Improving quality of care for maternal and newborn health: a pre-post evaluation of the Safe Childbirth Checklist at a hospital in Bangladesh

Geographic accessibility to hospital childbirths in Brazil (2010-2011 and 2018-2019): a cross-sectional study

Background

Delays in obstetric care are associated with adverse maternal outcomes, while long-distance travel for delivery is associated with high neonatal mortality and increased maternal morbidity. Distance and travel time are key components of geographic accessibility to health services and important risk indicators for maternal and neonatal care. This study evaluated whether the Brazilian Unified Health System (SUS) has been geographically accessible in providing hospital childbirth services, over time.

Methods

Geographic accessibility to hospital deliveries in Brazil was mapped over two biennia (2010-2011 and 2018-2019), spanning a 10-year period, using national aggregated data from SUS Hospital Admissions Authorizations. Travel flows, distances, and times between women's municipalities of residence and hospitals were estimated.

Findings

A total of 6,930,944 hospital deliveries were analyzed. Overall, 25.4% (n = 1,759,306) of pregnant women traveled outside their municipalities to give birth in SUS hospitals, increasing from 23.6% (n = 843,501) in 2010-2011 to 27.3% (n = 915,805) in 2018-2019. Distance and travel time rose by 31.1% (54.0 km-70.8 km) and 33.6% (63.1-84.3 min), respectively. Women experiencing maternal and/or neonatal death traveled longer distances and times. Regional disparities were evident: the Northeast had the highest proportion of women traveling (35.6%; n = 817,499), and the North had the lowest (16.0%; n = 138,295). Women in the North faced the longest travel distances (97.5-133.4 km) and times (1,012-1,850 min), while those in the Southeast and South experienced the shortest distances (37.2-55.9 km and 41.2-54.8 km, respectively) and times (38-52 min and 41-52 min).

Interpretation

The results highlight regional disparities in maternal health service access within the SUS, which may affect maternal and neonatal outcomes. Targeted public health measures are needed to improve the availability of service, particularly in the North and Northeast regions, where access issues are most severe.

Funding

Fundação Oswaldo Cruz; CNPq; FAPERJ.

Impact of the WHO safe childbirth checklist on birth attendant behavior and maternal-newborn outcomes: A systematic review and meta-analysis

BACKGROUND

The intrapartum period is critical for reducing maternal and perinatal morbidity and mortality. The WHO's Safe Childbirth Checklist (SCC) was designed as a reminder of the most critical, evidence-based practices (EBPs) to improve quality care and reduce preventable complications and deaths.

OBJECTIVE

To assess the impact of SCC on birth attendant behavior and maternal and newborn health outcomes.

SEARCH STRATEGY

A systematic review and meta-analysis was performed searching across five databases from 2009 to 2023.

SELECTION CRITERIA

We included randomized controlled trials, quasi-experimental studies, and pre/post studies.

DATA ANALYSIS

A meta-analysis yielded a pooled estimate of relative risk (RR) for adherence to and effectiveness of the SCC.

MAIN RESULTS

Of 1070 articles identified, 16 were included. Use of the SCC increased adherence to EBPs by 65% (RR 1.65; 95% confidence interval [CI] 1.34-2.02). The behaviors that improved the most were danger sign counseling (RR 12.37; 95% CI 1.95-78.52; P = 0.008) and pre-eclampsia management (RR 3.43; 95% CI 1.33-8.88; P = 0.011). There was moderate evidence for stillbirth reduction (RR 0.89; 95% CI 0.80-0.99; P = 0.034).

CONCLUSION

There is moderate evidence demonstrating the effectiveness of the SCC in reducing stillbirths and improving adherence to EBPs.

Iranian midwives' experiences of using the World Health Organization's Safe Childbirth Checklist: A qualitative research

BACKGROUND

The goal of natural childbirth care is to have a healthy mother and baby with minimal interventions that are contrary to health. Worldwide, there is concern that non-evidence-based interventions and care in labor and childbirth will remain standard practice. Therefore, access to care related to pregnancy and childbirth is considered a priority. To address safety concerns during organized births, the Safe Childbirth Checklist (SCC) was created by the World Health Organization (WHO). This checklist is a tool that combines evidence-based practices that should be provided before, during, and after childbirth. As midwives have a vital role in using this up-to-date evidence, this study was conducted to explore Iranian midwives' perception of using SCC.

