Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview

Women's satisfaction with midwife-led continuity of care: an observational study in Palestine

OBJECTIVES

A midwife-led continuity model of care had been implemented in the Palestinian governmental health system to improve maternal services in several rural areas. This study investigated if the model influenced women's satisfaction with care, during antenatal, intrapartum and postnatal period.

DESIGN

An observational case-control design was used to compare the midwife-led continuity model of care with regular maternity care.

PARTICIPANTS AND SETTING

Women with singleton pregnancies, who had registered for antenatal care at a rural governmental clinic in the West Bank, were between 1 to 6 months after birth invited to answer a questionnaire rating satisfaction with care in 7-point Likert scales.

PRIMARY OUTCOME

The mean sum-score of satisfaction with care through the continuum of antenatal, intrapartum and postnatal period, where mean sum-scores range from 1 (lowest) to 7 (highest).

SECONDARY OUTCOME

Exclusive breastfeeding.

RESULTS

Two hundred women answered the questionnaire, 100 who received the midwife-led model and 100 who received regular care. The median time point of interview were 16 weeks postpartum in both groups. The midwife-led model was associated with a statistically significant higher satisfaction with care during antenatal, intrapartum and postnatal period, with a mean sum-score of 5.2 versus 4.8 in the group receiving regular care. The adjusted mean difference between the groups' sum-score of satisfaction with care was 0.6 (95% CI 0.35 to 0.85), p<0.0001. A statistically significant higher proportion of women who received the midwife-led continuity model of care were still exclusively breastfeeding at the time point of interview, 67% versus 46% in the group receiving regular care, an adjusted OR of 2.56 (1.35 to 4.88) p=0.004.

CONCLUSIONS

There is an association between receiving midwife-led continuity of care and increased satisfaction with care through the continuum of pregnancy, intrapartum and postpartum period, and an increased duration of exclusive breastfeeding.

TRIAL REGISTRATION NUMBER

NCT03863600.

Health Extension Workers' diagnostic accuracy for common childhood illnesses in four regions of Ethiopia: a cross-sectional study

Aim

The Ethiopian primary care of sick children is provided within the integrated Community Case Management of childhood illnesses by Health Extension Workers (HEW). There is limited knowledge whether this cadre correctly assess and classify common diseases. The aim was to study their ability to correctly classify common childhood illnesses.

Methods

A survey was conducted from December 2016 to February 2017 in four regions of Ethiopia. Observations of the HEWs‘ assessment and classification of sick children were followed by child re-examination by a trained health officer.

Results

The classification by the HEWs of 620 sick children as compared to the reexaminer had a sensitivity of 89% and specificity of 94% for diarrhoea, sensitivity 52% and specificity 91% for febrile disorders, and a sensitivity of 59% and specificity of 94% for acute respiratory tract infection. Malnutrition and ear infection had a sensitivity of 39 and 61%, and a specificity of 99 and 99%, respectively.

Conclusion

Most cases of diarrhoea were correctly classified, while other illnesses were not frequently identified. The identification of malnutrition was especially at fault. These findings suggest that a significant number of sick children were undiagnosed that could lead to absent or incorrect management and treatment.

Women's experiences of disrespectful and abusive maternal health care in a low resource rural setting in eastern Zimbabwe

BACKGROUND

There has been an increase in recent publications, in high and medium resource settings, documenting women's dissatisfaction with the quality of maternity care they receive. Their discontent is mostly related to their midwives' disrespectful or negative attitudes.

OBJECTIVE

To explore women's experiences and perceptions of disrespect and abuse from their maternity care providers in a low resource rural setting in Zimbabwe.

DESIGN

A critical, qualitative research methodology, using in-depth interviews and two focus group discussions, was employed to capture rural women's experiences during antenatal care, postpartum care, and the use of maternity waiting homes' services.

SETTING

Three rural health centres in Mutare district, Manicaland Province in eastern Zimbabwe.

PARTICIPANTS

A total of 20 purposively sampled women, 16-30 years of age, who were accessing various stages of maternal health services, were recruited from three conveniently selected rural health centres. Eight women participated in the in-depth interviews. A further eight women were discussants in the first focus group, and a further four women participated in the second focus group.

FINDINGS

Multifaceted and interconnected factors contribute to midwives' attitudes and behaviours towards their clients. Midwives' subjective perceptions, women's social status, and health system constraints (i.e., availability of trained midwives and quality of midwifery training) in rural and poorly resourced community, often result in inappropriate services, negative attitudes, abusive treatment, and disrespectful behaviour towards women. Poor treatment in maternity care directly contribute to adverse health outcomes and women's satisfaction with services.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Women's social status, level of education and age, were perceived to influence the quality of care or treatment they received. Improving women's experience of maternal care requires targeted interventions at the interpersonal level between a woman and her health care providers, as well as at the level of the health care facility and the health system. The results of this study challenge all tiers of health personnel including policy makers, in low resource settings to reappraise the present situation thereby challenging these established behaviours, to ensure that the continuum of maternity care is respectfully and socio-culturally delivered.

