Approaches to improve quality of care (QoC) for women and newborns: conclusions, evidence gaps and research priorities

Perceived effectiveness and recommendations from a childbirth quality assurance and improvement programme in India's private sector: a qualitative evaluation using the RE-AIM framework

Introduction

Previous studies have revealed inconsistent quality of care in India's private sector, where nearly one in three facility births take place. Manyata is a quality assurance and improvement programme launched in 2016 by the Federation of Obstetrics and Gynaecological Societies of India (FOGSI) that provides training, mentorship and accreditation to private maternity facilities. We aimed to understand participants' motivations for joining or not joining, the perceived value of Manyata and recommendations for sustainment and scale.

Methods

We aimed to sample 238 Manyata participants for semi-structured, in-depth interviews between February and July 2021. Participants included facility owners, nurses, FOGSI quality assessors, programme implementers and Manyata leaders. Data were coded and analysed using a deductive and inductive process. Codes were mapped to the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, which we expanded to include scale.

Results

We interviewed 185 programme participants. Maternity facility owners joined Manyata due to its affiliation with FOGSI, encouragement from peers and the desire to standardise care and train their staff. Barriers to joining included cost, unclear value and little motivation to improve practice. Participants most valued Manyata for improving staff competency, quality of care, standardised care processes and staff satisfaction. Participants felt that continuous training, mentorship and quality assurance would be necessary to maintain Manyata over time, and Manyata could and should be scaled across India and to other countries.

Conclusion

Strategies for engaging with the private sector should include building strategic partnerships and messaging a value proposition that emphasises training, standardised care processes and improved quality of care. A blended virtual and in-person model may be leveraged for ongoing training and quality assurance and to scale across contexts. Our evaluation of Manyata distills tangible lessons that policymakers, professional societies and public health practitioners can use to bridge the quality gap in their own private-sector maternity systems.

Improving the quality of neonatal health care in Ethiopia: a systematic review

Background

Ensuring high-quality healthcare for newborns is essential for improving their chances of survival within Ethiopia's healthcare system. Although various intervention approaches have been implemented, neonatal mortality rates remain stable. Therefore, the present review seeks to identify initiatives for enhancing healthcare quality, their effects on neonatal wellbeing, and the factors hindering or supporting these Quality Improvement (QI) efforts' success in Ethiopia.

Methods

We searched for original research studies up to June 23, 2023, using PubMed/Medline, WHO-Global Health Library, Cochrane, Clinical Trials.gov, and Hinari. After selecting eligible studies, we assessed their quality using a mixed-method appraisal tool. Quality of care refers to how healthcare services effectively improve desired outcomes for individuals and patient populations. It encompasses vital principles such as safety, effectiveness, timeliness, efficiency, equity, and patient-centeredness.

Results

We found 3,027 publication records and included 13 studies during our search. All these interventions primarily aimed to provide safe healthcare, with a strong focus on Domain One, which deals with the evidence-based routine upkeep and handling of complications, and Domain Seven, which revolves around ensuring staff competency, emerged as a frequent target for intervention. Many interventions aimed at improving quality also concentrate on essential quality measure elements such as processes, focusing on the activities that occur during care delivery, and quality planning, involving distributing resources, such as basic medicine and equipment, and improving infrastructure. Moreover, little about the facilitators and barriers to QI interventions is investigated.

Conclusions

This review highlights the significance of introducing QI initiatives in Ethiopia, enhancing the healthcare system's capabilities, engaging the community, offering financial incentives, and leveraging mobile health technologies. Implementing QI interventions in Ethiopia poses difficulties due to resource constraints, insufficient infrastructure, and medical equipment and supplies shortages. It necessitates persistent endeavors to improve neonatal care quality, involving ongoing training, infrastructure enhancement, the establishment of standardized protocols, and continuous outcome monitoring. These efforts are crucial to achieving the optimal outcomes for newborns and their families.

Interconception care in Australian general practice: a qualitative study

BACKGROUND

GPs provide care for women across the lifespan. This care currently includes preconception and postpartum phases of a woman's life. Interconception care (ICC) addresses women's health issues between pregnancies that then have impact on maternal and infant outcomes, such as lifestyle and biomedical risks, interpregnancy intervals, and contraception provision. However, ICC in general practice is not well established.

AIM

To explore GP perspectives about ICC.

DESIGN AND SETTING

Qualitative interviews were undertaken with GPs between May and July 2018.

METHOD

Eighteen GPs were purposively recruited from South-Eastern Australia. Audiorecorded semi- structured interviews were transcribed verbatim and analysed thematically using the Framework Method.

RESULTS

Most participants were unfamiliar with the concept of ICC. Delivery was mainly opportunistic, depending on the woman's presenting need. Rather than a distinct and required intervention, participants conceptualised components of ICC as forming part of routine practice. GPs described many challenges including lack of clarity about recommended ICC content and timing, lack of engagement and perceived value from mothers, and time constraints during consultations. Facilitators included care continuity and the availability of patient education material.

CONCLUSION

Findings indicate that ICC is not a familiar concept for GPs, who feel that they have limited capacity to deliver such care. Further research to evaluate patient perspectives and potential models of care is required before ICC improvements can be developed, trialled, and evaluated. These models could include the colocation of multidisciplinary services and services in combination with well-child visits.

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method

Background

Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh.

Methods

We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh.

Results

Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh.

Conclusions

This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

Comparison of obstetric emergency clinical readiness: A cross-sectional analysis of hospitals in Amhara, Ethiopia

Measuring facility readiness to manage basic obstetric emergencies is a critical step toward reducing persistently elevated maternal mortality ratios (MMR). Currently, the Signal Functions (SF) is the gold standard for measuring facility readiness globally and endorsed by the World Health Organization. The presence of tracer items classifies facilities' readiness to manage basic emergencies. However, research suggests the SF may be an incomplete indicator. The Clinical Cascades (CC) have emerged as a clinically-oriented alternative to measuring readiness. The purpose of this study is to determine Amhara's clinical readiness and quantify the relationship between SF and CC estimates of readiness. Data were collected in May 2021via Open Data Kit (ODK) and KoBo Toolbox. We surveyed 20 hospitals across three levels of the health system. Commodities were used to create measures of SF-readiness (e.g., % tracers) and CC-readiness. We calculated differences in SF and CC estimates and calculated readiness loss across six emergencies and 3 stages of care in the cascades. The overall SF estimate for all six obstetric emergencies was 29.6% greater than the estimates using the CC. Consistent with global patterns, hospitals were more prepared to provide medical management (70.0% ready) compared to manual procedures (56.7% ready). The SF overestimate was greater for manual procedures 33.8% overall for retained placenta and incomplete abortion) and less for medical treatments (25.3%). Hospitals were least prepared to manage retained placentas (30.0% of facilities were ready at treatment and 0.0% were ready at monitor and modify) and most prepared to manage hypertensive emergencies (85.0% of facilities were ready at the treatment stage). When including protocols in the analysis, no facilities were ready to monitor and modify the initial therapy when clinically indicated for 3 common emergencies-sepsis, post-partum hemorrhage and retained placentas. We identified a significant discrepancy between SF and CC readiness classifications. Those facilities that fall within this discrepancy are unprepared to manage common obstetric emergencies, and employees in supply management may have difficulty identify the need. Future research should explore the possibility of modifying the SF or replacing it with a new readiness measurement.

Impact of Point of Care Quality Improvement Training and Coaching on Quality Perceptions of Health Care Workers: Implication for Quality Policy

Background

The quality of infant healthcare service is one of the essential factors in preventing infant mortality. The purpose of the study was to analyze the quality performance in primary healthcare centers (PHC) and hospitals before and after the point of care quality improvement (POCQI) training for Infant Healthcare Services (IHS).

