The effect of catchment based mentorship on quality of maternal and newborn care in primary health care facilities in Tigray Region, Northern Ethiopia: A controlled quasi-experimental study

BACKGROUND

In Ethiopia, quality of maternal and newborn care is poor. This situation has persisted, despite the wide implementation of several capacity building-oriented interventions including clinical mentoring for skilled birth attendants that were anticipated to translate in to high-quality maternal and newborn care on each encounter. The effectiveness of mentoring programs is not yet well documented in the research literature. Therefore, we evaluated the effect of a catchment based clinical mentorship in improving the quality of maternal and newborn care in primary level facilities of Tigray, Northern Ethiopia.

METHODS

We conducted a controlled quasi-experimental pre-post study among 19 primary health care facilities, with 10 facilities assigned to the group where the catchment based clinical mentorship program was implemented (intervention group), and 9 facilities to the control group. We assigned the group based on administrative criteria, number of deliveries in each facility, accessibility, and ease of implementation of the intervention. A sample of 1320 women(662 at baseline; 658 at post intervention) and 233 skilled birth attendants(121 at baseline and 112 at end line) were included. We collected data from mothers, skilled birth attendants and facilities. The first round of data collection (baseline) took place two weeks prior the inauguration of the intervention, 05 October to 04 November 2019. The end line data collection occurred from 22 May to 03 July 2020. The primary Outcome was "receipt quality of maternal/newborn care". We analyzed the data using difference in differences (DiD) and logistic regression with Generalized Estimating Equation. The level of significance of predictors was declared at p-value less than 0.05in the multivariable analysis.

INTERVENTION

We deployed a team of local clinical mentors working at primary hospitals to provide clinical mentorship, and direct feedback in routine and emergency obstetrical and newborn care to the mentees (all skilled birth attendants performing maternal and newborn health services) functioning in their catchment rural health centers for duration of six months. While visiting a facility, mentors remain at the facility each lasting at least five to seven days per month, over the course of intervention period.

RESULTS

A significantly higher proportion of women at intervention facilities received quality of care services, compared with women at comparison facilities. (DiD = 18.4%, p<0.001). Moreover, following the implementation of the intervention we detected a difference in the occurrences of maternal complication outcome during delivery and immediately after birth. This was decreased by 4.5%, with significant differences between intervention and comparison sites (DiD = 4.5%, p = 0.013). We also found a favorable difference in occurrences of neonatal obstetric complications, with a decrease of 4.8% in the intervention site and almost no change in the comparison site (DiD = 4.8%, p = 0.002). Among the determinants of quality of care, we found that providers' job satisfaction (AoR = 2.95, 95%CI: 1.26 to 6.91), and making case presentation at regular basis(AoR = 1.89, 95%CI: 1.05 to 3.39) were significantly associated to improve the quality of care. However, delivery load(AoR = 0.95, 95%CI: 0.93 to 0.98) was negatively associated with quality of care.

CONCLUSIONS

We conclude that the catchment based clinical mentorship intervention is effective to improve quality of care and reduce childbirth complications in northern Ethiopia. This finding further elaborated that incorporating maternal and newborn health catchment based clinical mentorship activities into the existing health system strengthening strategies can catalyze improvement processes to quality practice and health systems. This is seen as a necessary step to achieve the effective quality universal health care required to meet the health-related Sustainable Development Goals. Besides, more attention needs to be given to develop interventions and strategies that directly enhance providers' job satisfaction and reduce delivery work load.

Healthcare Providers' Experiences With a Clinical Mentorship Intervention to Improve Reproductive, Maternal and Newborn Care in Mwanza, Tanzania

INTRODUCTION

There is increasing evidence suggesting that clinical mentorship (CM) involving on-the-job training is one of the critical resources-friendly entry points for strengthening the knowledge and skills of healthcare providers (HCPs), which in turn facilitate the delivery of effective reproductive, maternal, and newborn health (RMNH) care. The article explores the experiences of HCPs following participation in the CM program for RMNH in eight districts of Mwanza Region in Tanzania.

