2016: A Year in Review UCSF East Africa Preterm Birth Initiative

Together with our partners, the University of California East Africa Preterm Initiative (PTBi-EA) is taking a place-based approach to reducing the burden of preterm birth (before 37 weeks gestation). Funded by the Bill & Melinda Gates Foundation and working in select regions of western Kenya, eastern Uganda, and Rwanda – our multi-year effort aims to reduce mortality among preterm infants by improving quality of care during the antenatal, intrapartum, and immediate postnatal periods.

PTBi research area in East Africa

Dear friends, partners, and supporters:

As I reflect on this past year and think about the progress that we, as a multi-country collaboration have made, I can’t help but smile. I think about the young mothers learning to care for their fragile, tiny newborns. I imagine our committed midwives wrapping those babies to their mothers’ chests for vital skin-to-skin warming. I think about the tremendous progress we’ve made in strengthening data and national health information systems, as well as mentoring and training for clinicians in all three countries to improve their quality of care. I am grateful for the strong partnerships we have built with Drs. Phelgona Otieno, Peter Waiswa, Sabine Musange, and their teams in Kenya, Uganda, and Rwanda respectively. Together, we will make measurable impact, we will save mothers and newborns.

The journey has not and will not be easy. Every day, I am reminded that for so many newborns in East Africa, prematurity is a death sentence. Last year, across the world, nearly 750,000 preterm babies died within the first 28 days of life – the places where we work see a disproportionate share of these deaths. Our partnership is committed to dramatically reducing these numbers.

To see an overview of our efforts in East Africa, please view the first video below. To learn more about the importance of data collection to our work, please view the second. Then scroll through this report to learn more about our data-strengthening work, interventions package, group antenatal care trial, capacity-building fellowship, and discovery research in preterm birth.

In closing and with much gratitude, I want to acknowledge our generous funder, the Bill & Melinda Gates Foundation; our tireless staff and researchers at UCSF, KEMRI, Makerere University, and the National University of Rwanda School of Public Health; as well as our partners at the ministries of health in Kenya, Rwanda, and Uganda. As the saying goes, “it takes a village to raise a child.” Well, it takes a village to save these newborns too, and I couldn’t ask for a more committed, passionate village to be working with.

Dilys Walker MD, Principal Investigator, PTBi-EA

The East Africa Preterm Birth Initiative Story

A Day in the Life of Data: Making Every Action Count

Preterm infant, Migori Referral Hospital, Kenya

Kenya

Together with the Kenya Medical Research Institute (KEMRI), we are conducting implementation research, lead by Dr. Phelgona Otieno, at 17 health facilities in Migori County. Our work in early 2016 focused on assessing those facilities for project readiness and strengthening use of existing facility-based data collection, tools, and practices. Towards the later part of the year, we began rolling out an interventions package that includes a customized version of the WHO’s Safe Childbirth Checklist, simulation and team training for providers through PRONTO International (preparing clinicians to better identify and manage preterm births), and training for health facility staff in quality improvement cycles. We feel confident that this package of interventions will improve the quality of care for mothers and newborns and ultimately save lives.

Pronto simulation training, Migori Kenya

Group antenatal care participants, Kigali, Rwanda

Rwanda

Drawing on previous research in the US that shows group care can reduce preterm birth rates, our work in Rwanda focuses on group antenatal and postnatal care (referred to as prenatal and postpartum in the US). Partnering with the University of Rwanda’s Dr. Sabine Musange and the Rwanda Biomedical Center, we are performing the largest cluster randomized control trial of group antenatal and postnatal care in the world. 10,000 women across 36 government health centers in five districts will participate.

Our work in 2016 focused on the assessment of facility readiness, qualitative work on attitudes toward antenatal care, and development of a model for group care that would meet the specific needs of Rwandan women. A technical working group of stakeholders met several times during the year to develop and refine the model. Towards the end of 2016, we began training Rwandan midwives as master trainers, who will in turn train the midwives, nurses, and community health workers charged with delivering group care.

The trial will launch in April 2017. Our results will provide the global maternal-child health community with long-awaited information about the feasibility and effectiveness of group antenatal care in low- and middle-income countries. With positive findings from this trial, we hope to provide a model of group care that can be adapted to other low- and middle-income countries, ultimately curbing preterm birth. In 2019, with results from all 10,000 women and newborns, we will report on whether this innovative model of antenatal care is able to reduce the preterm birth rate in Rwanda.