MATERIALS AND METHOD

This qualitative study was conducted from January 2022 to April 2023 in two public (teaching and nonteaching) hospitals in Ahvaz, Iran. Seventeen semi-structured interviews were conducted with midwives who had more than one year of work experience in maternity wards. Participants were selected purposefully. A content analysis approach was used to analyze the data and extract themes.

RESULTS

All midwives had a positive attitude toward using SCC. The midwives' reasons for being in favor of using the checklist during the clinical procedures of childbirth are summarized in four main themes, namely "standardized maternity care practices," "SCC as a guide for performing essential childbirth practices," "self-efficacy of midwifery care," and "improved maternal and neonatal outcomes."

CONCLUSION

Midwives have endorsed this checklist as a guide to standard childbirth management. It seems that the use of this checklist will help to improve the health outcomes of mothers and babies by strengthening the self-efficacy of midwives.

Barriers and facilitators for implementing the WHO Safe Childbirth Checklist (SCC) in Mozambique: A qualitative study using the Consolidated Framework for Implementation Research (CFIR)

High maternal and neonatal mortality rates persist in Mozambique, with stillbirths remaining understudied. Most maternal and neonatal deaths in the country are due to preventable and treatable childbirth-related complications that often occur in low-resource settings. The World Health Organization introduced the Safe Childbirth Checklist (SCC) in 2015 to reduce adverse birth outcomes. The SCC, a structured list of evidence-based practices, targets the main causes of maternal and neonatal deaths and stillbirths in healthcare facilities. The SCC has been tested in over 35 countries, demonstrating its ability to improve the quality of care. However, it has not been adopted in Mozambique. This study aimed to identify potential facilitators and barriers to SCC implementation from the perspective of birth attendants, clinical administrators, and decision-makers to inform future SCC implementation in Mozambique. We conducted a qualitative study involving focus group discussions with birth attendants (n = 24) and individual interviews with clinical administrators (n = 6) and decision-makers (n = 8). The Consolidated Framework for Implementation Research guided the questions used in the interviews and focus group discussions, as well as the subsequent data analysis. A deductive thematic analysis of Portuguese-to-English translated transcripts was performed. In Mozambique, most barriers to potential SCC implementation stem from the challenges within a weak health system, including underfunded maternal care, lack of infrastructure and human resources, and low provider motivation. The simplicity of the SCC and the commitment of healthcare providers to better childbirth practices, combined with their willingness to adopt the SCC, were identified as major facilitators. To improve the feasibility of SCC implementation and increase compatibility with current childbirth routines for birth attendants, the SCC should be tailored to context-specific needs. Future research should prioritize conducting pre-implementation assessments to align the SCC more effectively with local contexts and facilitate sustainable enhancements in childbirth practices.

Developmental Strategy and Validation of the Midwifery Interventions Classification (MIC): A Delphi Study Protocol and Results from the Developmental Phase

This study protocol aims to describe the rationale and developmental strategy of the first study in the Italian context which aimed to define a Midwifery Interventions Classification, an evidence-based, standardized taxonomy and classification of midwifery interventions. Midwifery interventions require a specific definition, developed through a consensus-building process by stakeholders to develop the Italian taxonomy of the Midwifery Interventions Classification with the potential for international transferability, implementation, and scaling up. A multi-round Delphi study was designed between June and September 2022, and data collection is planned between February 2023 and February 2024. The developmental phase of the study is based on a literature review to select meaningful midwifery interventions from the international literature, aiming to identify an evidence-based list of midwifery interventions. This phase led to including 16 articles derived from a systematic search performed on PubMed, CINAHL, and Scopus; 164 midwifery interventions were selected from the data extraction performed on the 16 included articles. Healthcare professionals, researchers, and service users will be eligible panelists for the Delphi surveys. The protocol designed a dynamic number of consultation rounds based on the ratings and interim analysis. A nine-point Likert scoring system is designed to evaluate midwifery interventions. Attrition and attrition bias will be evaluated. The results from the study designed in this protocol will inform the development of the Italian taxonomy of the Midwifery Interventions Classification. A shared classification of midwifery interventions will support audit and quality improvement, education, and comparable data collections for research, sustaining public recognition of midwifery interventions to promote optimal maternal and newborn health.

Impact of the implementation of the WHO Safe Childbirth Checklist on essential birth practices and adverse events in two Brazilian hospitals: a before and after study

OBJECTIVE

The WHO Safe Childbirth Checklist (SCC) is a promising initiative for safety in childbirth care, but the evidence about its impact on clinical outcomes is limited. This study analysed the impact of SCC on essential birth practices (EBPs), obstetric complications and adverse events (AEs) in hospitals of different profiles.