Methods

This is a mixed-method study design with convergence triangulation strategy, conducted at six public PHCs and four hospitals in two districts of West Java Province, Indonesia. One hundred health care workers (HCWs) were involved for quantitative study at baseline and end of intervention. An additional 40 patients participated as informants for qualitative study. Quantitative data analysis was performed by Rasch modeling and independent t-test for all variables, followed by content analysis for qualitative data.

Results

There were significant changes in the variables of POCQI skill (mean diff: 5.14, p=0.001), quality improvement (QI) understanding (mean diff: 1.2; p=0.001), and QI engagement (mean diff: 1.7; p=0.001) in the PHC group. Although there was an increase in process and outcome variables, the changes were not significant. There was a significant change in all variables in the hospital group which were outcome (mean diff: 2.32 (p=0.19); POCQI skill (mean diff: 2.80, p=0.001); process (mean diff: 1.48, p= 0.01); QI understanding (mean diff: 1.01; p=0.01), and QI engagement (mean diff: 1.52; p=0.03). Patient perception in the qualitative study showed that PHCs and Hospitals’ services improved. Moreover, health care workers found they have a better understanding of service quality and created quality changes and improved POCQI steps.

Conclusion

Implementation of POCQI in PHC and hospitals improved the performance of the quality of his, therefore assuring that POCQI is an appropriate approach and tool to be adopted in the policy for strengthening the health system.

"Even though they insult us, the delivery they give us is the greatest thing": a qualitative study contextualizing women's experiences with facility-based maternal health care in Ethiopia

BACKGROUND

Globally, amidst increased utilization of facility-based maternal care services, there is continued need to better understand women's experience of care in places of birth. Quantitative surveys may not sufficiently characterize satisfaction with maternal healthcare (MHC) in local context, limiting their interpretation and applicability. The purpose of this study is to untangle how contextual and cultural expectations shape women's care experience and what women mean by satisfaction in two Ethiopian regions.

METHODS

Health center and hospital childbirth care registries were used to identify and interview 41 women who had delivered a live newborn within a six-month period. We used a semi-structured interview guide informed by the Donabedian framework to elicit women's experiences with MHC and delivery, any prior delivery experiences, and recommendations to improve MHC. We used an inductive analytical approach to compare and contrast MHC processes, experiences, and satisfaction.

RESULTS

Maternal and newborn survival and safety were central to women's descriptions of their MHC experiences. Women nearly exclusively described healthy and safe deliveries with healthy outcomes as 'satisfactory'. The texture behind this 'satisfaction', however, was shaped by what mothers bring to their delivery experiences, creating expectations from events including past births, experiences with antenatal care, and social and community influences. Secondary to the absence of adverse outcomes, health provider's interpersonal behaviors (e.g., supportive communication and behavioral demonstrations of commitment to their births) and the facility's amenities (e.g., bathing, cleaning, water, coffee, etc) enhanced women's experiences. Finally, at the social and community levels, we found that family support and material resources may significantly buffer against negative experiences and facilitate women's overall satisfaction, even in the context of poor-quality facilities and limited resources.

CONCLUSION

Our findings highlight the importance of understanding contextual factors including past experiences, expectations, and social support that influence perceived quality of MHC and the agency a woman has to negotiate her care experience. Our finding that newborn and maternal survival primarily drove women's satisfaction suggests that quantitative assessments conducted shortly following delivery may be overly influenced by these outcomes and not fully capture the complexity of women's care experience.

Care Around Birth Approach: A Training, Mentoring, and Quality Improvement Model to Optimize Intrapartum and Immediate Postpartum Quality of Care in India

BACKGROUND

With the highest risk of maternal and newborn mortality occurring during the period around birth, quality of care during the intrapartum and immediate postpartum periods is critical for maternal and neonatal survival.

METHODS

The United States Agency for International Development's Scaling Up Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions project, also known as the Vriddhi project, collaborated with the national and 6 state governments to design and implement the Care Around Birth approach in 141 high caseload facilities across 26 high-priority districts of India from January 2016 to December 2017. The approach aimed to synergize evidence-based technical interventions with quality improvement (QI) processes, respectful maternity care, and health system strengthening efforts. The approach was designed using experiential training, mentoring, and a QI model. A baseline assessment measured the care ecosystem, staff competencies, and labor room practices. At endline, the approach was externally evaluated.

RESULTS

Availability of logistics, recording and reporting formats, and display of protocols improved across the intervention facilities. At endline (October-December 2017), delivery and newborn trays were available in 98% of facilities compared to 66% and 55% during baseline (October-December 2015), respectively. Competency scores (> 80%) for essential newborn care and newborn resuscitation improved from 7% to 70% and from 5% to 82% among health care providers, respectively. The use of partograph in monitoring labor improved from 29% at the baseline to 61%; administration of oxytocin within 1 minute of delivery from 35% to 93%; newborns successfully resuscitated from 71% to 96%; and postnatal monitoring of mothers from 52% to 94%.

CONCLUSION

The approach successfully demonstrated an operational design to improve the provision and experience of care during the intrapartum and immediate postpartum periods, thereby augmenting efforts aimed at ending preventable child and maternal deaths.

Improving quality of care for pregnancy, perinatal and newborn care at district and sub-district public health facilities in three districts of Haryana, India: An Implementation study

Introduction

Improving quality of care (QoC) for childbirth and sick newborns is critical for maternal and neonatal mortality reduction. Information on the process and impact of quality improvement at district and sub-district hospitals in India is limited. This implementation research was prioritized by the Haryana State (India) to improve the QoC for maternal and newborn care at the busy hospitals in districts.

Methods

This study at nine district and sub-district referral hospitals in three districts (Faridabad, Rewari and Jhajjar) during April 2017-March 2019 adopted pre-post, quasi-experimental study design and plan-do-study-act quality improvement method. During the six quarterly plan-do-study-act cycles, the facility and district quality improvement teams led the gap identification, solution planning and implementation with external facilitation. The external facilitators monitored and collected data on indicators related to maternal and newborn service availability, patient satisfaction, case record quality, provider’s knowledge and skills during the cycles. These indicators were compared between baseline (pre-intervention) and endline (post-intervention) cycles for documenting impact.

Results

The interventions closed 50% of gaps identified, increased the number of deliveries (1562 to 1631 monthly), improved care of pregnant women in labour with hypertension (1.2% to 3.9%, p<0.01) and essential newborn care services at birth (achieved ≥90% at most facilities). Antenatal identification of high-risk pregnancies increased from 4.1% to 8.8% (p<0.01). Hand hygiene practices improved from 35.7% to 58.7% (p<0.01). The case record completeness improved from 66% to 87% (p<0.01). The time spent in antenatal clinics declined by 19–42 minutes (p<0.01). The pooled patient satisfaction scores improved from 82.5% to 95.5% (p<0.01). Key challenges included manpower shortage, staff transfers, leadership change and limited orientation for QoC.

Conclusion

This multipronged quality improvement strategy improved the maternal and newborn services, case documentation and patient satisfaction at district and sub-district hospitals. The processes and lessons learned shall be useful for replicating and scaling up.