MATERIALS AND METHODS

A qualitative descriptive design employing data from midterm project review meetings and Key Informant Interviews (KIIs) with purposefully selected HCPs (mentors and mentees) and District Medical Officers (DMOs) during endline evaluation were employed. Interview data were managed using Nvivo Software and analyzed thematically.

RESULTS

A total of 42 clinical mentors and master mentors responded to a questionnaire during the midterm review meeting. Then, a total of 17 KIIs were conducted with Mentees (8), Mentors (5), and DMOs (4) during endline evaluation. Five key themes emerged from participants' accounts: (i) the topics covered during CM visits; (ii) the benefits of CM; (iii) the challenges of CM; (iv) the drivers of CM sustainability; and (iv) suggestions for CM improvement. The topics of CM covered during visits included antenatal care, neonatal resuscitation, pregnancy monitoring, management of delivery complications, and infection control and prevention. The benefits of CM included increased knowledge, skills, confidence, and change in HCP's attitude and increased client service uptake, quality, and efficiency. The challenges of CM included inadequate equipment for learning and practice, the limited financial incentive to mentees, shortage of staff and time constraints, and weaker support from management. The drivers of CM sustainability included the willingness of mentees to continue with clinical practice, ongoing peer-to-peer mentorship, and integration of the mentorship program into district health plans. Finally, the suggestions for CM improvement included refresher training for mentors, engagement of more senior mentors, and extending mentorship beyond IMPACT catchment facilities.

CONCLUSION

CM program appears to be a promising entry point to improving competence among HCPs and the quality and efficiency of RMNH services potentially contributing to the reduction of maternal and neonatal deaths. Addressing the challenges cited by participants, particularly the equipment for peer learning and practice, may increase the success of the CM program.

High-Frequency, Low-Dose Education to Improve Neonatal Outcomes in Low-Resource Settings: A Cluster Randomized Controlled Trial

BACKGROUND

Annually 2.5 million infants die in the first 28 days of life, with a significant regional distribution disparity. An estimated 80% of those could be saved if neonatal resuscitation were correctly and promptly initiated. A barrier to achieving the target is the knowledge and skills of healthcare workers.

PURPOSE

The objective of this cluster randomized trial was to assess the improvement and retention of resuscitation skills of nurses, midwives, and birth attendants in 2 birth centers serving 60 villages in rural India using high-frequency, low-dose training.

RESULTS

There was a significant difference (P < .05) between the groups in the rate of resuscitation, with 18% needing resuscitation in the control group and 6% in the intervention group. The posttest scores for knowledge retention at the final 8-month evaluation were significantly better in the intervention group than in the control group (intervention group mean rank 19.4 vs control group mean rank 10.3; P < .05). The success rate of resuscitation was not significantly different among the groups.

IMPLICATIONS FOR PRACTICE

Improved knowledge retention at 8 months and the lower need for resuscitation in the intervention group support the efficacy of the high-frequency, low-dose education model of teaching in this setting.

IMPLICATIONS FOR RESEARCH

Replication of these findings in other settings with a larger population cohort is needed to study the impact of such intervention on birth outcomes in low-resource settings.

Enabling change in public health services: Insights from the implementation of nurse mentoring interventions to improve quality of obstetric and newborn care in two North Indian states