Improving Maternal and Neonatal Health by a Midwife-led Continuity Model of Care - An Observational Study in One Governmental Hospital in Palestine

BACKGROUND

From 2013 a midwife-led continuity model of care was implemented in the Nablus region in occupied Palestine, involving a governmental hospital and ten rural villages. This study analysed the relation between the midwife-led model and maternal and neonatal health outcomes.

METHOD

A register-based, retrospective cohort design was used, involving 2201 singleton births between January 2016 and June 2017 at Nablus governmental hospital. Data from rural women, with singleton pregnancies and mixed risk status, who either lived in villages that offered the midwife-led continuity model and had registered at the governmental clinic, or who lived in villages without the midwife-led model and received regular care, were compared. Primary outcome was unplanned caesarean section. Secondary outcomes were other modes of birth, postpartum anaemia, preterm birth, birth weight, and admission to neonatal intensive care unit.

FINDINGS

Statistically significant less women receiving the midwife-led model had unplanned caesarean sections, 12·8% vs 15·9%, adjusted risk ratio (aRR) 0·80 (95% CI 0·64-0·99) and postpartum anaemia,19·8% vs 28·6%, aRR 0·72 (0·60-0·85). There was also a statistically significant lower rate of preterm births within the exposed group, 13·1% vs 16·8, aRR 0·79 (0·63-0·98), admission to neonatal intensive care unit, 7·0% vs 9·9%, aRR 0·71 (0·52-0·98) and newborn with birth weight 1500 g and less, 0·1% vs 1·1%, aRR 0·13 (0·02-0·97).

INTERPRETATION

Receiving the midwife-led continuity model of care in Palestine was associated with several improved maternal and neonatal health outcomes. The findings support further implementation of the model. Implementation research, including randomised studies, would be useful to further investigate the effect and feasibility of the model in a low resource setting.

FUNDING

This study was partly funded by the Research Council of Norway through the Global Health and Vaccination Program (GLOBVAC), project number 243706. The implementation received public funding through Norwegian Aid Committee (NORWAC).

WOMEN's Knowledge of Obstetric Danger signs in Ethiopia (WOMEN's KODE):a systematic review and meta-analysis

BACKGROUND

According to the 2015 World Health Organization report, globally, an estimated 10.7 million mothers died from 1990 to 2015 due to obstetric complications. This report showed that almost all global maternal deaths (99%) occurred in developing countries and two thirds of these deaths took place in sub-Saharan Africa where the majority of women lack knowledge about obstetric danger signs. In Ethiopia, in several research reports, it has been indicated that women have poor knowledge about obstetric danger signs. Although several studies have been conducted to assess women's knowledge of obstetric danger signs, to date, no systematic review has been conducted in Ethiopia. Therefore, this review is aimed at synthesising the existing literature about women's knowledge of obstetric danger signs.

METHODS

We systematically searched for articles from MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Web of Science, Scopus, Google Scholar and Maternity and Infant Care databases. A combination of search terms including 'knowledge' or 'awareness' or 'information' and 'pregnancy danger signs' or 'obstetric danger signs' or 'obstetric warning signs' and 'Ethiopia' was used to locate appropriate articles. Two reviewers conducted article screening and data abstraction independently. Observational studies published in English and conducted in Ethiopia to date were assessed for quality using the adapted Newcastle Ottawa Scale for cross-sectional studies. The PRISMA checklist was used to present the findings of this systematic review.

RESULTS

From the 215 articles initially screened by abstracts and titles, 12 studies fulfilled the inclusion criteria. All the studies reported women's knowledge of obstetric danger signs during pregnancy, ten articles reported on the level of knowledge during delivery and eight studies reported on the level of knowledge of danger signs during the postpartum period. The pooled random effect meta-analysis level of women's knowledge about obstetric danger signs during pregnancy, delivery and postpartum was 48%, 43% and 32%, respectively. Maternal age, education, income, health service use, distance from facility and women's autonomy were reported in several studies as determinants of women's knowledge of obstetric danger signs.

CONCLUSIONS

Women's knowledge about obstetric danger signs in Ethiopia was very poor, which could hamper access to obstetric care when women encounter obstetric complications. Counselling services during antenatal care and community-based health information dissemination about obstetric danger signs should be strengthened.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017077000.

An Innovative Mobile Health System to Improve and Standardize Antenatal Care Among Underserved Communities: A Feasibility Study in an Italian Hosting Center for Asylum Seekers

Innovative migrant-friendly tools are needed to assist health personnel manage the high number of pregnancies within reception centers. This study tests functionality and acceptability of a new mHealth system in providing antenatal care amongst migrants. The study, carried out between 2014 and 2016, involved 150 pregnant women residing in the largest European migrant reception center in Sicily. A ticket tracking system assessed the system's functionality and a questionnaire assessed women's acceptability. The system facilitated the collection of clinical data, enabling the creation of electronic patient records and identifying 10% of pregnancies as high-risk. The application's digital format increased health providers' adherence to antenatal-care recommendations, while the graphic interface facilitated women's engagement and retention of the health education modules. The study recorded a 91.9% patient satisfaction rate. The system was efficient in providing comprehensive and high-quality antenatal care amongst migrants, facilitating the continuity of care for a population undergoing frequent relocations.