DESIGN

Quasi-experimental, time-series study and pre/post intervention.

SETTING

Two hospitals in North-East Brazil, one at a tertiary level (H1) and another at a secondary level (H2).

PARTICIPANTS

1440 women and their newborns, excluding those with congenital malformations.

INTERVENTIONS

The implementation of the SCC involved its cross-cultural adaptation, raising awareness with videos and posters, learning sessions about the SCC and auditing and feedback on adherence indicators.

PRIMARY AND SECONDARY OUTCOME MEASURES

Simple and composite indicators related to seven EBPs, 3 complications and 10 AEs were monitored for 1 year, every 2 weeks, totalling 1440 observed deliveries.

RESULTS

The checklist was adopted in 83.3% (n=300) of deliveries in H1 and in 33.6% (n=121) in H2. The hospital with the highest adoption rate for SCC (H1) showed greater adherence to EBPs (improvement of 50.9%;p<0.001) and greater reduction in clinical outcome indicators compared with its baseline: percentage of deliveries with severe complications (reduction of 30.8%;p=0.005); Adverse Outcome Index (reduction of 25.6%;p=0.049); Weighted Adverse Outcome Score (reduction of 39.5%;p<0.001); Severity Index (reduction of 18.4%;p<0.001). In H2, whose adherence to the SCC was lower, there was an improvement of 24.7% compared with before SCC implementation in the composite indicator of EBPs (p=0.002) and a reduction of 49.2% in severe complications (p=0.027), but there was no significant reduction in AEs.

CONCLUSIONS

A multifaceted SCC-based intervention can be effective in improving adherence to EBPs and clinical outcomes in childbirth. The context and adherence to the SCC seem to modulate its impact, working better in a hospital of higher complexity.

Implementing the WHO Safe Childbirth Checklist modified for preterm birth: lessons learned and experiences from Kenya and Uganda

Background

The WHO Safe Childbirth Checklist (SCC) contains 29 evidence-based practices (EBPs) across four pause points spanning admission to discharge. It has been shown to increase EBP uptake and has been tailored to specific contexts. However, little research has been conducted in East Africa on use of the SCC to improve intrapartum care, particularly for preterm birth despite its burden. We describe checklist adaptation, user acceptability, implementation and lessons learned.

Methods

The East Africa Preterm Birth Initiative (PTBi EA) modified the SCC for use in 23 facilities in Western Kenya and Eastern Uganda as part of a cluster randomized controlled trial evaluating a package of facility-based interventions to improve preterm birth outcomes. The modified SCC (mSCC) for prematurity included: addition of a triage pause point before admission; focus on gestational age assessment, identification and management of preterm labour; and alignment with national guidelines. Following introduction, implementation lasted 24 and 34 months in Uganda and Kenya respectively and was supported through complementary mentoring and data strengthening at all sites. PRONTO® simulation training and quality improvement (QI) activities further supported mSCC use at intervention facilities only. A mixed methods approach, including checklist monitoring, provider surveys and in-depth interviews, was used in this analysis.

Results

A total of 19,443 and 2229 checklists were assessed in Kenya and Uganda, respectively. In both countries, triage and admission pause points had the highest rates of completion. Kenya’s completion was greater than 70% for all pause points; Uganda ranged from 39 to 75%. Intervention facilities exposed to PRONTO and QI had higher completion rates than control sites. Provider perceptions cited clinical utility of the checklist, particularly when integrated into patient charts. However, some felt it repeated information in other documentation tools. Completion was hindered by workload and staffing issues.

Conclusion

This study highlights the feasibility and importance of adaptation, iterative modification and complementary activities to reinforce SCC use. There are important opportunities to improve its clinical utility by the addition of prompts specific to the needs of different contexts. The trial assessing the PTBi EA intervention package was registered at ClinicalTrials.gov NCT03112018 Registered December 2016, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07650-x.

Effects of the World Health Organization Safe Childbirth Checklist on Quality of Care and Birth Outcomes in Aceh, Indonesia: A Cluster-Randomized Clinical Trial

Importance

To address major causes of perinatal and maternal mortality, the World Health Organization developed the Safe Childbirth Checklist (SCC), which to our knowledge has been rigorously evaluated only in combination with high-intensity coaching.