Progress towards Every Newborn Action Plan (ENAP) implementation in Iran: obstacles and bottlenecks

Background

Neonatal mortality accounts for more than 47% of deaths among children under five globally but proper care at and around the time of birth could prevent about two-thirds of these deaths. The Every Newborn Action Plan (ENAP) offers a plan and vision to improve and achieve equitable and high-quality care for mothers and newborns. We applied the bottleneck analysis tool offered by ENAP to identify obstacles and bottlenecks hindering the scale-up of newborn care across seven health system building blocks.

Methods

We applied the every newborn bottleneck analysis tool to identify obstacles hindering the scale-up of newborn care across seven health system building blocks. We used qualitative methods to collect data from five medical universities and their corresponding hospitals in three provinces. We also interviewed other national experts, key informants, and stakeholders in neonatal care. In addition, we reviewed and qualitatively analyzed the performance report of neonatal care and services from 16 medical universities around the country.

Results

We identified many challenges and bottlenecks in the scale-up of newborn care in Iran. The major obstacles included but were not limited to the lack of a single leading and governing entity for newborn care, insufficient financial resources for neonatal care services, insufficient number of skilled health professionals, and inadequate patient transfer.

Conclusions

To address identified bottlenecks in neonatal health care in Iran, some of our recommendations were as follows: establishing a single national authorizing and leading entity, allocating specific budget to newborn care, matching high-quality neonatal health care providers to the needs of all urban and rural areas, maintaining clear policies on the distribution of NICUs to minimize the need for patient transfer, and using the available and reliable private sector NICU ambulances for safe patient transfer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03800-x.

Barriers to optimal and appropriate use of uterotonics during active labour and for prevention of postpartum haemorrhage in public health care facilities: An exploratory study in five states of India

OBJECTIVE

The main objective is to understand the practices regarding use of uterotonics during active labour and for prevention of postpartum haemorrhage and the barriers for its optimal and appropriate use at different levels of health facilities in five states of India.

STUDY DESIGN

Mixed methods approach comprising of cross-sectional observational study of existing practices of uterotonics use during labour and early postpartum period for 1479 vaginal deliveries at 56 facilities. Quantitative data was collected using pre-tested proformas filled by on-site observers and qualitative data was collected by in-depth interviews of 125 maternity care providers of the observed facilities.

MAIN OUTCOME MEASURE

Providers' knowledge, attitude and patterns of use of uterotonics during active labour and for prevention of postpartum haemorrhage during childbirth.

RESULTS

On-site observation and interviews indicated inappropriate choice of uterotonics administered in varied doses for labour management across facilities. Unnecessary augmentation of labour was observed in 44.7% low-risk pregnancies and only 31% women were administered uterotonics in optimal doses for preventing postpartum haemorrhage. Only 46.4% providers in the observed facilities reported to have received maternal and child healthcare training according to the updated guidelines. Lack of supportive supervision for mandated practices among peers emerged as an important barrier for appropriate uterotonics usage in labour.

CONCLUSION

There is an urgent scope of standardizing the institutional health policies regarding administration of uterotonics during labour and for prevention of postpartum haemorrhage. Capacity building of maternity care providers regarding appropriate uterotonics usage is recommended for all levels of health facilities.

Obstetric violence: Comparing medical student perceptions in India and the UK

OBJECTIVE(S)

Obstetric Violence refers to professional deficiencies in maternity care, which can occur in both low and high resource settings. Examples include non-dignified care, lack of respect when giving care, discrimination and abandonment of care. The objective of this study was to assess knowledge and attitudes towards obstetric violence in a cohort of medical students in India and the UK.

STUDY DESIGN

An online survey was sent to 240 UK and 280 Indian medical students. This incorporated a video showing a dramatized scenario of obstetric violence. The survey assessed participant's demographics and prior knowledge of obstetric violence. Participants scored their perceptions of eight behaviours in the video on visual analogue scales. Participants were asked to reflect on their own practice and score this. Comparisons of survey responses between UK and Indian participants were made using chi squared/Student's t-test.

RESULTS

62 Indian medical students and 58 UK medical students completed the survey. Indian medical students were significantly more likely to be male (p < 0.001). 26 % of UK participants had previously heard the term obstetric violence, compared to 34 % of Indian participants (p = 0.15). Both were able to correctly define obstetric violence at similar rates (32 % versus 34 %). Indian medical students were significantly less critical (p < 0.001) of all eight scored behaviours in the video of obstetric violence compared to their UK counterparts. UK medical students were significantly less likely to agree that the video had changed their perception on how teams should behave and act in this context (p < 0.001). 90 % of UK participants and 38 % of Indian participants had received training in professional behaviours. 14 % of UK participants had seen examples of obstetric violence in clinical practice compared to 49 % of Indian participants.

CONCLUSIONS

UK and Indian medical students were able to identify behaviours associated with obstetric violence, although the majority were previously unaware of the term. Indian medical students in this study were less critical of obstetric violence in the video, which may be because of cultural reasons, greater numbers of male students, greater exposure to obstetric violence or less training on professional behaviours. Standardised training to prevent obstetric violence should be part of undergraduate medical training internationally.

Person-centered antenatal care and associated factors in Rwanda: a secondary analysis of program data

BACKGROUND

Research suggests that women's experience of antenatal care is an important component of high-quality antenatal care. Person-centered antenatal care (PCANC) reflects care that is both respectful of, and responsive to, the preferences, needs, and values of pregnant women. Little is known in Rwanda about either the extent to which PCANC is practiced or the factors that might determine its use. This is the first study to quantitatively examine the extent of and the factors associated with PCANC in Rwanda.

METHODS

We used quantitative data from a randomized control trial in Rwanda. A total of 2150 surveys were collected and analyzed from 36 health centers across five districts. We excluded women who were less than 16 years old, were referred to higher levels of antenatal care or had incomplete survey responses. Both bivariate and multivariate logistic regression analyses were used to test the hypothesis that certain participant characteristics would predict high PCANC.

RESULTS

PCANC level was found to be sub-optimal with one third of women leaving antenatal care (ANC) with questions or confused and one fourth feeling disrespected. In bivariate analysis, social support, greater parity, being in the traditional care (control group), and being from Burera district significantly predict high PCANC. Additionally, in the multivariate analysis, being in the traditional care group and the district in which women received care were significantly associated with PCANC.

CONCLUSIONS

This quantitative analysis indicates sub-optimal levels of PCANC amongst our study population in Rwanda. We find lower levels of PCANC to be regional and defined by the patient characteristics parity and social support. Given the benefits of PCANC, improvements in PCANC through provider training in Rwanda might promote an institutional culture shift towards a more person-centered model of care.

Human Resources for Health-Related Challenges to Ensuring Quality Newborn Care in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

A critical shortage of health workers with needed maternal and newborn competencies remains a major challenge for the provision of quality care for mothers and newborns, particularly in low- and middle-income countries. Supply-side challenges related to human resources for health (HRH) worsen shortages and can negatively affect health worker performance and quality of care. This review scoped country-focused sources to identify and map evidence on HRH-related challenges to quality facility-based newborn care provision by nurses and midwives.

METHODS

Evidence for this review was collected iteratively, beginning with pertinent World Health Organization documents and extending to articles identified via database and manual reference searches and country reports. Evidence from country-focused sources from 2000 onward was extracted using a data extraction tool that was designed iteratively; thematic analysis was used to map the 10 categories of HRH challenges.

FINDINGS

A total of 332 peer-reviewed articles were screened, of which 22 met inclusion criteria. Fourteen additional sources were added from manual reference search and gray literature sources. Evidence has been mapped into 10 categories of HRH-related challenges: (1) lack of health worker data and monitoring; (2) poor health worker preservice education; (3) lack of HW access to evidence-based practice guidelines, continuing education, and continuing professional development; (4) insufficient and inequitable distribution of health workers and heavy workload; (5) poor retention, absenteeism, and rotation of experienced staff; (6) poor work environment, including low salary; (7) limited and poor supervision; (8) low morale, motivation, and attitude, and job dissatisfaction; (9) weaknesses of policy, regulations, management, leadership, governance, and funding; and (10) structural and contextual barriers.

