Chlorhexidine for facility-based umbilical cord care: EN-BIRTH multi-country validation study

Abstract Background Umbilical cord hygiene prevents sepsis, a leading cause of neonatal mortality. The World Health Organization recommends 7.1% chlorhexidine digluconate (CHX) application to the umbilicus after home birth in high mortality contexts. In Bangladesh and Nepal, national policies recommend CHX use for all facility births. Population-based household surveys include optional questions on CHX use, but indicator validation studies are lacking. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study assessing measurement validity for maternal and newborn indicators. This paper reports results regarding CHX. Methods The EN-BIRTH study (July 2017–July 2018) included three public hospitals in Bangladesh and Nepal where CHX cord application is routine. Clinical-observers collected tablet-based, time-stamped data regarding cord care during admission to labour and delivery wards as the gold standard to assess accuracy of women’s report at exit survey, and of routine-register data. We calculated validity ratios and individual-level validation metrics; analysed coverage, quality and measurement gaps. We conducted qualitative interviews to assess barriers and enablers to routine register-recording. Results Umbilical cord care was observed for 12,379 live births. Observer-assessed CHX coverage was very high at 89.3–99.4% in all 3 hospitals, although slightly lower after caesarean births in Azimpur (86.8%), Bangladesh. Exit survey-reported coverage (0.4–45.9%) underestimated the observed coverage with substantial “don’t know” responses (55.5–79.4%). Survey-reported validity ratios were all poor (0.01 to 0.38). Register-recorded coverage in the specific column in Bangladesh was underestimated by 0.2% in Kushtia but overestimated by 9.0% in Azimpur. Register-recorded validity ratios were good (0.9 to 1.1) in Bangladesh, and poor (0.8) in Nepal. The non-specific register column in Pokhara, Nepal substantially underestimated coverage (20.7%). Conclusions Exit survey-report highly underestimated observed CHX coverage in all three hospitals. Routine register-recorded coverage was closer to observer-assessed coverage than survey reports in all hospitals, including for caesarean births, and was more accurately captured in hospitals with a specific register column. Inclusion of CHX cord care into registers, and tallied into health management information system platforms, is justified in countries with national policies for facility-based use, but requires implementation research to assess register design and data flow within health information systems.

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Cost and consequences of using 7.1% chlorhexidine gel for newborn umbilical cord care in Kenya

10.21203/rs.3.rs-362323/v1 ◽

2021 ◽

Author(s):

Lecia Brown ◽

Alan Martin ◽

Christopher Were ◽

Nandita Biswas ◽

Alexander Liakos ◽

...

Keyword(s):

Umbilical Cord ◽

Direct Cost ◽

Cost Savings ◽

Cost Of Care ◽

World Health ◽

Healthcare Sector ◽

Cord Care ◽

Outpatient Visits ◽

Umbilical Cord Care ◽

Bed Days

Abstract Background: Umbilical-cord infection (omphalitis) is a major cause of neonatal mortality in Kenya. Chlorhexidine 7.1% digluconate gel, (CHX), delivering 4% chlorhexidine was identified as a life-saving commodity for newborn cord care by the United Nations and is included on the World Health Organization and Kenyan Essential Medicines Lists. Methods: We employed a cost-consequence model to assess resource saving and breakeven price of implementing CHX for neonatal umbilical cord care versus dry cord care (DCC) in a Kenyan birth cohort. Firstly, the number of omphalitis cases and cases avoided by healthcare sector were estimated. Economic outcomes associated with omphalitis cases avoided were then determined, including direct, indirect and total cost of care associated with omphalitis, resource use (outpatient visits and bed days) and societal impact (caregiver workdays lost). Treatment effect inputs were calculated from a Cochrane meta-analysis of randomised clinical trials (RCTs) (base case) and 2 other RCTs. Costs and other inputs were sourced from the literature and supplemented by expert clinical opinion/informed inputs, making assumptions as necessary. Reports: The model estimated that, over 1 year, ~23,000 omphalitis cases per 500,000 births could be avoided through CHX application versus DCC, circumventing ~13,000 outpatient visits, ~43,000 bed days and preserving ~114,000 workdays. CHX was associated with annual direct cost savings of ~590,000 US dollars (USD) versus DCC (not including drug-acquisition cost), increasing to ~2.5 million USD after including indirect costs (productivity, notional salary loss). The most-influential model parameter was relative risk of omphalitis with CHX versus DCC. Breakeven analysis identified a budget-neutral price for CHX use of 1.18 USD/course when accounting for direct cost savings only, and of 5.43 USD/course when also including indirect cost savings. The estimated breakeven price was robust to parameter input changes. DCC does not necessarily represent standard of care in Kenya; other, potentially harmful, approaches may be used, meaning cost savings may be understated. Conclusions: Estimated healthcare cost savings and potential health benefits provide compelling evidence to implement CHX for umbilical cord care in Kenya. We encourage comprehensive data collection to make future models and estimates of the impacts of upscaling CHX use more robust.