Group antenatal care participants, Kigali, Rwanda.

Kangaroo mother care, Jinja Regional Referral Hospital, Uganda

Uganda

Principal investigator, Dr. Peter Waiswa of Makerere University, leads our implementation research collaboration in Uganda, where we are working with six health facilities in the Busoga region. As with our work in Kenya, our teams spent the first half of 2016 assessing those facilities for project readiness and strengthening the use of existing facility-based data collection tools and practices. Later in 2016, we began rolling out the same interventions package we introduced in Kenya. The package includes a Uganda-specific, customized version of the WHO’s Safe Childbirth Checklist, simulation and team training for providers through PRONTO International (preparing clinicians to better identify and manage preterm births), and training for health facility staff in quality improvement cycles. We feel confident that this package of interventions will improve the quality of care for mothers and newborns, ultimately saving lives in both Kenya and Uganda.

Kangaroo Care, Jinja Referral Hospital, Uganda
Simulation training, Rongo, Kenya

PTBi-EA Fellowship

At PTBi-EA, we are committed to increasing the capacity of new leaders in the field of preterm birth research, programming, policy and advocacy. To this end, we, along with our sister initiative, the California Preterm Birth Initiative (PTBi-CA), offer a two-year, non-accredited, transdisciplinary postdoctoral fellowship focused on prematurity. The inaugural cohort of six fellows started in July 2015 and brought together discovery and implementation interests spanning socio-behavioral risk factors during pregnancy, deeper investigation within kangaroo care and group antenatal care, and neuroprotection in preterm infants.

While pursuing their mentored fellowship projects in prematurity science, our fellows have learned to work collaboratively across disciplines and sectors with an emphasis on delivery pipeline challenges and the important role of dissemination. They've also participated in a robust career development program, including grant and manuscript writing and presentation coaching. Three of our six PTBi fellows focus their research in East Africa – their profiles follow.

Patience Alfulani, MBChB, MPh, PhD

Dr. Patience Afulani's research interests are in reproductive, maternal, neonatal, and child health, with a focus on how these are shaped by the quality of care in health facilities. Her current work is focused on understanding sources of disparities in the use and quality of maternal health services and how these translate into disparities in maternal and fetal outcomes. As part of her PTBi fellowship project in Kenya, she is studying community perceptions of quality of care during childbirth, and how these are associated with disparities in facility deliveries. Dr. Afulani has developed a tool to measure women’s perceptions of the care they receive in health facilities during childbirth—focusing on the person-centered dimensions of care. Dr. Afulani holds a PhD in public health, as well as an MPH with a certificate in global health from the University of California, Los Angeles, and a bachelor of medicine and surgery (MBChB) from the University of Ghana Medical School.

Melissa Morgan, MD

Dr. Melissa Morgan is an assistant professor in the UCSF Division of Neonatology and a faculty affiliate in UCSF Global Health Sciences. Her career goal is to become a leader in neonatal global health, performing research and transforming evidence into policy for neonates in low-income countries. She received a MSc in global health science from Oxford University in 2006 and an MD from the University of Texas, Houston in 2010. She then completed her pediatric residency and neonatology fellowship at UCSF. Prior to this fellowship, her research focused on implementation of neonatal pulse oximetry and transcutaneous bilirubinometry screening at facilities in Kenya and India, respectively. She also works with PRONTO International on simulation-based obstetric and neonatal emergency training for midwives in Bihar, India. In collaboration with investigators at the London School of Hygiene and Tropical Medicine and Makerere University, Dr. Morgan’s fellowship research explores the feasibility and acceptability of kangaroo mother care for clinically unstable infants weighing less than 2000 grams at Jinja Regional Referral Hospital in Jinja, Uganda.

Joseph Musana, MBchB, MMED

Dr. Joseph Wangira Musana is a faculty member and senior instructor in the Department of Obstetrics and Gynecology at the Aga Khan University in Nairobi, Kenya. He received his MBChB and MMED degrees from the University of Nairobi and a diploma in sexual and reproductive health and rights from Lund University in Sweden. For the past six years, he has been involved in offering care to women with complex pregnancies in a specialized multidisciplinary “One-Stop Medical Antenatal Clinic.” He has also been building research collaborations – local, regional, and international – and has been involved in writing research grants and an article on preterm birth in the Maternal and Child Health Journal. Dr. Musana’s fellowship research in Migori, Kenya focuses on the relationship between preterm birth and a mother's stress, anxiety, and depression during pregnancy.