CONCLUSION

The mapping provides needed insight that informed new World Health Organization strategies and supporting efforts to address the challenges identified and strengthen human resources for neonatal care, with the ultimate goal of improving newborn care and outcomes.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 1: Review of implementation features and observed quality gaps in 25 countries

BACKGROUND

A substantial proportion of maternal and neonatal mortality and morbidity is attributable to gaps in quality of care. A systematic, standard-based tool for quality assessment and improvement for maternal and neonatal hospital care (QA/QI MN tool) was developed in 2009 by the World Health Organization (WHO). The tool guides the assessment process along the whole continuum from admission to discharge, collects the views of the recipients of care and engages hospital mangers and staff in identifying gaps and drafting an action plan.

METHODS

Publications describing use of the WHO QA/QI MN tool from 2009 to 2017 and reports retrievable from WHO or other development partners' websites were searched and considered for inclusion in the review. Only assessments of hospitals were considered. Quality gaps were classified as regarding case management in maternal care, case management in neonatal care, hospital infrastructure, hospital policies and according to severity and frequency. Quotations from women regarding key issues in effective communication, respect and dignity, emotional support and costs incurred were selected.

RESULTS

In the period 2009-2017, use of the WHO QA/QI MN tool was documented in 25 countries, belonging to Central and Eastern Europe (8), Central Asia (4), Sub-Saharan Africa (11), Latin America (1) and Middle East (1). Overall, 133 hospitals were assessed. The tool allowed to identify in great detail serious quality gaps including: insufficient or incomplete adherence to recommended evidence-based procedures for normal childbirth and maternal and neonatal complications; excess of inappropriate or unnecessary interventions; insufficient infection control; failure to provide respectful care, adequate communication and emotional support to mothers and babies; poor use of information generated locally to analyse processes and outcomes. These gaps were observed in all countries. Significant differences were observed among facilities belonging to the same health systems, ie, with very similar staffing, infrastructure and equipment.

CONCLUSIONS

The experience made, the largest of this kind, provides comprehensive and detailed insight into the existing quality gaps in a wide variety of settings. QI cycles at facility level should be primarily based on assessments made by multidisciplinary teams of professionals to identify the parts of the care pathways which require improvement through a participatory approach involving managers, staff and patients.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 2: Review of the results of quality cycles and of factors influencing change

BACKGROUND

Information about the use of the findings of quality assessments in maternal and neonatal (MN) care is lacking and the development of tools capable to effectively address quality gaps is a key priority. Furthermore, little is known about factors that act as barriers or facilitators to change at facility level. Based on the extensive experience made with the WHO Quality Assessment and Improvement MN (QA/QI MN) tool, an overview is provided of the improvements in quality of care (QoC) which were obtained over time and of the factors influencing change.

METHODS

All documented reports on the implementation of the WHO QA/QI MN tool were searched and screened for inclusion. Reports were considered if bringing evidence from both the baseline assessment and the reassessment. Changes were considered in four domains: maternal care, neonatal care, infrastructure and policies, with reference made to WHO maternal and neonatal care standards. The observed improvements were categorized according to intensity and extent across the sample of health facilities. Factors influencing change were categorized into internal and external and further classified as barriers or facilitators.

RESULTS

Changes were documented after an average period of 1.2 years from first assessment in 27 facilities belonging to 9 different countries in Central and Eastern Europe (3), Central Asia (3), sub-Saharan Africa (2) and Latin America (1). Improvements were observed in all areas of care but were greater and more frequently observed in areas related to appropriate case management and respectful care for both mothers and newborns. Although widespread across most facilities and countries, the observed improvements were not covering all the quality gaps observed at the baseline assessment nor were always sufficient to achieve standard care. Factors facilitating change as well as barriers were mainly related to the capacity of the managers and head of units to involve and motivate their staff members.

CONCLUSIONS

The use of WHO QA/QI MN tool proved effective in promoting significant changes in quality of care. The review of observed improvements and of factors influencing change at facility level shows that participatory assessment tools that promote a constructive dialogue with hospital managers and staff and support them in acquiring capacity in this role are crucial to implement effective quality cycles.

The impacts of quality improvement on maternal and newborn health: preliminary findings from a health system integrated intervention in four Ethiopian regions

Background

Quality improvement (QI) methods are effective in improving healthcare delivery using sustainable, collaborative, and cost-effective approaches. Systems-integrated interventions offer promise in terms of producing sustainable impacts on service quality and coverage, but can also improve important data quality and information systems at scale.

Methods

This study assesses the preliminary impacts of a first phase, quasi-experimental, QI health systems intervention on maternal and neonatal health outcomes in four pilot districts in Ethiopia. The intervention identified, trained, and coached QI teams to develop and test change ideas to improve service delivery. We use an interrupted time-series approach to evaluate intervention effects over 32-months. Facility-level outcome indicators included: proportion of mothers receiving four antenatal care visits, skilled delivery, syphilis testing, early postnatal care, proportion of low birth weight infants, and measures of quality delivery of childbirth services.

Results

Following the QI health systems intervention, we found a significant increase in the rate of syphilis testing (ß = 2.41, 95% CI = 0.09,4.73). There were also large positive impacts on health worker adherence to safe child birth practices just after birth (ß = 8.22, 95% CI = 5.15, 11.29). However, there were limited detectable impacts on other facility-usage indicators. Findings indicate early promise of systems-integrated QI on the delivery of maternal health services, and increased some service coverage.

Conclusions

This study preliminarily demonstrates the feasibility of complex, low-cost, health-worker driven improvement interventions that can be adapted in similar settings around the world, though extended follow up time may be required to detect impacts on service coverage. Policy makers and health system workers should carefully consider what these findings mean for scaling QI approaches in Ethiopia and other similar settings.

Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania

BACKGROUND

Ensuring efficient use and allocation of limited resources is crucial to achieving the UHC goal. Performance-based financing that provides financial incentives for health providers reaching predefined targets would be expected to enhance technical efficiency across facilities by promoting an output-oriented payment system. However, there is no study which has systematically assessed efficiency scores across facilities before and after the introduction of pay-for-performance (P4P). This paper seeks to fill this knowledge gap.

METHODS

We used data of P4P evaluation related to healthcare inputs (staff, equipment, medicines) and outputs (outpatient consultations and institutional deliveries) from 75 health facilities implementing P4P in Pwani region, and 75 from comparison districts in Tanzania. We measured technical efficiency using Data Envelopment Analysis and obtained efficiency scores across facilities before and after P4P scheme. We analysed which factors influence technical efficiency by regressing the efficiency scores over a number of contextual factors. We also tested the impact of P4P on efficiency through a difference-in-differences regression analysis.

RESULTS

The overall technical efficiency scores ranged between 0.40 and 0.65 for hospitals and health centres, and around 0.20 for dispensaries. Only 21% of hospitals and health centres were efficient when outpatient consultations and deliveries were considered as output, and <3% out of all facilities were efficient when outpatient consultations only were considered as outputs. Higher efficiency scores were significantly associated with the level of care (hospital and health centre) and wealthier catchment populations. Despite no evidence of P4P effect on efficiency on average, P4P might have improved efficiency marginally among public facilities.