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Cost and consequences of using 7.1 % chlorhexidine gel for newborn umbilical cord care in Kenya

BMC Health Services Research ◽

10.1186/s12913-021-06971-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Lecia Brown ◽

Alan Martin ◽

Christopher Were ◽

Nandita Biswas ◽

Alexander Liakos ◽

...

Keyword(s):

Umbilical Cord ◽

Direct Cost ◽

Cost Savings ◽

Cost Of Care ◽

World Health ◽

Healthcare Sector ◽

Cord Care ◽

Outpatient Visits ◽

Umbilical Cord Care ◽

Bed Days

Abstract Background Omphalitis is an important contributor to neonatal mortality in Kenya. Chlorhexidine digluconate 7.1 % w/w (CHX; equivalent to 4 % w/w chlorhexidine) was identified as a life-saving commodity for newborn cord care by the United Nations and is included on World Health Organization and Kenyan Essential Medicines Lists. This pilot study assessed the potential resource savings and breakeven price of implementing CHX for neonatal umbilical cord care versus dry cord care (DCC) in Kenya. Methods We employed a cost-consequence model in a Kenyan birth cohort. Firstly, the number of omphalitis cases and cases avoided by healthcare sector were estimated. Incidence rates and treatment effect inputs were calculated from a Cochrane meta-analysis of randomised clinical trials (RCTs) (base case) and 2 other RCTs. Economic outcomes associated with omphalitis cases avoided were determined, including direct, indirect and total cost of care associated with omphalitis, resource use (outpatient visits and bed days) and societal impact (caregiver workdays lost). Costs and other inputs were sourced from literature and supplemented by expert clinical opinion/informed inputs, making necessary assumptions. Results The model estimated that, over 1 year, ~ 23,000 omphalitis cases per 500,000 births could be avoided through CHX application versus DCC, circumventing ~ 13,000 outpatient visits, ~ 43,000 bed days and preserving ~ 114,000 workdays. CHX was associated with annual direct cost savings of ~ 590,000 US dollars (USD) versus DCC (not including drug-acquisition cost), increasing to ~ 2.5 million USD after including indirect costs (productivity, notional salary loss). The most-influential model parameter was relative risk of omphalitis with CHX versus DCC. Breakeven analysis identified a budget-neutral price for CHX use of 1.18 USD/course when accounting for direct cost savings only, and 5.43 USD/course when including indirect cost savings. The estimated breakeven price was robust to parameter input changes. DCC does not necessarily represent standard of care in Kenya; other, potentially harmful, approaches may be used, meaning cost savings may be understated. Conclusions Estimated healthcare cost savings and potential health benefits provide compelling evidence to implement CHX for umbilical cord care in Kenya. We encourage comprehensive data collection to make future models and estimates of impacts of upscaling CHX use more robust.

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Survey of Electronic Health Record (EHR) Systems in Kenyan Public Hospitals: A mixed-methods survey (Preprint)

10.2196/preprints.12995 ◽

2018 ◽

Cited By ~ 1

Author(s):

Naomi Muinga ◽

Steve Magare ◽

Jonathan Monda ◽

Mike English ◽

Hamish Fraser ◽

...

Keyword(s):

Management Information System ◽

Health Management ◽

Public Hospitals ◽

Health Management Information System ◽

Adoption Process ◽

Management Information ◽

Health Records ◽

Hospital Administrators ◽

Ehr Adoption ◽

Electronic Health

BACKGROUND As healthcare facilities in Low- and Middle-Income Countries (LMICs) such as Kenya adopt Electronic Health Record (EHR) systems to improve hospital administration and patient care, it is important to understand the adoption process, identify the key stakeholders, and assess the capabilities of the systems in use. OBJECTIVE To describe the level of adoption of Electronic Health Records systems in public hospitals and understand the process of adoption from Health Management Information System (HMIS) system vendors and system users. METHODS We conducted a survey of County Health Records Information Officers (CHRIOs) in Kenya to determine the level of adoption of Electronic Health Records systems in public hospitals. We conducted site visits to hospitals to view systems in use and to interview hospital administrators and end users. We also interviewed Health Management Information System (HMIS) system vendors to understand the adoption process from their perspective. RESULTS From the survey of CHRIOs, all facilities mentioned had adopted some form of EHR. Hospitals commonly purchased systems for patient administration and hospital billing functions. Radiology and laboratory management systems were commonly standalone systems. There were varying levels of interoperability within facilities that had more than one system in operation. We only saw one in-patient EHR system in use although many vendors and hospital administrators we interviewed were planning to adopt or support such systems. From the user perspective, issues such as system usability, adequate training, availability of adequate infrastructure and system support emerged. From the vendor perspective, a wide range of services was available to the hospital though constrained by funding and the need to computerise service areas that were deemed as priority. Additionally, vendors were unable to implement some data sharing modules linking to national HMIS due to lack of appropriate policies to facilitate this and users’ lack of confidence in new technologies such as cloud services. CONCLUSIONS EHR adoption in Kenya has been underway for some years, particularly in comprehensive care clinics, and hospitals are increasing purchasing systems to support administrative functions. Considerable support from government, donors and regional health informatics organisations will be required to enable hospitals to move to full EHR adoption for in-patient care.

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