Women suffer more from disrespectful and abusive care than from the labour pain itself: a qualitative study from Women's perspective

Background

Utilization of institutional delivery services could be hampered by women’s experience of disrespectful and abusive care during childbirth. However, such experiences are not well documented and taken into consideration id planning maternal health services in many developing countries. The aim of this study was to describe women’s experience of disrespect and abuse during giving birth at health facilities in northern Ethiopia.

Methods

A qualitative phenomenological study was conducted in Tigray, Ethiopia. Focus group discussions (FGDs) with primipara and multipara women were conducted to collect the necessary information. All study participants had their last delivery at a health facility in the year preceding the study. A semi-structured discussion guide was used to elicit discussion. Discussions were audio recorded and transcribed verbatim in the local language and then translated to English. Data were analyzed using thematic analysis approach assisted by the Open Code qualitative data management software.

Results

The study participants described disrespect and abuse as serious obstacles to utilization of maternal health services. Women reported experiencing feelings of being infantilized, losing self-control, being overlooked, being informed bad news without proper preparation, repeated examination without being properly communicated/informed, disallow companions, and left unattended during labor. Facility related issues include women’s perception of incompetence of professionals attending delivery, unhygienic facilities, and unavailability of basic supplies.

Conclusion

Women consider health facilities not fully prepared to provide respectful maternal care. Sustainable increase in institutional delivery requires ensuring quality, compassionate and caring services in all health facilities.

Is quality of care during childbirth consistent from admission to discharge? A qualitative study of delivery care in Uttar Pradesh, India

Background

Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality.

Methods

Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care.

Results

Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments.

Conclusions

The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.

The coverage of continuum of care in maternal, newborn and child health: a cross-sectional study of woman-child pairs in Ghana

Introduction

The continuum of care has recently received attention in maternal, newborn and child health. It can be an effective policy framework to ensure that every woman and child receives timely and appropriate services throughout the continuum. However, a commonly used measurement does not evaluate if a pair of woman and child complies with the continuum of care. This study assessed the continuum of care based on two measurements: continuous visits to health facilities (measurement 1) and receiving key components of services (measurement 2). It also explored individual-level and area-level factors associated with the continuum of care achievement and then investigated how the continuum of care differed across areas.

Methods

In this cross-sectional study in Ghana in 2013, the continuum of care achievement and other characteristics of 1401 pairs of randomly selected women and children were collected. Multilevel logistic regression was used to estimate the factors associated with the continuum of care and its divergence across 22 areas.

Results

Throughout the pregnancy, delivery and post-delivery stages, 7.9% of women and children achieved the continuum of care through continuous visits to health facilities (measurement 1). Meanwhile, 10.3% achieved the continuum of care by receiving all key components of maternal, newborn and child health services (measurement 2). Only 1.8% of them achieved it under both measurements. Women and children from wealthier households were more likely to achieve the continuum of care under both measurements. Women’s education and complications were associated with higher continuum of care services-based achievement. Variance of a random intercept was larger in the continuum of care services-based model than the visit-based model.

Conclusions

Most women and children failed to achieve the continuum of care in maternal, newborn and child health. Those who consistently visited health facilities did not necessarily receive key components of services.

Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa-a systematic review protocol

BACKGROUND

Nearly 15% of all pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labor, and complications of abortion. Between 1990 and 2015, an estimated 10.7 million women died due to obstetric complications. Almost all of these deaths (99%) happened in developing countries, and 66% of maternal deaths were attributed to sub-Saharan Africa. The majority of cases of maternal mortalities can be prevented through provision of evidence-based potentially life-saving signal functions of emergency obstetric care. However, different factors can hinder women's ability to access and use emergency obstetric services in sub-Saharan Africa. Therefore, the aim of this review is to synthesize current evidence on barriers to accessing and utilizing emergency obstetric care in sub-Saharan African. Decision-makers and policy formulators will use evidence generated from this review in improving maternal healthcare particularly the emergency obstetric care.

METHODS

Electronic databases including MEDLINE, CINAHL, Embase, and Maternity and Infant Care will be searched for studies using predefined search terms. Articles published in English language between 2010 and 2017 with quantitative and qualitative design will be included. The identified papers will be assessed for meeting eligibility criteria. First, the articles will be screened by examining their titles and abstracts. Then, two reviewers will review the full text of the selected articles independently. Two reviewers using a standard data extraction format will undertake data extraction from the retained studies. The quality of the included papers will be assessed using the mixed methods appraisal tool. Results from the eligible studies will be qualitatively synthesized using the narrative synthesis approach and reported using the three delays model. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be employed to present the findings.

DISCUSSION

This systematic review will present a detailed synthesis of the evidence for barriers to access and utilization of emergency obstetric care in sub-Saharan Africa over the last 7 years. This systematic review is expected to provide clear information that can help in designing maternal health policy and interventions particularly in emergency obstetric care in sub-Saharan Africa where maternal mortality remains high.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074102 .

Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine

OBJECTIVES

To improve maternal health services in rural areas, the Palestinian Ministry of Health launched a midwife-led continuity model in the West Bank in 2013. Midwives were deployed weekly from governmental hospitals to provide antenatal and postnatal care in rural clinics. We studied the intervention's impact on use and quality indicators of maternal services after 2 years' experience.

DESIGN

A non-randomised intervention design was chosen. The study was based on registry data only available at cluster level, 2 years before (2011and2012) and 2 years after (2014and2015) the intervention.

SETTING

All 53 primary healthcare clinics in Nablus and Jericho regions were stratified for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was number of antenatal visits. Important secondary outcomes were number of referrals to specialist care and number of postnatal home visits. Differences in changes within the two groups before and after the intervention were compared by using mixed effect models.

RESULTS

14 intervention clinics and 25 control clinics were included. Number of antenatal visits increased by 1.16 per woman in the intervention clinics, while declined by 0.39 in the control clinics, giving a statistically significant difference in change of 1.55 visits (95% CI 0.90 to 2.21). A statistically significant difference in number of referrals was observed between the groups, giving a ratio of rate ratios of 3.65 (2.78-4.78) as number of referrals increased by a rate ratio of 3.87 in the intervention group, while in the control the rate ratio was only 1.06.Home visits increased substantially in the intervention group but decreased in the control group, giving a ratio of RR 97.65 (45.20 - 210.96) CONCLUSION: The Palestinian midwife-led continuity model improved use and some quality indicators of maternal services. More research should be done to investigate if the model influenced individual health outcomes and satisfaction with care.

TRIAL REGISTRATION NUMBER

NCT03145571; Results.

Screening for recommended antenatal risk factors: How long does it take?

BACKGROUND

Detection and management of antenatal risk factors is critical for quality care.

AIMS

To determine (1) women's views about when they should be asked about antenatal health factors as recommended in the Australian antenatal guidelines; and (2) the time required to provide recommended care using a clinical scenario.

METHODS

In Phase 1, pregnant women attending an outpatient obstetrics clinic at a public hospital were surveyed about preferred screening for antenatal risk factors during visit(s). In Phase 2, a hypothetical clinical scenario of a woman attending her first antenatal visit with a practising midwife was video-recorded to extrapolate the time taken to ask about and offer assistance to manage clinical, screening and lifestyle risk factors.

FINDINGS

Most women (96%) perceived they should be asked about each of the risk factors at least once (i.e. at first visit). Total time taken to ask about all risk factors was 52min. More time was spent discussing clinical (11min) than lifestyle factors (4min). Adjusting for the estimated prevalence of each risk factor, the time taken to offer assistance was 8min per woman. Average time required for detecting and offering assistance to manage risk factors is 60min per average risk woman.

CONCLUSION

Women are willing to be asked about risk factors; however this process is time-consuming. Strategies to streamline visits and prioritise recommendations so time-efficient yet comprehensive care can be delivered are needed, particularly when factors require monitoring over time and for those who may be 'at-risk' for multiple factors.

Preference in place of delivery among rural Indian women

India accounts for the highest number of maternal and child deaths globally. A large body of empirical research suggests that improvement in the coverage of institutional delivery is essential to reduce the burden of maternal and child death. However the dynamics of choice of place of delivery is poorly understood. Using qualitative survey data consisting of twelve focus group discussions, conducted in a rural setting of West Bengal, India, this study aims to understand the reasons behind preferring home or institution for delivery. Findings reveal that some women who underwent an institutional delivery preferred to deliver their baby at home. On the other hand, of women who delivered their baby at home, 60% wanted to deliver their babies in institutions but could not do so, primarily due to the unwillingness of family members and misreporting of the onset of true labour pain. With the help of Accredited Social Health Activists, the village level health workers, there is need for an intervention that focuses on educating household members (essentially targeting husbands and mother-in-laws) about birth preparedness, and identification of true labour pain.

Bridging the quality chasm in maternal, newborn, and child healthcare in low- and middle-income countries

In a Perspective, Lars Åke Persson discusses the need to focus on quality of care to improve maternal, newborn, and child healthcare.

Preterm birth: the role of knowledge transfer and exchange

BACKGROUND

Preterm birth (PTB) is the leading cause of death in children under age five. Healthcare policy and other decision-making relevant to PTB may rely on obsolete, incomplete or inapplicable research evidence, leading to worsened outcomes. Appropriate knowledge transfer and exchange (KTE) strategies are an important component of efforts to reduce the global PTB burden. We sought to develop a 'landscape' analysis of KTE strategies currently used in PTB and related contexts, and to make recommendations for optimising programmatic implementation and for future research.

METHODS

In the University of California, San Francisco's Preterm Birth Initiative, we convened a multidisciplinary working group and examined KTE frameworks. After selecting a widely-used, adaptable, theoretically-strong framework we reviewed the literature to identify evidence-based KTE strategies. We analysed KTE approaches focusing on key PTB stakeholders (individuals, families and communities, healthcare providers and policymakers). Guided by the framework, we articulated KTE approaches that would likely improve PTB outcomes. We further applied the KTE framework in developing recommendations.