CONCLUSION

Most facilities were not operating at their full capacity indicating potential for improving resource usage. A better understanding of the production process at the facility level and of how different healthcare financing reforms affects efficiency is needed. Effective reforms should improve inputs, outputs but also efficiency.

A qualitative study on acceptability of the mistreatment of women during childbirth in Myanmar

BACKGROUND

Improving the quality of maternal health care is critical to reduce mortality and improve women's experiences. Mistreatment during childbirth in health facilities can be an important barrier for women when considering facility-based childbirth. Therefore, this study attempted to explore the acceptability of mistreatment during childbirth in Myanmar according to women and healthcare providers, and to understand how gender power relations influence mistreatment during childbirth.

METHODS

A qualitative study was conducted in two townships in Bago Region in September 2015, among women of reproductive age (18-49 years), healthcare providers and facility administrators. Semi-structured discussion guides were used to explore community norms, and experiences and perceptions regarding mistreatment. Coding was conducted using athematic analysis approach and Atlas.ti. Results were interpreted using a gender analysis approach to explore how power dynamics, hierarchies, and gender inequalities influence how women are treated during childbirth.

RESULTS

Women and providers were mostly unaccepting of different types of mistreatment. However, some provided justification for slapping and shouting at women as encouragement during labour. Different access to resources, such as financial resources, information about pregnancy and childbirth, and support from family members during labor might impact how women are treated. Furthermore, social norms around pregnancy and childbirth and relationships between healthcare providers and women shape women's experiences. Both informal and formal rules govern different aspects of a woman's childbirth care, such as when she is allowed to see her family, whether she is considered "obedient", and what type of behaviors she is expected to have when interacting with providers.

CONCLUSIONS

This is the first use of gender analysis to explore how gender dynamics and power relations contribute to women's experiences of mistreatment during childbirth. Both providers and women expected women to understand and "obey" the rules of the health facility and instructions from providers in order to have better experiences. In this way, deviation from following the rules and instructions puts the providers in a place where perpetrating acts of mistreatment were justifiable under certain conditions. Understanding how gender norms and power structures how women are treated during childbirth is critical to improve women's experiences.

Respectful maternity care and associated factors among women who delivered at Harar hospitals, eastern Ethiopia: a cross-sectional study

Background

In Ethiopia, approximately three-fourths of mothers do not deliver in health facilities. Disrespect and abuse during childbirth fallouts in underutilization of institutional delivery that upshots maternal morbidity and mortality. Thus, the ambition of this study was to assess respectful maternity care and associated factors in Harar hospitals, Eastern Ethiopia.

Methods

A facility-based cross-sectional study was conducted from April 01 to July 01, 2017. A total of 425 women, delivered at Harar town hospitals, were nominated using a systematic random sampling technique. A pretested and organized questionnaire was used to collect the data. After checking for completeness, the data were entered into EpiData version 3.1 and exported to SPSS version 22.0 for cleaning and analyses. Both bivariate and multivariable logistic regression was computed to identify factors associated with respectful maternity care. Statistical significance was declared at a P-value of < 0.05.

Results

Data were collected on 425 women. Overall, only 38.4% (95% CI: 33.7, 42.0%) of women received respectful maternity care. Delivering at private hospitals [AOR: 2.3, 95% CI: 1.25, 4.07], having ANC follow-up [AOR: 1.8, 95% CI: 1.10, 3.20], planned pregnancy [AOR: 3.0, 95% CI: 1.24, 7.34], labor attended by male provider [AOR: 1.8, 95% CI: 1.14, 2.77] and normal maternal outcome [AOR: 2.3, 95% CI: 1.13, 4.83] were significantly associated with respectful maternity care.

Conclusions

Only four out of ten women received respectful care during labor and delivery. Providing women-friendly, abusive free, timely and discriminative free care are the bases to improve the uptake of institutional delivery. Execution of respectful care advancement must be the business of all healthcare providers. Furthermore, to come up with a substantial reduction in maternal mortality, great emphasis should be given to make the service woman-centered.

Implementation of maternal and perinatal death reviews: a scoping review protocol

INTRODUCTION

Maternal and perinatal death surveillance and response (MPDSR), or any related form of audit, is a systematic process used to prevent future maternal and perinatal deaths. While the existence of MPDSR policies is routinely measured, measurement and understanding of policy implementation has lagged behind. In this paper, we present a theory-based conceptual framework for understanding MPDSR implementation as well as a scoping review protocol to understand factors influencing MPDSR implementation in low/ middle-income countries (LMIC).

METHODS AND ANALYSIS

The Consolidated Framework for Implementation Research will inform the development of a theory-based conceptual framework for MPDSR implementation. The methodology for the scoping review will be guided by an adapted Arksey and O'Malley approach. Documents will include published and grey literature sourced from electronic databases (PubMed, CINAHL, SCOPUS, Web of Science, JSTOR, LILACS), the WHO Library, Maternal Death Surveillance and Response Action Network, Google, the reference lists of key studies and key experts. Two reviewers will independently screen titles, abstracts and full studies for inclusion. All discrepancies will be resolved by an independent third party. We will include studies published in English from 2004 to July 2018 that present results on factors influencing implementation of MPDSR, or any related form. Qualitative content and thematic analysis will be applied to extracted data according to the theory-based conceptual framework. Stakeholders will be consulted at various stages of the process.

ETHICS AND DISSEMINATION

The scoping review will synthesise implementation factors relating to MPDSR in LMIC as described in the literature. This review will contribute to the work of the Countdown to 2030 Drivers Group, which seeks to explore key contextual drivers for equitable and effective coverage of maternal and child health interventions. Ethics approval is not required. The results will be disseminated through various channels, including a peer-reviewed publication.

The quality of childbirth in the light of research the new guidelines of the World Health Organization and Polish Perinatal Care Standards

The quality of birth is assessed by means of a comprehensive approach to the process of coming into the world, taking into account the perspective of the mother and the child and the influence of labour on their future health and life. According to the recommendations of the World Health Organization, the delivery of every child should be consistent with the mother's personal and socio-cultural beliefs and should meet her expectations as to the care provided.

Evaluation of the psychometric properties of Hindi-translated Scale for Measuring Maternal Satisfaction among postnatal women in Chhattisgarh, India

Satisfaction with childbirth services is a multi-dimensional phenomenon, providing relevant insights into women's opinion on quality of services received. Research studies report a dearth of standardised scales that quantify this phenomenon; and none have been tested in India to the best of authors' knowledge. The current study was undertaken to evaluate psychometric properties of Hindi version of the Turkish Scale for Measuring Maternal Satisfaction: Normal and Caesarean Births versions in order to fill this gap. A cross-sectional survey was conducted in selected public health facilities in Chhattisgarh, India. Healthy women (n = 1004) who gave birth to a single, live neonate, vaginally or via Caesarean section participated. Psychometric assessment was carried out in four steps: 1) scales translated from Turkish to Hindi; 2) Content Validity Index scores calculated for Hindi scales; 3) data collection; 4) statistical analyses for Hindi scales (Normal and Caesarean Birth). A 10-factor model with 36 items emerged for both scales. The Hindi- translated Normal Birth and Caesarean Birth scales had good internal reliability (Cronbach's α coefficients of 0.85 and 0.80, respectively). The Hindi Scales for Measuring Maternal Satisfaction (Normal and Caesarean Birth) are valid and reliable tools for utilization in Indian health facilities. Their multi-dimensional nature presents an opportunity for the care providers and health administrators to incorporate women's opinions in intervention to improve quality of childbirth services. Having an international tool validated within India also provides a platform for comparing cross-country findings.

