22
Delays in Deciding to Seek Clinical Care (Delay 1) 24
Delays in Reaching Healthcare Facilities (Delay 2) 24
Delays in Receiving Optimal Clinical Care in Healthcare Facilities (Delay 3) 24
Subgroup Comparisons of Documented Delays 25
Discussion 25
Quality of Antenatal Care 26
Delays in Deciding to Seek Clinical Care (Delay 1) 26
HIV 27
Delays in Reaching Healthcare Facilities (Delay 2) 27
Delays in Receiving Optimal Clinical Care in Healthcare Facilities (Delay 3) 28
Time-trends 28
Limitations 29
Conclusion 30
References 31
Supplemental Materials 38
Figure 1. PRISMA flow diagram for included stillbirths and deaths among neonates. 38
Figure 2. Venn Diagram of each type of delay among stillbirths and deceased neonates. 39
Figure 3. Percent of stillbirths and deceased neonates that experienced at least one delay per year. 40
Figure 4. Percent of stillbirths and deceased neonates who experienced each delay in the “Three Delays-in-Healthcare” model. 41
Table 1. Demographics of included stillbirths and neonatal deaths that enrolled in the Child Health and Mortality Prevention Surveillance (CHAMPS) network South Africa site, 2017-2023. 42
Supplemental Table 1. Demographics of included and excluded stillbirths and neonatal deaths that enrolled in the Child Health and Mortality Prevention Surveillance (CHAMPS) network South Africa site, 2017-2023. 43
About this Master's Thesis
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