Objective

To evaluate the effect of the SCC with medium-intensity coaching on health care workers' performance of essential birth practices.

Design, Setting, and Participants

This cluster randomized clinical trial without blinding included 32 hospitals and community health centers in the province of Aceh, Indonesia (a medium-resource setting) that met the criterion of providing at least basic emergency obstetric and newborn care. Baseline data were collected from August to October 2016, and outcomes were measured from March to April 2017. Data were analyzed from January 2020 to October 2021.

Interventions

After applying an optimization method, facilities were randomly assigned to the treatment or control group (16 facilities each). The SCC with 11 coaching visits was implemented during a 6-month period.

Main Outcomes and Measures

For the primary outcome, clinical observers documented whether 36 essential birth practices were applied at treatment and control facilities at 1 or more of 4 pause points during the birthing process (admission to the hospital, just before pushing or cesarean delivery, soon after birth, and before hospital discharge). Probability models for binary outcome measures were estimated using ordinary least-squares regressions, complemented by Firth logit and complier average causal effect estimations.

Results

Among the 32 facilities that participated in the trial, a significant increase of up to 41 percentage points was observed in the application of 5 of 36 essential birth practices in the 16 treatment facilities compared with the 16 control facilities, including communication of danger signs at admission (treatment: 136 of 155 births [88%]; control: 79 of 107 births [74%]), measurement of neonatal temperature (treatment: 9 of 31 births [29%]; control: 1 of 20 births [5%]), newborn feeding checks (treatment: 22 of 34 births [65%]; control: 5 of 21 births [24%]), and the rate of communication of danger signs to mothers and birth companions verbally (treatment: 30 of 36 births [83%]; control: 14 of 22 births [64%]) and in a written format (treatment: 3 of 24 births [13%]; control: 0 of 16 births [0%]).

Conclusions and Relevance

In this cluster randomized clinical trial, health facilities that implemented the SCC with medium-intensity coaching had an increased rate of application for 5 of 36 essential birth practices compared with the control facilities. Medium-intensity coaching may not be sufficient to increase uptake of the SCC to a satisfying extent, but it may be worthwhile to assess a redesigned coaching approach prompting long-term behavioral change and, therefore, effectiveness.

Trial Registration

isrctn.org Identifier: ISRCTN11041580.

Feasibility study on the adoption of the WHO safe childbirth checklist by front-line healthcare providers and managers in Burkina Faso and Côte d'Ivoire

Background

The World Health Organization Safe Childbirth Checklist tool was specifically designed for developing countries such as sub-Saharan African countries, to ensure safety and security of the couple mother and newborn around the time of childbirth. However, the implementation of the Safe Childbirth Checklist tool requires a good knowledge of the context setting to face challenges. Our study objectives were (1) to assess the acceptability of the WHO SCC tool and (2) to identify conditions and strategies for a better introduction and use of the WHO SSC tool.

Methods

This was a pilot multi-country study conducted from January to March 2019 in Burkina Faso and Côte d’Ivoire, respectively, in the health regions of central-North and Agnéby-Tiassa-Mé. In each health region, 5 health facilities of different levels within the health system pyramid were selected through a purposive sampling. The study was conducted in 2 phases: 38 healthcare providers and 15 managers were first trained to use the Safe Childbirth Checklist tool; secondly, the trained providers were allowed to use the tool in real-life conditions for 2 weeks. Then, semi-structured interviews were conducted among healthcare providers and managers. The topics covered by the interview guides were acceptability of the tool, barriers and facilitators to its use, as well as strategies for better introduction and use within the healthcare system. Analysis was carried out using the Nvivo 12 software.

Results

Respondents reported an overall good acceptance of using the tool. However, they suggested minor content adaptation. The design of the tool and increased workload were the main barriers to its use. Potential facilitators to its introduction were managers’ commitment, healthcare providers’ motivation, and the availability of supplies. The best strategies for optimal use were its attachment to existing tool such as partograph or/and its display in the maternity ward.

Conclusions

The findings showed that the implementation of the Safe Childbirth Checklist tool is acceptable in Burkina Faso and Côte d’Ivoire. These findings are important and will help to design a trial aiming at assessing the effectiveness of the tool WHO SCC tool in these two countries.

