Dr. Maia Nofal is a general surgery resident at Boston Medical Center and a post-doctoral NIH-Fogarty Fellow in the Global Health Equity Scholars program at Stanford. Her research interests focus on improving peri-operative surgical care in low-resource settings. She works primarily on adapting implementation and evaluation of the Clean Cut program, a surgical quality improvement program run by Lifebox to reduce surgical site infections through strengthening systems of infection prevention and control. More recently, her work has focused on antibiotic prescribing practices, resistance patterns, and antibiotic stewardship systems at partner hospitals Ethiopia where she is developing quality improvement initiatives to promote evidence-based prescribing practices.

Boards, Advisory Committees, Professional Organizations

  • Global Health Postdoctoral Affiliate, Center for Innovation in Global Health (CIGH) (2023 - Present)

All Publications

  • An observational cohort study on the effects of extended postoperative antibiotic prophylaxis on surgical-site infections in low- and middle-income countries. The British journal of surgery Clean Cut Investigators Group, Nofal, M. R., Zhuang, A. Y., Gebeyehu, N., Starr, N., Haile, S. T., Woldeamanuel, H., Tesfaye, A., Alemu, S. B., Bekele, A., Mammo, T. N., Weiser, T. G., Abdukadir, A. A., Abebe, B. M., Admasu, A. K., Alito, T. A., Ambulkar, R., Arimino, S., Arusi, M., Aynalem, N., Bajaj, V., Delelo, T. S., Gutu, M., Habte, F., Hurrisa, G. A., Kunte, A., Rocabado, K., Shiferaw, M. A., Harrell-Shreckengost, C., Tiruneh, A., Zamorano, R., Abreha, M., Aguilera, C., Lima, B., Kebede, H. 2024; 111 (1)


    BACKGROUND: Worldwide, approximately one in six inpatient antibiotic prescriptions are for surgical-infection prophylaxis, including postoperative prophylaxis. The WHO recommends against prolonged postoperative antibiotics to prevent surgical-site infection. However, in many low- and middle-income countries, postoperative antibiotic prophylaxis is common due to perceptions that it protects against surgical-site infection and data informing recommendations against antibiotic administration are largely derived from high-income countries. The aim of this study was to describe postoperative antibiotic-prescribing patterns and related surgical-site infection rates in hospitals in low- and middle-income countries.METHODS: Patients from 19 hospitals in Ethiopia, Madagascar, India, and Bolivia with wound class I and II operations were included. Data on antibiotic administration, indication, surgical-site infection, length of hospital stay, and adherence to perioperative infection-prevention standards were collected by trained personnel. The association between postoperative antibiotic prophylaxis for greater than or equal to 24 h and surgical-site infection was analysed via modified robust Poisson regression, controlling for patient and procedural factors and degree of adherence to perioperative infection-prevention practices.RESULTS: Of 8714 patients, 92.9% received antibiotics for prophylaxis after surgery and 27.7% received antibiotics for greater than or equal to 24 h. Patients receiving postoperative prophylaxis for greater than or equal to 24 h did not have lower surgical-site infection rates (Relative risk 1.09 (95% c.i. 0.89 to 1.33); P = 0.399), but the length of hospital stay was 1.4 days longer (P < 0.001).CONCLUSION: Prolonged postoperative antibiotics did not reduce surgical-site infection, but pervasive use was associated with a longer length of hospital stay, in resource-limited healthcare systems. With the growing threat of antimicrobial resistance, surgical initiatives to implement antimicrobial stewardship programmes in low- and middle-income countries are critical.

    View details for DOI 10.1093/bjs/znad438

    View details for PubMedID 38198157

  • Scalability and Sustainability of a Surgical Infection Prevention Program in Low-Income Environments. JAMA surgery Starr, N., Gebeyehu, N., Nofal, M. R., Forrester, J. A., Tesfaye, A., Mammo, T. N., Weiser, T. G., Amdie, D. A., Abreha, M., Alemu, M., Ally, S., Abdukadir, A. A., Assefa, G., Bedore, Y., Bekele, A., Berhanu, M., Alemu, S. B., Chimdesa, Z., Derbew, M., Fast, C., Fernandez, K., Kahsay, S., Kassahun, A., Kebede, H., Kitesa, G., Koritsanszky, L., Lima, B., Mellese, B., Mengistu, M., Negash, S., Tara, M., Taye, S., Torgeson, K., Tsehaye, M., Tiruneh, A., Stave, K. 2023