Obstetric violence: Clinical staff perceptions from a video of simulated practice

Objectives

Obstetric Violence refers to professional deficiencies in maternity care. Examples include non-dignified care, discrimination and abandonment of care. Obstetric violence has been described in both low and high resource settings. The objective of this study was to assess knowledge and attitudes towards obstetric violence in a cohort of multinational obstetric nursing/midwifery staff and obstetricians at a private maternity hospital in Qatar.

Study design

An online survey for anonymous completion was sent to the hospital email accounts of obstetric nursing/midwifery staff and obstetricians at Sidra Medicine (n = 640). The survey incorporated a video showing a dramatized scenario of obstetric violence. The survey assessed the participant's demographics and knowledge of the term obstetric violence. The participants scored their perceptions on the behaviors in the video using a visual analogue scale. The participants were then asked to reflect on their own practice. Comparisons of the survey responses were made between both doctors and nursing/midiwfery staff members using student's t-test.

Results

50 obstetricians and 167 obstetric nursing/midwifery staff fully completed the survey. Fifty two percent had previously heard of the term obstetric violence, and 48% could define it correctly. 136 (63%) had witnessed obstetric violence at some point in their career. Significant differences were seen when each professional group was asked to report on the behavior of the opposite professional team as depicted in the video (p = 0.01 and p < 0.001). Doctors completing the survey were also more critical of the doctors-in-training than were the midwifery/nursing staff (p = 0.06). Obstetricians and nursing/midiwfery responders identified patient dignity, privacy and patient-centred care as the leading professional deficiencies seen in the video. Obstetricians were significantly less likely to change their perceptions of how a care team should interact with a patient compared to the obstetric nursing/midwifery group (p < 0.001).

Conclusions

This questionnaire study demonstrates that the majority of staff in this cohort were aware of obstetric violence and able to identify negative behaviours in the video and then reflect on how this impacts care they provide. Further studies are needed to identify ways in which obstetric violence can be prevented in both low resource and high resource settings.

Improving immediate newborn care practices in Philippine hospitals: impact of a national quality of care initiative 2008-2015

Objective

To determine whether intrapartum and newborn care practices improved in 11 large hospitals between 2008 and 2015.

Design

Secondary data analysis of observational assessments conducted in 11 hospitals in 2008 and 2015.

Setting

Eleven large government hospitals from five regions in the Philippines.

Participants

One hundred and seven randomly sampled postpartum mother-baby pairs in 2008 and 106 randomly sampled postpartum mothers prior to discharge from hospitals after delivery.

Interventions

A national initiative to improve quality of newborn care starting in 2009 through development of a standard package of intrapartum and newborn care services, practice-based training, formation of multidisciplinary hospital working groups, and regular assessments and meetings in hospitals to identify actions to improve practices, policies and environments. Quality improvement was supported by policy development, health financing packages, health facility standards, capacity building and health communication.

Main outcome measures

Sixteen intrapartum and newborn care practices.

Results

Between 2008 and 2015, initiation of drying within 5 s of birth, delayed cord clamping, dry cord care, uninterrupted skin-to-skin contact, timing and duration of the initial breastfeed, and bathing deferred until 6 h after birth all vastly improved (P<0.001). The proportion of newborns receiving hygienic cord handling and the hepatitis B birth dose decreased by 11-12%. Except for reduced induction of labor, inappropriate maternal care practices persisted.

Conclusions

Newborn care practices have vastly improved through an approach focused on improving hospital policies, environments and health worker practices. Maternal care practices remain outdated largely due to the ineffective didactic training approaches adopted for maternal care.

Early Essential Newborn Care Is Associated With Reduced Adverse Neonatal Outcomes in a Tertiary Hospital in Da Nang, Viet Nam: A Pre- Post- Intervention Study

BACKGROUND

To accelerate reductions in neonatal mortality, Viet Nam rolled out early essential newborn care (EENC) using clinical coaching, quality improvement assessments in hospitals, and updated protocols. Da Nang Hospital for Women and Children, a tertiary referral hospital in central Viet Nam, compared outcomes pre- and post-EENC introduction.

METHODS

Records of live births and NICU admissions were reviewed pre- (November 2013-October 2014) and post- (November 2014-October 2015) EENC implementation. Delivery room practices, NICU admissions and adverse outcomes on NICU admission were compared using descriptive statistics.

FINDINGS

A total of 13,201 live births were delivered pre- and 14,180 live births post-EENC introduction. Post-EENC, delivery practice scores, rates of early and prolonged skin-to-skin contact and early breastfeeding rose significantly. There was a significant reduction in risk of NICU admissions (relative risk [RR] 0.68; 95% confidence interval [CI] 0.64-0.71; p < 0.0001), hypothermia on NICU admission (RR 0.72; 95% CI 0.65-0.81, p < 0.0001) and sepsis (RR 0.28; 95% CI 0.23-0.35, p < 0.0001). Exclusive breastfeeding rates in NICU increased from 49% to 88% (p < 0.0001) and of kangaroo mother care (KMC) from 52% to 67% (p < 0.0001). Reduced formula use resulted in decreased monthly costs.

INTERPRETATION

EENC introduction, including staff coaching, quality improvement assessments and changes in hospital protocols and environments, were associated with improved clinical practices, reduced NICU admissions, admissions with hypothermia and sepsis and increased rates of exclusive breastfeeding and KMC in the NICU.

FUNDING

Data collection was funded by the World Health Organization Western Pacific Regional Office and Newborns Vietnam.

OUTSTANDING QUESTIONS

•What is the impact of the package of early essential newborn care interventions on newborn mortality?•What are the total direct and indirect cost savings of early essential newborn care implementation?•What is the cost effectiveness of kangaroo mother care for preterm and low birth weight babies?•What strategies can help reduce unnecessary cesarean sections in hospitals?

Technical quality of delivery care in private- and public-sector health facilities in Enugu and Lagos States, Nigeria

Private-sector providers are increasingly being recognized as important contributors to the delivery of healthcare. Countries with high disease burdens and limited public-sector resources are considering using the private sector to achieve universal health coverage. However, evidence for the technical quality of private-sector care is lacking. This study assesses the technical quality of maternal healthcare during delivery in public- and private-sector facilities in resource-limited settings, from a systems and programmatic perspective. A summary index (the skilled attendance index, SAI), was used. Two-staged cluster sampling with stratification was used to select representative samples of case records in public- and private-sector facilities in Enugu and Lagos States, Nigeria. Information to assess criteria was extracted, and the SAI calculated. Linear regression models examined the relationship between SAI and the private and public sectors, controlling for confounders. The median SAI was 54.8% in Enugu and 85.7% in Lagos. The private for-profit sector's SAI was lower than and the private not-for-profit sector's SAI was higher than the public sector in Enugu [coefficient = -3.6 (P = 0.018) and 12.6 (P < 0.001), respectively]. In Lagos, the private for-profit sector's SAI was higher and the private not-for-profit sector's SAI was lower than the public sector [3.71 (P = 0.005) and -3.92 (P < 0.001)]. Results indicate that the technical quality of private for-profit providers' care was poorer than public providers where the public provision of care was weak, while private for-profit facilities provided better technical quality care than public facilities where the public sector was strong and there was a relatively strong regulatory body. Our findings raise important considerations relating to the quality of maternity care, the public-private mix and needs for regulation in global efforts to achieve universal healthcare.

Improving quality of care during childbirth in primary health centres: a stepped-wedge cluster-randomised trial in India

Background

Low/middle-income countries need a large-scale improvement in the quality of care (QoC) around the time of childbirth in order to reduce high maternal, fetal and neonatal mortality. However, there is a paucity of scalable models.