Effectiveness of utilizing the WHO safe childbirth checklist on improving essential childbirth practices and maternal and perinatal outcome: A systematic review and meta-analysis

INTRODUCTION

The World Health Organization (WHO) Safe Childbirth Checklist (SCC) is a 29-item checklist based on essential childbirth practices to help health-care workers to deliver consistently high quality maternal and perinatal care. The Checklist was intended to reduce maternal and perinatal mortality and address the primary cause of maternal death, intrapartum stillbirth, and early neonatal death. The objective of this review was to locate international literature reporting on the effectiveness of utilizing the WHO safe childbirth checklist on improving essential childbirth practices, early neonatal death, stillbirth, maternal mortality, and morbidity.

METHODS

We searched MEDLINE, google scholar, Cochrane Central Register of Controlled Trials (CENTRAL), met-Register of Controlled Trials (m-RCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/stop/search/en) to retrieve all available comparative studieshttp://www.opengrey.eu/ published in English after 2008. Two reviewers did study selection, critical appraisal, and data extraction independently. We did a random or fixed-effect meta-analysis to pool studies together and effect estimates were expressed as an odds ratio. Quality of evidence for major outcomes was assessed using the Grading of Recommendations, Assessment, development, and evaluation(GRADE).

RESULTS

We retained three cluster randomized trials and six pre-and-post intervention studies reporting on WHO SCC's. The WHO SCC utilization improved quality of preeclampsia management(moderate quality of evidence) (OR = 7.05 [95% CI 2.34-21.29]), maternal infection management(moderate quality of evidence) (OR = 7.29[95%CI 2.29-23.27]), Partograph utilization(moderate quality of evidence) (OR = 3.81 [95% 1.72-8.43]), postpartum counselling(low quality of evidence) (RR = 132.51[95% 49.27-356.36]) and still birth(moderate quality of evidence) (OR = 0.92[95% CI 0.87-0.96]). However, the utilization of the checklist had no impact on early neonatal death (very low quality of evidence) (OR = 1.07[95%CI [1.01-1.13]) and maternal death (low quality of evidence) (OR = 1.06[95% CI 0.77-1.45]).

CONCLUSIONS

Moderate quality of evidence indicates that WHO SCC utilization is effective in reducing stillbirth and Improving preeclampsia management, maternal infection management and partograph utilization Low quality of evidence indicates that WHO SCC is effective in enhancing postpartum danger sign counseling. Low and very low quality of evidence suggests that WHO SCC has no impact on maternal and early neonatal death, respectively.

Coaching Intensity, Adherence to Essential Birth Practices, and Health Outcomes in the BetterBirth Trial in Uttar Pradesh, India

BACKGROUND

Coaching can improve the quality of care in primary-level birth facilities and promote birth attendant adherence to essential birth practices (EBPs) that reduce maternal and perinatal mortality. The intensity of coaching needed to promote and sustain behavior change is unknown. We investigated the relationship between coaching intensity, EBP adherence, and maternal and perinatal health outcomes using data from the BetterBirth Trial, which assessed the impact of a complex, coaching-based implementation of the World Health Organization's Safe Childbirth Checklist in Uttar Pradesh, India.

METHODS

For each birth, we defined multiple coaching intensity metrics, including coaching frequency (coaching visits per month), cumulative coaching (total coaching visits accrued during the intervention), and scheduling adherence (coaching delivered as scheduled). We considered coaching delivered at both facility and birth attendant levels. We assessed the association between coaching intensity and birth attendant adherence to 18 EBPs and with maternal and perinatal health outcomes using regression models.

RESULTS

Coaching frequency was associated with modestly increased EBP adherence. Delivering 6 coaching visits per month to facilities was associated with adherence to 1.3 additional EBPs (95% confidence interval [CI]=0.6, 1.9). High-frequency coaching delivered with high coverage among birth attendants was associated with greater improvements: providing 70% of birth attendants at a facility with at least 1 visit per month was associated with adherence to 2.0 additional EBPs (95% CI=1.0, 2.9). Neither cumulative coaching nor scheduling adherence was associated with EBP adherence. Coaching was generally not associated with health outcomes, possibly due to the small magnitude of association between coaching and EBP adherence.

CONCLUSIONS

Frequent coaching may promote behavior change, especially if delivered with high coverage among birth attendants. However, the effects of coaching were modest and did not persist over time, suggesting that future coaching-based interventions should explore providing frequent coaching for longer periods.