    Surgical infections are a major cause of perioperative morbidity and mortality, particularly in low-resource settings. Clean Cut, a 6-month quality improvement program developed by the global nonprofit organization Lifebox, has demonstrated improvements in postoperative infectious complications. However, the pilot program required intense external programmatic and resource support.To examine the improvement in adherence to infection prevention and control standards and rates of postoperative infections in hospitals in the Clean Cut program after implementation strategies were updated and program execution was refined.This cohort study evaluated and refined the Clean Cut implementation strategy to enhance scalability based on a qualitative study of its pilot phase, including formalizing programmatic and educational materials, building an automated data entry and analysis platform, and reorganizing hospital-based team composition. Clean Cut was introduced from January 1, 2019, to February 28, 2022, in 7 Ethiopian hospitals that had not previously participated in the program. Prospective data initiated on arrival in the operating room were collected, and patients were followed up through hospital discharge and with 30-day follow-up telephone calls.Implementation of the refined Clean Cut program.The primary outcome was surgical site infection (SSI); secondary outcomes were adherence to 6 infection prevention standards, mortality, hospital length of stay, and other infectious complications.A total of 3364 patients (mean [SD] age, 26.5 [38.0] years; 2196 [65.3%] female) from 7 Ethiopian hospitals were studied (1575 at baseline and 1789 after intervention). After controlling for confounders, the relative risk of SSIs was reduced by 34.0% after program implementation (relative risk, 0.66; 95% CI, 0.54-0.81; P < .001). Appropriate Surgical Safety Checklist use increased from 16.3% to 43.0% (P < .001), surgeon hand and patient skin antisepsis improved from 46.0% to 66.0% (P < .001), and timely antibiotic administration improved from 17.8% to 39.0% (P < .001). Surgical instrument (38.7% vs 10.2%), linen sterility (35.5% vs 12.8%), and gauze counting (89.2% vs 82.5%; P < .001 for all comparisons) also improved significantly.A modified implementation strategy for the Clean Cut program focusing on reduced external resource and programmatic input from Lifebox, structured education and training materials, and wider hospital engagement resulted in outcomes that matched our pilot study, with improved adherence to recognized infection prevention standards resulting in a reduction in SSIs. The demonstration of scalability reinforces the value of this SSI prevention program.

    View details for DOI 10.1001/jamasurg.2023.6033

    View details for PubMedID 38019510

  • Receptiveness, Barriers, and Facilitators to a Surgical Quality Improvement Program in Rwanda: A Pre-Implementation Mixed Methods Approach Zhuang, A., Iradukunda, J., Nofal, M. R., Alayande, B. T., Alemu, S. B., Starr, N., Admasu, N. G., Bekele, A., Mammo, T. N., Weiser, T. G. LIPPINCOTT WILLIAMS & WILKINS. 2023: S233
  • Adaptive Improvement of a Surgical Infection Prevention Program for Scalability and Sustainability in Low-Income Environments Starr, N., Admasu, N. G., Nofal, M., Tesfaye, A. M., Forrester, J., Weiser, T. G., Mammo, T. N. LIPPINCOTT WILLIAMS & WILKINS. 2023: S216
  • Addressing knowledge gaps in Surgical Safety Checklist use: statistical process control analysis of a surgical quality improvement programme in Ethiopia. The British journal of surgery Nofal, M. R., Starr, N., Negussie Mammo, T., Trickey, A. W., Gebeyehu, N., Koritsanszky, L., Alemu, M., Tara, M., Alemu, S. B., Evans, F., Kahsay, S., Weiser, T. G. 2023


    BACKGROUND: The WHO Surgical Safety Checklist reduces morbidity and mortality after surgery, but uptake remains challenging. In particular, low-income countries have been found to have lower rates of checklist use compared with high-income countries. The aim of this study was to determine the impact of educational workshops on Surgical Safety Checklist use implemented as part of a quality improvement initiative in five hospitals in Ethiopia that had variable experience with the Surgical Safety Checklist.METHODS: From April 2019 to September 2020, each hospital implemented a 6-month surgical quality improvement programme, which included a Surgical Safety Checklist workshop. Statistical process control methodology was used to understand the variation in Surgical Safety Checklist compliance before and after workshops and a time-series analysis was performed using population-averaged generalized estimating equation Poisson regression. Checklist compliance was defined as correctly completing a sign in, timeout, and sign out. Incidence rate ratios of correct checklist use pre- and post-intervention were calculated and the change in mean weekly compliance was predicted.RESULTS: Checklist compliance data were obtained from 2767 operations (1940 (70 per cent) pre-intervention and 827 (30 per cent) post-intervention). Mean weekly checklist compliance improved from 27.3 to 41.2 per cent (mean difference 13.9 per cent, P = 0.001; incidence rate ratio 1.51, P = 0.001). Hospitals with higher checklist compliance at baseline had the greatest overall improvements in compliance, more than 50 per cent over pre-intervention, while low-performing hospitals showed no improvement.CONCLUSION: Surgical Safety Checklist workshops improved checklist compliance in hospitals with some experience with its use. Workshops had little effect in hospitals unfamiliar with the Surgical Safety Checklist, emphasizing the importance of multifactorial interventions and culture-change approaches. In receptive facilities, short workshops can accelerate behaviour change.

    View details for DOI 10.1093/bjs/znad234

    View details for PubMedID 37551706

  • Sustainability of a Surgical Quality Improvement Program at Hospitals in Ethiopia. JAMA surgery Starr, N., Nofal, M. R., Gebeyehu, N., Forrester, J. A., Derbew, M., Weiser, T. G., Mammo, T. N. 2021

    View details for DOI 10.1001/jamasurg.2021.5569

    View details for PubMedID 34730799