Methods

We conducted a stepped-wedge cluster-randomised trial in 15 primary health centres (PHC) of the state of Haryana in India to test the effectiveness of a multipronged quality management strategy comprising capacity building of providers, periodic assessments of the PHCs to identify quality gaps and undertaking improvement activities for closure of the gaps. The 21-month duration of the study was divided into seven periods (steps) of 3  months each. Starting from the second period, a set of randomly selected three PHCs (cluster) crossed over to the intervention arm for rest of the period of the study. The primary outcomes included the number of women approaching the PHCs for childbirth and 12 directly observed essential practices related to the childbirth. Outcomes were adjusted with random effect for cluster (PHC) and fixed effect for ‘months of intervention’.

Results

The intervention strategy led to increase in the number of women approaching PHCs for childbirth (26 vs 21 women per PHC-month, adjusted incidence rate ratio: 1.22; 95% CI 1.17 to 1.28). Of the 12 practices, 6 improved modestly, 2 remained near universal during both intervention and control periods, 3 did not change and 1 worsened. There was no evidence of change in mortality with a majority of deaths occurring either during referral transport or at the referral facilities.

Conclusion

A multipronged quality management strategy enhanced utilisation of services and modestly improved key practices around the time of childbirth in PHCs in India.

Trial registration number

CTRI/2016/05/006963.

Improvement in the active management of the third stage of labor for the prevention of postpartum hemorrhage in Tanzania: a cross-sectional study

BACKGROUND

Tanzania has a maternal mortality ratio of 556 per 100,000 live births, representing 21% of all deaths of women of reproductive age. Hemorrhage, mostly postpartum hemorrhage (PPH), is estimated to cause at least 25% of maternal deaths in Tanzania. In 2008, the Ministry of Health, Community Development, Gender, Elderly and Children launched interventions to improve efforts to prevent PPH. Competency-based training for skilled birth attendants and ongoing quality improvement prioritized the practice of active management of the third stage of labor (AMTSL).

METHODS

A cross-sectional study was conducted in 52 health facilities in Tanzania utilizing direct observations of women during labor and delivery. Observations were conducted in 2010 and, after competency-based training and quality improvement interventions in the facilities, in 2012. A total of 489 deliveries were observed in 2010 and 558 in 2012. Steps for AMTSL were assessed using a standardized structured observation checklist that was based on World Health Organization guidelines.

RESULTS

The proportion of deliveries receiving all three AMTSL steps improved significantly by 19 percentage points (p < 0.001) following the intervention, with the most dramatic increase occurring in health centers and dispensaries (47.2 percentage point change) compared to hospitals (5.2 percentage point change). Use of oxytocin for PPH prevention rose by 37.1 percentage points in health centers and dispensaries but remained largely the same in hospitals, where the baseline was higher. There was substantial improvement in the timely provision of uterotonics (within 3 min of birth) across all facilities (p = 0.003). Availability of oxytocin, which was lower in health centers and dispensaries than hospitals at baseline, rose from 73 to 94% of all facilities.

CONCLUSION

The quality of PPH prevention increased substantially in facilities that implemented competency-based training and quality improvement interventions, with the most dramatic improvement seen at lower-level facilities. As Tanzania continues with efforts to increase facility births, it is imperative that the quality of care also be improved by promoting use of up-to-date guidelines and ensuring regular training and mentoring for health care providers so that they adhere to the guidelines for care of women during labor. These measures can reduce maternal and newborn mortality.

Neonatal nursing policy and practice in Kenya: Key stakeholders and their views on task-shifting as an intervention to improve care quality

Background: Improving the quality of facility based neonatal care is central to tackling the burden of neonatal mortality in Low and Middle Income Countries (LMIC).  Quality neonatal care is highly dependent on nursing care but a major challenge facing health systems in LMICs is human resource shortage. In Kenya, task-shifting among professional care cadres is being discussed as one potential strategy of addressing the human resource shortage, but little attention is being paid to the potential for task-shifting in the provision of in-patient sick newborn care. This study identified key neonatal policy-making and implementation stakeholders in Kenya and explored their perceptions of task-shifting in newborn units.    Methods: The study was exploratory and descriptive, employing qualitative methods including: document review, stakeholder analysis, observation of policy review process meetings and stakeholder feedback. A framework approach was used for analysis. Results: In Kenya, guidelines for the care of sick neonates exist but there are few specialized neonatal nurses and no policy documents outlining the nurse to patient ratio required in neonatal care or other higher dependency areas. The Ministry of Health, Nursing Council of Kenya and international agencies were identified as playing key roles in policy formulation while County governments, the National Nurses Association of Kenya and frontline care providers are central to implementation. Newborns were perceived to be highly vulnerable requiring skilled care but in light of human resources challenges, most expressed some support for shifting ‘unskilled’ tasks. However, a few of the key implementers were concerned about the use of unqualified staff and all stakeholders emphasized the need for training, regulation and supervision. Conclusions: Task-shifting has the potential to help address human recourse challenge in low-income settings. However, any potential task-shifting intervention in neonatal care would require a carefully planned process involving all key stakeholders and clear regulations to steer implementation.

Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness

Background

Globally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model.

Objective-method

We compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial.

Findings

Although most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%.

Significance

Comparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade’s intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted.

Health system reforms in five sub-Saharan African countries that experienced major armed conflicts (wars) during 1990-2015: a literature review

BACKGROUND

Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades - including 13 wars during 1990-2015 - than any other part of the world, and this has had an adverse effect on health systems in the region.

OBJECTIVE

To understand the best health system practices in five SSA countries that experienced wars during 1990-2015, and yet managed to achieve a maternal mortality reduction - equal to or greater than 50% during the same period - according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). Maternal mortality is a death of a woman during pregnancy, or within 42 days after childbirth - measured as maternal mortality ratio (MMR) per 100,000 live births.

DESIGN

We conducted a selective literature review based on a framework that drew upon the World Health Organisation's (WHO) six health system building blocks. We searched seven databases, Google Scholar as well as conducting a manual search of sources in articles' reference lists - restricting our search to articles published in English. We searched for terms related to maternal healthcare, the WHO six health system building blocks, and names of the five countries.

RESULTS

Our study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms.

CONCLUSION

Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars. Our findings provide insight from five war-affected SSA countries which could inform policy. However, since few studies have been conducted concerning this topic, our findings require further research to inform policy, and to help countries rebuild and maintain their health systems resilience.

Quality of Midwife-provided Intrapartum Care in Amhara Regional State, Ethiopia

BACKGROUND

Despite much progress recently, Ethiopia remains one of the largest contributors to the global burden of maternal and newborn deaths and stillbirths. Ethiopia's plan to meet the sustainable development goals for maternal and child health includes unprecedented emphasis on improving quality of care. The purpose of this study was to assess the quality of midwifery care during labor, delivery and immediate postpartum period.

METHODS

A cross-sectional study using multiple data collection methods and a 2-stage cluster sampling technique was conducted from January 25 to February 14, 2015 in government health facilities of the Amhara National Regional State of Ethiopia. Direct observation of performance was used to determine competence of midwives in providing care during labor, delivery, and the first 6 h after childbirth. Inventory of drugs, medical equipment, supplies, and infrastructure was conducted to identify availability of resources in health facilities. Structured interview was done to assess availability of resources and performance improvement opportunities. Data analysis involved calculating percentages, means and chi-square tests.