Optimizing the development and evaluation of complex interventions: lessons learned from the BetterBirth Program and associated trial

BACKGROUND

Despite extensive efforts to develop and refine intervention packages, complex interventions often fail to produce the desired health impacts in full-scale evaluations. A recent example of this phenomenon is BetterBirth, a complex intervention designed to implement the World Health Organization's Safe Childbirth Checklist and improve maternal and neonatal health. Using data from the BetterBirth Program and its associated trial as a case study, we identified lessons to assist in the development and evaluation of future complex interventions.

METHODS

BetterBirth was refined across three sequential development phases prior to being tested in a matched-pair, cluster randomized trial in Uttar Pradesh, India. We reviewed published and internal materials from all three development phases to identify barriers hindering the identification of an optimal intervention package and identified corresponding lessons learned. For each lesson, we describe its importance and provide an example motivated by the BetterBirth Program's development to illustrate how it could be applied to future studies.

RESULTS

We identified three lessons: (1) develop a robust theory of change (TOC); (2) define optimization outcomes, which are used to assess the effectiveness of the intervention across development phases, and corresponding criteria for success, which determine whether the intervention has been sufficiently optimized to warrant full-scale evaluation; and (3) create and capture variation in the implementation intensity of components. When applying these lessons to the BetterBirth intervention, we demonstrate how a TOC could have promoted more complete data collection. We propose an optimization outcome and related criteria for success and illustrate how they could have resulted in additional development phases prior to the full-scale trial. Finally, we show how variation in components' implementation intensities could have been used to identify effective intervention components.

CONCLUSION

These lessons learned can be applied during both early and advanced stages of complex intervention development and evaluation. By using examples from a real-world study to demonstrate the relevance of these lessons and illustrating how they can be applied in practice, we hope to encourage future researchers to collect and analyze data in a way that promotes more effective complex intervention development and evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02148952; registered on May 29, 2014.

Quality of maternal and newborn healthcare services in two public hospitals of Bangladesh: identifying gaps and provisions for improvement

BACKGROUND

Healthcare service delivery systems need to ensure standard quality of care (QoC) for achieving expected health outcomes. Although Bangladesh has a good healthcare service delivery system, there are major concerns about the quality of maternal and newborn health (MNH) care services, which is imperative for achievements in health. The study aimed to measure the QoC for different MNH services in two selected public health facilities of Bangladesh. This study also documented the specific areas of each care which needs intervention.

METHODS

The study was conducted in two district-level public health facilities-a district hospital (DH) and a mother and child welfare centre (MCWC). A total of 228 cases of MNH services were observed by using contextualized checklist 'Standards-based Management and Recognition (S-BMR)' for 8 selected MNH care services. For scoring, performed activities were calculated as percentages of the total recommended activities and categorized as high (> 80%), moderate (50 to 80%), and low (< 50%).

RESULTS

Overall QoC scores were moderate for each DH (54.8%), and MCWC (56.1%). In DH, the QoC score was high for blood transfusion (80.3%); moderate for maternal complications management (77.0%), caesarean section (CS) (65.6%), infection prevention (64.3%), sick newborn care (54.1%), and normal vaginal delivery (NVD) (52.6%); and low for antenatal care (ANC) (25.6%) and postnatal care (PNC) (19.0%). In MCWC, the QoC scores were high for infection prevention (83.0%); moderate for CS (76.5%) and NVD (59.8%); and low for ANC (36.9%) and PNC (24.5%).

CONCLUSIONS

In the study facilities, the QoC for MNH services is found to be unsatisfactory, particularly for ANC and PNC. Urgent initiative needs to be taken by introducing contextualized quality monitoring tools at health facilities, along with training of the care providers and introducing a quality monitoring system.

Quality of care during childbirth at public health facilities in Bangladesh: a cross-sectional study using WHO/UNICEF 'Every Mother Every Newborn (EMEN)' standards

Background

This manuscript presents findings from a baseline assessment of health facilities in Bangladesh prior to the implementation of the ‘Every Mother Every Newborn Quality Improvement’ initiative.

Methodology

A cross-sectional survey was conducted between June and August 2016 in 15 government health facilities. Structural readiness was assessed by observing the physical environment, the availability of essential drugs and equipment, and the functionality of the referral system. Structured interviews were conducted with care providers and facility managers on human resource availability and training in the maternal and newborn care. Observation of births, reviews of patient records and exit interviews with women who were discharged from the selected health facilities were used to assess the provision and experience of care.