Newborn, Migori, Kenya

Discovery

As part of our holistic approach to address preterm birth, PTBi-EA supports locally driven discovery research and innovation to better understand its causes, epidemiology, and outcomes. During the 2015-2016 period, we launched two request for proposal (RFP) cycles, and to date have selected six pilot projects and two collaborative Team Science awards for funding. We are committed to capacity building, having successfully fostered connections among researchers, mentors, and students. Our discovery projects focus on improving gestational age assessment, understanding risk factors for preterm birth (infection, environmental toxins, and nutrition), and testing new innovations to address the care of preterm infants. In late 2017, we will launch our third call for proposals.

In addition, PTBi-EA is co-funding a Grand Challenges Explorations grant focused on the validation of a metabolic algorithm for gestational age prediction at birth in Tororo, Uganda. We also piloted a clinical phenotyping study at Migori County Referral Hospital (MCRH), which aimed to better understand the maternal, fetal, and placental characteristics associated with preterm birth. During her graduate work at UCSF, Lara Miller, PTBi-EA program manager, collected information from over 500 women who delivered a preterm or low-birth-weight baby over the last six months at MCRH. In 2017, we hope to expand this work to Iganga Hospital in Uganda.

PTBi Annual Symposium, Nairobi, Kenya

Principal Investigators

Phelgona Otieno, MBChB, MPH PTBi-Kenya

"One of the greatest challenges of doing this work is having facility staff involvement in the interventions we are providing. We are using several approaches to create awareness, build confidence in correct diagnoses, and increase active involvement of facility staff. These are key for the care of preterm babies"

Dr. Phelgona Otieno, PTBi-Kenya principal investigator, is a pediatrician and epidemiologist with long-standing experience in conducting HIV research, running child health programs, and mentoring health professionals. She currently serves as a principal research officer at Kenya Medical Research Institute (KEMRI) within the Sexual, Reproductive, Adolescent and Child Health Division.

Sabine Musange MD, MSc, PTBi-Rwanda

"To turn the curve on prematurity is to continue to build local human capacity in the area of maternal, neonatal, and child health, and scale up interventions that have been proven to work in this setting. We are motivated about our work because every mother and child deserves the chance to thrive without the burden and stress of preventable complications, death, or prematurity."

Dr. Sabine Musange, PTBi-Rwanda principal investigator, has significant experience in healthcare, financing, and economics along with leading donor projects. She is currently completing a PhD in implementation science at the University of Washington, Seattle.

Peter Waiswa MBChB, MPH, PhD, PTBi-Uganda

“Our vision is a country and an Africa that recognizes the problem of prematurity but also implements low-cost health systems innovations with quality, equity, and scalability”

Dr. Peter Waiswa, PTBi-Uganda principal investigator, is a medical doctor and health-systems researcher with particular focus on newborn health and development and maternal-newborn-child health services. He is a frequent advisor to international organizations on perinatal-newborn health. With a background in district health service provision in rural Uganda he holds a joint PhD degree from Karolinska Institutet and Makerere University, and is on the faculty at Makerere University School of Public Health, Uganda, as well as Karolinska Institutet, Sweden.

Dilys Walker MD, PTBi-East Africa

"We will not rest until pregnancy complications are no longer a death sentence for mothers and newborns. We are moving forward with a clear vision and approach that are both sustainable and scalable."

Dr. Dilys Walker, PTBi-EA principal investigator, is an obstetrician gynecologist and a professor in the departments of Obstetrics, Gynecology, and Reproductive Sciences, and Global Health Sciences at the University of California, San Francisco. Dr. Walker and her team developed a novel approach to emergency training – PRONTO – using highly-realistic simulation and team training to improve obstetric and neonatal outcomes. She is the co-founder of the NGO PRONTO International and is currently running PRONTO implementation trials in Mexico, Guatemala, Kenya, and India. As principal investigator for PTBi-EA, Dr. Walker provides oversight and leadership for the research in Kenya, Uganda, and Rwanda.

PTBi-EA Team, Nairobi, Kenya

Thank you for taking the time to learn about our work, which is made possible by the generous support of our funder.

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UCSF East Africa Preterm Birth Initiative East Africa
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Credits:

Photos courtesy of Nicholas Berger and Matthew Gillooley

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