RESULTS

We selected the Linking Research to Action framework. Searches identified 19 systematic reviews, including two 'reviews of reviews'. Twelve reviews provided evidence for KTE strategies in the context of maternal, neonatal and child health, though not PTB specifically; seven reviews provided 'cross-cutting' evidence that could likely be generalised to PTB contexts. For individuals, families and communities, potentially effective KTE strategies include community-based approaches, 'decision aids', regular discussions with providers and other strategies. For providers, KTE outcomes may be improved through local opinion leaders, electronic reminders, multifaceted strategies and other approaches. Policy decisions relevant to PTB may best be informed through the use of evidence briefs, deliberative dialogues, the SUPPORT tools for evidence-informed policymaking and other strategies. Our recommendations for research addressed knowledge gaps in regard to partner engagement, applicability and context, implementation strategy research, monitoring and evaluation, and infrastructure for sustainable KTE efforts.

CONCLUSIONS

Evidence-based KTE, using strategies appropriate to each stakeholder group, is essential to any effort to improve health at the population level. PTB stakeholders should be fully engaged in KTE and programme planning from its earliest stages, and ideally before planning begins.

Effect of support supervision on maternal and newborn health services and practices in Rural Eastern Uganda

BACKGROUND

Support supervision is one of the strategies used to check the quality of services provided at health facilities. From 2013 to 2015, Makerere University School of Public Health strengthened support supervision in the district of Kibuku, Kamuli and Pallisa in Eastern Uganda to improve the quality of maternal and newborn services.

OBJECTIVE

This article assesses quality improvements in maternal and newborn care services and practices during this period.

METHODS

District management teams were trained for two days on how to conduct the supportive supervision. Teams were then allocated particular facilities, which they consistently visited every quarter. During each visit, teams scored the performance of each facility based on checklists; feedback and corrective actions were implemented. Support supervision focused on maternal health services, newborn care services, human resources, laboratory services, availability of Information, education and communication materials and infrastructure. Support supervision reports and checklists from a total of 28 health facilities, each with at least three support supervision visits, were analyzed for this study and 20 key-informant interviews conducted.

RESULTS

There was noticeable improvement in maternal and newborn services. For instance, across the first, second and third quarters, availability of parenteral oxytocin increased from 57% to 75% and then to 82%. Removal of retained products increased from 14% to 50% to 54%, respectively. There was perceived improvement in the use of standards and guidelines for emergency obstetric care and quality of care provided. Qualitatively, three themes were identified that promote the success of supportive supervision: changes in the support supervision style, changes in the adherence to clinical standards and guidelines, and multi-stakeholder engagement.

CONCLUSION

Support supervision helped district health managers to identify and address maternal and newborn service-delivery gaps. However, issues beyond the jurisdiction of district health managers and facility managers may require additional interventions beyond supportive supervision.

Healthcare provider's attitude towards disability and experience of women with disabilities in the use of maternal healthcare service in rural Nepal

Background

Women with disabilities are less likely to receive maternal healthcare services compared to women without disabilities. While few studies have reviewed healthcare experience of women with disabilities, no studies have been conducted to understand provider’s attitude towards disability in Nepal, yet the attitude and behaviour of healthcare providers may have a significant influence on aspects of care and the use of service by women with disabilities. This study examines healthcare provider’s attitudes towards disability and explores the experience of women with disabilities in maternal healthcare service utilization during pregnancy and childbirth.

Method

The study used mixed method approach. An attitude survey was conducted among 396 healthcare providers currently working in public health facilities in Rupandehi district of Nepal. For additional insight, eighteen in-depth interviews with women with disabilities who used maternal healthcare services in a healthcare facility within the study district in their last pregnancy were undertaken. The Attitude Towards Disabled Persons (ATDP) scale score was used to measure the attitudes of healthcare providers. For quantitative data, univariate and multivariate analysis using ANOVA was used to understand the association between outcome and independent variables and qualitative analysis generated and described themes.

Results

Mean ATDP score among healthcare providers (78.52; SD = 14.75), was low compared to the normative score of 100 or higher. Nurses/auxiliary nurse midwives obtained the highest mean score (85.59, SD = 13.45), followed by general clinical health workers (Mean score = 82.64, SD 15.10). The lowest score was obtained by Female Community Health Volunteers (FCHV) (Score = 73.75, SD = 13.40) (P < 0.001). Younger providers were more positive compared to older age groups (P < 0.001). Similarly, providers working in urban health facilities compared to those working in rural health facilities, and non-Dalit providers compared to Dalit providers reported more positive attitudes towards disability (P < 0.05). However, there were no significant differences in ATDP mean scores between those who had or had not previously provided services for women with disabilities. The mean score difference between those who received disability training and who did not was also found statistically insignificant (P > 0.05). This may reflect the small number of individuals, who have had training on disability thus far, or the nature or quality of the training currently available.