RESULTS

A total of 150 midwives and 56 health facilities were included in the study. The performance assessment showed 16.5% of midwives were incompetent, 72.4% were competent, and 11.1% were outstanding in providing routine intrapartum care. Forty five midwives were observed while managing 54 obstetric and newborn complications and 41 (91%) of them were rated competent. Inventory of resources found that the proportion of facilities with more than 75% of the items in each category was 32.6% for drugs, 73.1% for equipment, 65.4% for supplies, 47.9% for infection prevention materials, and 43.6% for records and forms. Opportunities for performance improvement were inadequate, with 31.3% reporting emergency obstetric and newborn care training, and 44.7% quarterly or more frequent supportive supervision. Health centers fared worse in provider competence, physical resources, and quality improvement practices except for supportive supervision visits and in-service training.

CONCLUSIONS

Although our findings indicate most midwives are competent in giving routine and emergency intrapartum care, the major gaps in the enabling environment and the significant proportion of midwives with unsatisfactory performance suggest that the conditions for providing quality intrapartum care are not optimal.

Obstetric Facility Quality and Newborn Mortality in Malawi: A Cross-Sectional Study

BACKGROUND

Ending preventable newborn deaths is a global health priority, but efforts to improve coverage of maternal and newborn care have not yielded expected gains in infant survival in many settings. One possible explanation is poor quality of clinical care. We assess facility quality and estimate the association of facility quality with neonatal mortality in Malawi.

METHODS AND FINDINGS

Data on facility infrastructure as well as processes of routine and basic emergency obstetric care for all facilities in the country were obtained from 2013 Malawi Service Provision Assessment. Birth location and mortality for children born in the preceding two years were obtained from the 2013-2014 Millennium Development Goals Endline Survey. Facilities were classified as higher quality if they ranked in the top 25% of delivery facilities based on an index of 25 predefined quality indicators. To address risk selection (sicker mothers choosing or being referred to higher-quality facilities), we employed instrumental variable (IV) analysis to estimate the association of facility quality of care with neonatal mortality. We used the difference between distance to the nearest facility and distance to a higher-quality delivery facility as the instrument. Four hundred sixty-seven of the 540 delivery facilities in Malawi, including 134 rated as higher quality, were linked to births in the population survey. The difference between higher- and lower-quality facilities was most pronounced in indicators of basic emergency obstetric care procedures. Higher-quality facilities were located a median distance of 3.3 km further from women than the nearest delivery facility and were more likely to be in urban areas. Among the 6,686 neonates analyzed, the overall neonatal mortality rate was 17 per 1,000 live births. Delivery in a higher-quality facility (top 25%) was associated with a 2.3 percentage point lower newborn mortality (95% confidence interval [CI] -0.046, 0.000, p-value 0.047). These results imply a newborn mortality rate of 28 per 1,000 births at low-quality facilities and of 5 per 1,000 births at the top 25% of facilities, accounting for maternal and newborn characteristics. This estimate applies to newborns whose mothers would switch from a lower-quality to a higher-quality facility if one were more accessible. Although we did not find an indication of unmeasured associations between the instrument and outcome, this remains a potential limitation of IV analysis.

CONCLUSIONS

Poor quality of delivery facilities is associated with higher risk of newborn mortality in Malawi. A shift in focus from increasing utilization of delivery facilities to improving their quality is needed if global targets for further reductions in newborn mortality are to be achieved.

Improving quality for maternal care - a case study from Kerala, India

Background: The implementation of maternal health guidelines remains unsatisfactory, even for simple, well established interventions. In settings where most births occur in health facilities, as is the case in Kerala, India, preventing maternal mortality is linked to quality of care improvements.

Context: Evidence-informed quality standards (QS), including quality statements and measurable structure and process indicators, are one innovative way of tackling the guideline implementation gap. Having adopted a zero tolerance policy to maternal deaths, the Government of Kerala worked in partnership with the Kerala Federation of Obstetricians & Gynaecologists (KFOG) and NICE International to select the clinical topic, develop and initiate implementation of the first clinical QS for reducing maternal mortality in the state.

Description of practice: The NICE QS development framework was adapted to the Kerala context, with local ownership being a key principle. Locally generated evidence identified post-partum haemorrhage as the leading cause of maternal death, and as the key priority for the QS. A multidisciplinary group (including policy-makers, gynaecologists and obstetricians, nurses and administrators) was established. Multi-stakeholder workshops convened by the group ensured that the statements, derived from global and local guidelines, and their corresponding indicators were relevant and acceptable to clinicians and policy-makers in Kerala. Furthermore, it helped identify practical methods for implementing the standards and monitoring outcomes.

Lessons learned: An independent evaluation of the project highlighted the equal importance of a strong evidence-base and an inclusive development process. There is no one-size-fits-all process for QS development; a principle-based approach might be a better guide for countries to adapt global evidence to their local context.

Basic newborn care and neonatal resuscitation: a multi-country analysis of health system bottlenecks and potential solutions

BACKGROUND

An estimated two-thirds of the world's 2.7 million newborn deaths could be prevented with quality care at birth and during the postnatal period. Basic Newborn Care (BNC) is part of the solution and includes hygienic birth and newborn care practices including cord care, thermal care, and early and exclusive breastfeeding. Timely provision of resuscitation if needed is also critical to newborn survival. This paper describes health system barriers to BNC and neonatal resuscitation and proposes solutions to scale up evidence-based strategies.

METHODS

The maternal and newborn bottleneck analysis tool was applied by 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" that hinder the scale up of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for BNC and neonatal resuscitation.

RESULTS

Eleven of the 12 countries provided grading data. Overall, bottlenecks were graded more severely for resuscitation. The most severely graded bottlenecks for BNC were health workforce (8 of 11 countries), health financing (9 out of 11) and service delivery (7 out of 9); and for neonatal resuscitation, workforce (9 out of 10), essential commodities (9 out of 10) and service delivery (8 out of 10). Country teams from Africa graded bottlenecks overall more severely. Improving workforce performance, availability of essential commodities, and well-integrated health service delivery were the key solutions proposed.

CONCLUSIONS

BNC was perceived to have the least health system challenges among the seven maternal and newborn intervention packages assessed. Although neonatal resuscitation bottlenecks were graded more severe than for BNC, similarities particularly in the workforce and service delivery building blocks highlight the inextricable link between the two interventions and the need to equip birth attendants with requisite skills and commodities to assess and care for every newborn. Solutions highlighted by country teams include ensuring more investment to improve workforce performance and distribution, especially numbers of skilled birth attendants, incentives for placement in challenging settings, and skills-based training particularly for neonatal resuscitation.

The global epidemic of abuse and disrespect during childbirth: History, evidence, interventions, and FIGO's mother-baby friendly birthing facilities initiative

Recent evidence indicates that disrespectful/abusive/coercive service delivery by skilled providers in facilities, which results in actual or perceived poor quality of care, is directly and indirectly associated with adverse maternal and newborn outcomes. The present article reviews the evidence for disrespectful/abusive care during childbirth in facilities (DACF), describes examples of DACF, discusses organizations active in a rights-based respectful maternity care movement, and enumerates some strategies and interventions that have been identified to decrease DACF. It concludes with a discussion of one strategy, which has been recently implemented by FIGO with global partners-the International Pediatrics Association, International Confederation of Midwives, the White Ribbon Alliance, and WHO. This strategy, the Mother and Baby Friendly Birth Facility (MBFBF) Initiative, is a criterion-based audit process based on human rights' doctrines, and modeled on WHO/UNICEF's Baby Friendly Facility Initiative.