Influence of integrated community- and facility-based interventions on select maternal and neonatal outcomes in Northern Karnataka, India: Lessons for implementation and measurement

Improving the Quality of Maternity Care through the Introduction of Professional Midwives and Mentoring in Selected Sub-District Hospitals in Bangladesh: A Mixed Method Study Protocol

Introduction: Bangladesh introduced professional midwives in 2018 to address gaps in sexual and reproductive health services, focusing on improved maternity care. Facility mentoring has been introduced in selected facilities within the government to enable midwives as they move into their new roles. Objectives: To describe a protocol (1) to determine if introducing international standard midwives in rural sub-district hospitals in Bangladesh, both with and without facility mentoring, improve the availability and quality of maternal and newborn health care compared to the facility without midwives; and (2) to explore the experiences of the midwives, and the maternity staff and managers that they joined, following their introduction. Methods: This will be a mixed-methods study to examine differences between selected hospitals grouped into three categories: without midwives (only nurses), with midwives, and both with midwives and mentorship. Hospital selection will be based on choosing those with the highest birth caseload. The quantitative component will consist of facility observations and clinical data extraction to assess their (hospital and midwives) readiness (birth preparedness and complication readiness) and clinical care to explore whether facilities with newly introduced midwives have improved availability and quality of care. We will use facility assessment tools to extract clinical data. In addition, we will use a structured open-ended interview guideline to conduct focus groups and in-depth interviews to understand the perceptions, attitudes, and experiences among maternity staff (e.g., nurses and paramedics) and health managers (e.g., facility manager, residential medical officer, consultants), as well as the midwives themselves toward the newly introduced midwives and the quality of care. We plan to use a fixed effect logistic regression to compare the relationship between variables in the three hospital types for each observed data point. For analyzing qualitative data, we will adopt content analysis and use NVivo to identify themes related to perceptions, attitudes, and experiences. Expected results: The introduction of professional midwives may improve the quality of maternal health care in rural settings. The addition of a mentoring program can support midwives in transitioning into their new roles and introduce improved care quality.

Accelerated scale-up of Kangaroo Mother Care: Evidence and experience from an implementation-research initiative in south India

AIM

Though Kangaroo Mother Care (KMC) has demonstrated benefits for low birth weight newborns, coverage continues to be low in India. As part of a World Health Organization (WHO) multi-country study, we explored intervention models to accelerate KMC coverage in a high priority district of Karnataka, India.

METHODS

We used implementation-research methods, formative assessments and quality improvement approaches to design and scale-up interventions. Evaluation was done using prospective cohort study design; data were collected from facility records, and client interviews during KMC initiation, at discharge and at home after discharge.

RESULTS

KMC was initiated at health facilities for 87.6% of LBW babies under 2000 g. At discharge, 85.0% received KMC; 67.9% continued to receive KMC at home on the 7th day post-discharge. The interventions included training, mentoring and constant advocacy at many levels: public health facilities, private sector and the community. Innovations like a KMC case sheet, counselling, peer support group triggered KMC in the facilities; a KMC-link card, a microplanning and communication tool for CHWs helped to sustain practice at homes.

CONCLUSION

The study provides a novel approach to designing and scaling up interventions and suggests lessons that are applicable to KMC as well as to broader reproductive, maternal, neonatal and child health programmes.

Evaluating implementation strategies for essential newborn care interventions in low- and low middle-income countries: a systematic review

Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.