The majority of qualitative interview participants perceived providers to have the negative attitude with poor knowledge, skills and preparation for providing care to persons with disabilities. Few participants perceived the providers as kind, respectful, caring or helpful.

Conclusion

Overall, provider’s attitude towards disability was found to be negative with poor knowledge and skills about providing services. This may have adversely impact maternal healthcare service utilization by women with disabilities. More organized, effective training for healthcare providers is required through on-going mainstream efforts to develop favorable attitudes towards disability. Further research on this subject is also needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-017-0330-5) contains supplementary material, which is available to authorized users.

Facilitators and Barriers of Community-Level Quality Improvement for Maternal and Newborn Health in Tanzania

A quality improvement intervention for maternal and newborn health was carried out in southern Tanzania at the community level. It sought to improve health-seeking behaviors and uptake of community-level maternal and newborn health practices. A process evaluation populated using data primarily from in-depth interviews and focus group discussions with the intervention's implementers was undertaken in four villages receiving the intervention to evaluate the intervention's implementation, uncover facilitators and barriers of quality improvement, and highlight contextual factors that might have influenced implementation. Performance implementation scores were used to rank the villages. Identifying higher- and lower-performing villages highlighted key facilitators and barriers of community-level quality improvement related to support from local leaders, motivation through use of local quality improvement data, and regular education around quality improvement and maternal and newborn health. These findings can be taken formatively in the design of similar interventions in the future.

Labouring Together: collaborative alliances in maternity care in Victoria, Australia-protocol of a mixed-methods study

INTRODUCTION

For over a decade, enquiries into adverse perinatal outcomes have led to reports that poor collaboration has been detrimental to the safety and experience of maternity care. Despite efforts to improve collaboration, investigations into maternity care at Morecambe Bay (UK) and Djerriwarrh Health Services (Australia) have revealed that poor collaboration and decision-making remain a threat to perinatal safety. The Labouring Together study will investigate how elements hypothesised to influence the effectiveness of collaboration are reflected in perceptions and experiences of clinicians and childbearing women in Victoria, Australia. The study will explore conditions that assist clinicians and women to work collaboratively to support positive maternity outcomes. Results of the study will provide a platform for consumers, clinician groups, organisations and policymakers to work together to improve the quality, safety and experience of maternity care.

METHODS AND ANALYSIS

4 case study sites have been selected to represent a range of models of maternity care in metropolitan and regional Victoria, Australia. A mixed-methods approach including cross-sectional surveys and interviews will be used in each case study site, involving both clinicians and consumers. Quantitative data analysis will include descriptive statistics, 2-way multivariate analysis of variance for the dependent and independent variables, and χ² analysis to identify the degree of congruence between consumer preferences and experiences. Interview data will be analysed for emerging themes and concepts. Data will then be analysed for convergent lines of enquiry supported by triangulation of data to draw conclusions.

ETHICS AND DISSEMINATION

Organisational ethics approval has been received from the case study sites and Deakin University Human Research Ethics Committee (2014-238). Dissemination of the results of the Labouring Together study will be via peer-reviewed publications and conference presentations, and in written reports for each case study site to support organisational change.

Performance-based financing to increase utilization of maternal health services: Evidence from Burkina Faso

Performance-based financing (PBF) programs are increasingly implemented in low and middle-income countries to improve health service quality and utilization. In April 2011, a PBF pilot program was launched in Boulsa, Leo and Titao districts in Burkina Faso with the objective of increasing the provision and quality of maternal health services. We evaluate the impact of this program using facility-level administrative data from the national health management information system (HMIS). Primary outcomes were the number of antenatal care visits, the proportion of antenatal care visits that occurred during the first trimester of pregnancy, the number of institutional deliveries and the number of postnatal care visits. To assess program impact we use a difference-in-differences approach, comparing changes in health service provision post-introduction with changes in matched comparison areas. All models were estimated using ordinary least squares (OLS) regression models with standard errors clustered at the facility level. On average, PBF facilities had 2.3 more antenatal care visits (95% CI [0.446-4.225]), 2.1 more deliveries (95% CI [0.034-4.069]) and 9.5 more postnatal care visits (95% CI [6.099, 12.903]) each month after the introduction of PBF. Compared to the service provision levels prior to the interventions, this implies a relative increase of 27.7 percent for ANC, of 9.2 percent for deliveries, and of 118.7 percent for postnatal care. Given the positive results observed during the pre-pilot period and the limited resources available in the health sector, the PBF program in Burkina Faso may be a low-cost, high impact intervention to improve maternal and child health.

Predictors of nurses' and midwives' intentions to provide maternal and child healthcare services to adolescents in South Africa

Background

Adolescent mothers are at a much higher risk for maternal mortality compared to mothers aged 20 years and above. Newborns born to adolescent mothers are also more likely to have low birth weight, with the risk of long-term effects such as early onset of adult diabetes than newborns of older mothers. Few studies have investigated the determinants of adequate quality maternal and child healthcare services to pregnant adolescents. This study was conducted to gain an understanding of nurses’ and midwives’ intentions to provide maternal and child healthcare and family planning services to adolescents in South Africa.