Background: Few studies have explicitly examined the implementation of change interventions in low- and middle-income country (LMIC) public health services. We contribute to implementation science by analyzing the implementation of an organizational change intervention in a large, hierarchical and bureaucratic public service in a LMIC health system. Methods: Using qualitative methods, we critically interrogate the implementation of an intervention to improve quality of obstetric and newborn services across 692 facilities in Uttar Pradesh and Bihar states of India to reveal how to go about making change happen in LMIC public health services. Results: We found that focusing the interventions on a discreet part of the health service (labour rooms) ensured minimal disruption of the status quo and created room for initiating change. Establishing and maintaining respectful, trusting relationships is critical, and it takes time and much effort to cultivate such relationships. Investing in doing so allows one to create a safe space for change; it helps thaw entrenched practices, behaviours and attitudes, thereby creating opportunities for change. Those at the frontline of change processes need to be enabled and supported to: lead by example, model and embody desirable behaviours, be empathetic and humble, and make the change process a positive and meaningful experience for all involved. They need discretionary space to tailor activities to local contexts and need support from higher levels of the organisation to exercise discretion. Conclusions: We conclude that making change happen in LMIC public health services, is possible, and is best approached as a flexible, incremental, localised, learning process. Smaller change interventions targeting discreet parts of the public health services, if appropriately contextualised, can set the stage for incremental system wide changes and improvements to be initiated. To succeed, change initiatives need to cultivate and foster support across all levels of the organisation.

Enabling change in public health services: Insights from the implementation of nurse mentoring interventions to improve quality of obstetric and newborn care in two North Indian states

Background: Few studies have explicitly examined the implementation of change interventions in low- and middle-income country (LMIC) public health services. We contribute to implementation science by analyzing the implementation of an organizational change intervention in a large, hierarchical and bureaucratic public service in a LMIC health system. Methods: Using qualitative methods, we critically interrogate the implementation of an intervention to improve quality of obstetric and newborn services across 692 facilities in Uttar Pradesh and Bihar states of India to reveal how to go about making change happen in LMIC public health services. Results: We found that focusing the interventions on a discreet part of the health service (labour rooms) ensured minimal disruption of the status quo and created room for initiating change. Establishing and maintaining respectful, trusting relationships is critical, and it takes time and much effort to cultivate such relationships. Investing in doing so allows one to create a safe space for change; it helps thaw entrenched practices, behaviours and attitudes, thereby creating opportunities for change. Those at the frontline of change processes need to be enabled and supported to: lead by example, model and embody desirable behaviours, be empathetic and humble, and make the change process a positive and meaningful experience for all involved. They need discretionary space to tailor activities to local contexts and need support from higher levels of the organisation to exercise discretion. Conclusions: We conclude that making change happen in LMIC public health services, is possible, and is best approached as a flexible, incremental, localised, learning process. Smaller change interventions targeting discreet parts of the public health services, if appropriately contextualised, can set the stage for incremental system wide changes and improvements to be initiated. To succeed, change initiatives need to cultivate and foster support across all levels of the organisation.

Enabling change in public health services: Insights from the implementation of nurse mentoring interventions to improve quality of obstetric and newborn care in two North Indian states

Background: Few studies have explicitly examined the implementation of change interventions in low- and middle-income country (LMIC) public health services. We contribute to implementation science by adding to the knowledge base on strategies for implementing change interventions in large, hierarchical and bureaucratic public services in LMIC health systems. Methods: Using a mix of methods, we critically interrogate the implementation of an intervention to improve quality of obstetric and newborn services across 692 facilities in Uttar Pradesh and Bihar states of India to reveal how to go about making change happen in LMIC public health services. Results: We found that focusing the interventions on a discreet part of the health service (labour rooms) ensured minimal disruption of the status quo and created room for initiating change. Establishing and maintaining respectful, trusting relationships is critical, and it takes time and much effort to cultivate such relationships. Investing in doing so allows one to create a safe space for change; it helps thaw entrenched practices, behaviours and attitudes, thereby creating opportunities for change. Those at the frontline of change processes need to be enabled and supported to: lead by example, model and embody desirable behaviours, be empathetic and humble, and make the change process a positive and meaningful experience for all involved. They need discretionary space to tailor activities to local contexts and need support from higher levels of the organisation to exercise discretion. Conclusions: We conclude that making change happen in LMIC public health services, is possible, and is best approached as a flexible, incremental, localised, learning process. Smaller change interventions targeting discreet parts of the public health services, if appropriately contextualised, can set the stage for incremental system wide changes and improvements to be initiated. To succeed, change initiatives need to cultivate and foster support across all levels of the organisation.