Results

Only six (40%) facilities assessed had designated maternity wards and 11 had newborn care corners. There were stock-outs of emergency drugs including magnesium sulfate and oxytocin in nearly all facilities. Two-thirds of the positions for medical officers was vacant in district hospitals and half of the positions for nurses was vacant in subdistrict facilities. Only 60 (45%) healthcare providers interviewed received training on newborn complication management. No health facility used partograph for labour monitoring. Blood pressure was not measured in half (48%) and urine protein in 99% of pregnant women. Only 27% of babies were placed skin to skin with their mothers. Most mothers (97%) said that they were satisfied with the care received, however, only 46% intended on returning to the same facility for future deliveries.

Conclusions

Systematic implementation of quality standards to mitigate these gaps in service readiness, provision and experience of care is the next step to accelerate the country’s progress in reducing the maternal and neonatal deaths.

Perceptions of appropriate treatment among the informal allopathic providers: insights from a qualitative study in two peri-urban areas in Bangladesh

Background

How the informal providers deliver health services are not well understood in Bangladesh. However, their practices are often considered inappropriate and unsafe. This study attempted to fill-in this knowledge gap by exploring their perceptions about diagnosis and appropriate treatment, as well as identifying existing barriers to provide appropriate treatment.

Methods

This exploratory study was conducted in two peri-urban areas of metropolitan Dhaka. Study participants were selected purposively, and an interview guideline was used to collect in-depth data from thirteen providers. Content analysis was applied through data immersion and themes identification, including coding and sub-coding, as well as data display matrix creation to draw conclusion.

Results

The providers relied mainly on the history and presenting symptoms for diagnosis. Information and guidelines provided by the pharmaceutical representatives were important aids in their diagnosis and treatment decision making. Lack of training, diagnostic tools and medicine, along with consumer demands for certain medicine i.e. antibiotics, were cited as barriers to deliver appropriate care. Effective and supportive supervision, training, patient education, and availability of diagnostics and guidelines in Bangla were considered necessary in overcoming these barriers.

Conclusion

Informal providers lack the knowledge and skills for delivering appropriate treatment and care. As they provide health services for substantial proportion of the population, it’s crucial that policy makers become cognizant of the fact and take measures to remedy them. This is even more urgent if government’s goal to reach universal health coverage by 2030 is to be achieved.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4254-3) contains supplementary material, which is available to authorized users.

Effectiveness of a WHO Safe Childbirth Checklist Coaching-based intervention on the availability of Essential Birth Supplies in Uttar Pradesh, India

Objective

Evaluate the impact of a World Health Organization Safe Childbirth Checklist coaching-based intervention (BetterBirth Program) on availability and procurement of essential childbirth-related supplies.

Design

Matched pair, cluster-randomized controlled trial.

Setting

Uttar Pradesh, India.

Participants

120 government-sector health facilities (60 interventions, 60 controls). Supply-availability surveys were conducted quarterly in all sites. Coaches collected supply procurement sources from intervention sites.

Interventions

Coaching targeting implementation of Checklist with data feedback and action planning.

Main Outcome Measures

Mean supply availability by study arm; change in procurement sources for intervention sites.

Results

At baseline, 6 and 12 months, the intervention sites had a mean of 20.9 (95% confidence interval (CI): 20.2–21.5); 22.4 (95% CI: 21.8–22.9) and 22.1 (95% CI:21.4–22.8) items, respectively. Control sites had 20.8 (95% CI: 20.3–21.3); 20.9 (95% CI: 20.3–21.5) and 21.7 (95% CI: 20.8–22.6) items at the same time-points. There was a small but statistically significant higher availability in intervention sites at 6 months (difference-in-difference (DID) = 1.43, P < 0.001), which was not seen by 12 months (DID = 0.37, P = 0.53). Greater difference between intervention and control sites starting in the bottom quartile of supply availability was seen at 6 months (DID = 4.0, P = 0.0002), with no significant difference by 12 months (DID = 1.5, P = 0.154). No change was seen in procurement sources with ~5% procured by patients with some rates as high as 29% (oxytocin).

Conclusions

Implementation of the BetterBirth Program, incorporating supply availability, resulted in modest improvements with catch-up by control facilities by 12 months. Supply-chain coaching may be most beneficial in sites starting with lower supply availability. Efforts are needed to reduce reliance on patient-funding for some critical medications.

Trial Registration

ClinicalTrials.gov #NCT02148952; Universal Trial Number: U1111-1131–5647