Methods

A total of 190 nurses and midwives completed a cross-sectional survey. The survey included components on demographics, knowledge of maternal and child healthcare (MCH) and family planning (FP) services, attitude towards family planning services, subjective norms regarding maternal and child healthcare and family planning services, self-efficacy with maternal and child healthcare and family planning services, and intentions to provide maternal and child healthcare and family planning services to adolescents. Pearson’s correlation analysis was conducted to determine the association between knowledge, attitude, subjective norms, self-efficacy, and intention variables for FP and MCH services. A 2-step linear regression analysis was then conducted for both FP and MCH services to predict the intentions to provide FP and MCH services to adolescents.

Results

Self-efficacy to conduct MCH services (β = 0.55, p < 0.01) and years of experience as a nurse- midwife (β = 0.14, p < 0.05) were associated with stronger intentions to provide the services. Self-efficacy to provide FP services (β = 0.30, p < 0.01) was associated with stronger intentions to provide FP services.

Conclusions

Self-efficacy has a strong and positive association with the intentions to provide both MCH and FP services, while there is a moderate association with attitude and norms. There is a need to improve and strengthen nurses’ and midwives’ self-efficacy in conducting both MCH and FP services in order to improve the quality and utilization of the services by adolescents in South Africa.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1901-9) contains supplementary material, which is available to authorized users.

Using systematized tacit knowledge to prioritize implementation challenges in existing maternal health programs: implications for the post MDG era

Strategic priority setting and implementation of strategies to reduce maternal mortality are key to the post Millennium Development Goal (MDG) 2015 agenda. This article highlights the feasibility and the advantages of using a systematized tacit knowledge approach, using data from maternal health program personnel, to identify local challenges to implementing policies and programs to inform the post MDG era. Communities of practice, conceived as groups of people sharing professional interests, experiences and knowledge, were formed with diverse health personnel implementing maternal health programs in Mexico and Nicaragua. Participants attended several workshops and developed different online activities aiming to strengthen their capacities to acquire, analyze, adapt and apply research results and to systematize their experience and knowledge of the actual implementation of these programs. Concept mapping, a general method designed to organize and depict the ideas of a group on a particular topic, was used to manage, discuss and systematize their tacit knowledge about implementation problems of the programs they work in. Using a special online concept mapping platform, participants prioritized implementation problems by sorting them in conceptual clusters and rating their importance and feasibility of solution. Two hundred and thirty-one participants from three communities of practice in each country registered on the online concept mapping platform and 200 people satisfactorily completed the sorting and rating activities. Participants further discussed these results to prioritize the implementation problems of maternal health programs. Our main finding was a great similarity between the Mexican and the Nicaraguan general results highlighting the importance and the feasibility of solution of implementation problems related to the quality of healthcare. The use of rigorously organized tacit knowledge of health personnel proved to be a feasible and useful tool for prioritization to inform implementation priorities in the post MDG agenda.

Pregnant Women's Intentions and Subsequent Behaviors Regarding Maternal and Neonatal Service Utilization: Results from a Cohort Study in Nyanza Province, Kenya

Higher use of maternal and neonatal health (MNH) services may reduce maternal and neonatal mortality in Kenya. This study aims to: 1) prospectively explore women’s intentions to use MNH services (antenatal care, delivery in a facility, postnatal care, neonatal care) at <20 and 30–35 weeks’ gestation and their actual use of these services; 2) identify predictors of intention-behavior discordance among women with positive service use intentions; 3) examine associations between place of delivery, women’s reasons for choosing it, and birthing experiences. We used data from a 2012–2013 population-based cohort of pregnant women in the Demographic Surveillance Site in Nyanza province, Kenya. Of 1,056 women completing the study (89.1% response rate), 948 had live-births and 22 stillbirths, and they represent our analytic sample. Logistic regression analysis identified predictors of intention-behavior discordance regarding delivery in a facility and use of postnatal and neonatal care. At <20 and 30–35 weeks’ gestation, most women intended to seek MNH services (≥93.9% and ≥87.5%, respectively, for all services assessed). Actual service use was high for antenatal (98.1%) and neonatal (88.5%) care, but lower for delivery in a facility (76.9%) and postnatal care (51.8%). Woman’s age >35 and high-school education were significant predictors of intention-behavior discordance regarding delivery in a facility; several delivery-related factors were significantly associated with intention-behavior discordance regarding use of postnatal and neonatal care. Delivery facilities were chosen based on proximity to women’s residence, affordability, and service quality; among women who delivered outside a health facility, 16.3% could not afford going to a facility. Good/very good birth experiences were reported by 93.6% of women who delivered in a facility and 32.6% of women who did not. We found higher MNH service utilization than previously documented in Nyanza province. Further increasing the number of facility deliveries and use of postnatal care may improve MNH in Kenya.

Responsive versus scheduled feeding for preterm infants

BACKGROUND

Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of a policy of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth rates, levels of parent satisfaction, and time to hospital discharge.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 17 February 2016), Embase (1980 to 17 February 2016), and CINAHL (1982 to 17 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses. We assessed the quality of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.36, 95% CI -2.44 to -0.29 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.53, 95% CI -6.80 to -4.25 days). GRADE assessments indicated low quality of evidence. The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views.

AUTHORS' CONCLUSIONS

Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some (low quality) evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. This finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.

Women's perceptions of antenatal care: are we following guideline recommended care?

Background

Detection and management of antenatal risk factors is critical for improved maternal and infant outcomes. This study describes the proportion of pregnant women who self-reported being screened for and offered advice to manage antenatal risk factors in line with antenatal care recommendations; and the characteristics associated with rates of screening.

Methods

A survey was undertaken with 223 (64 % of eligible) pregnant women recruited from an outpatient obstetrics clinic at a public hospital. Participants self-reported whether they were: (i) screened for 23 guideline-recommended risk factors during their antenatal visit; (ii) offered assistance to manage identified risk factor(s); and (iii) received assistance that was of benefit. Association between rate of screening and participant characteristics was examined using multivariate quantile regression.

Results

Overall, 23 % of women reported that they were asked about every risk factor. Weight gain (48 %), diet (60 %) and oral health (31 %) were least frequently screened risk factors. The number of women who reported they were offered advice to manage identified risks and the value of that advice was perceived by women as suboptimal. Those women receiving shared care between a midwife and general practitioner, of Aboriginal or Torres Strait Islander descent, and without private health insurance reported being screened for a greater number of risk factors.

Conclusions

Pregnant women report suboptimal rates of screening and management of antenatal risk factors. Initiatives to improve consistency in detection of antenatal risk factors and the application of appropriate interventions to manage those risk factors that are detected are required.

eRegistries: Electronic registries for maternal and child health

BACKGROUND

The Global Roadmap for Health Measurement and Accountability sees integrated systems for health information as key to obtaining seamless, sustainable, and secure information exchanges at all levels of health systems. The Global Strategy for Women's, Children's and Adolescent's Health aims to achieve a continuum of quality of care with effective coverage of interventions. The WHO and World Bank recommend that countries focus on intervention coverage to monitor programs and progress for universal health coverage. Electronic health registries - eRegistries - represent integrated systems that secure a triple return on investments: First, effective single data collection for health workers to seamlessly follow individuals along the continuum of care and across disconnected cadres of care providers. Second, real-time public health surveillance and monitoring of intervention coverage, and third, feedback of information to individuals, care providers and the public for transparent accountability. This series on eRegistries presents frameworks and tools to facilitate the development and secure operation of eRegistries for maternal and child health.

METHODS

In this first paper of the eRegistries Series we have used WHO frameworks and taxonomy to map how eRegistries can support commonly used electronic and mobile applications to alleviate health systems constraints in maternal and child health. A web-based survey of public health officials in 64 low- and middle-income countries, and a systematic search of literature from 2005-2015, aimed to assess country capacities by the current status, quality and use of data in reproductive health registries.

RESULTS

eRegistries can offer support for the 12 most commonly used electronic and mobile applications for health. Countries are implementing health registries in various forms, the majority in transition from paper-based data collection to electronic systems, but very few have eRegistries that can act as an integrating backbone for health information. More mature country capacity reflected by published health registry based research is emerging in settings reaching regional or national scale, increasingly with electronic solutions. 66 scientific publications were identified based on 32 registry systems in 23 countries over a period of 10 years; this reflects a challenging experience and capacity gap for delivering sustainable high quality registries.

CONCLUSIONS

Registries are being developed and used in many high burden countries, but their potential benefits are far from realized as few countries have fully transitioned from paper-based health information to integrated electronic backbone systems. Free tools and frameworks exist to facilitate progress in health information for women and children.

Continuum of Care in a Maternal, Newborn and Child Health Program in Ghana: Low Completion Rate and Multiple Obstacle Factors

Background

Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 15–49.

Methods

A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion.

Results

Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.13–0.39), marital status (OR = 0.45; CI 0.22–0.95), education (OR = 2.71; CI 1.11–6.57), transportation (OR = 1.97; CI 1.07–3.62), and beliefs about childhood illnesses (OR = 0.34; CI0.21–0.61).

Conclusion

The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate.

Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa

Background

Poor quality of care at health facilities is a barrier to pregnant women and their families accessing skilled care. Increasing evidence from low resource countries suggests care women receive during labor and childbirth is sometimes rude, disrespectful, abusive, and not responsive to their needs. However, little is known about how frequently women experience these behaviors. This study is one of the first to report prevalence of respectful maternity care and disrespectful and abusive behavior at facilities in multiple low resource countries.

Methods

Structured, standardized clinical observation checklists were used to directly observe quality of care at facilities in five countries: Ethiopia, Kenya, Madagascar, Rwanda, and the United Republic of Tanzania. Respectful care was represented by 10 items describing actions the provider should take to ensure the client was informed and able to make choices about her care, and that her dignity and privacy were respected. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Clinical observers’ open-ended comments were also analyzed to identify examples of disrespect and abuse.

Results

A total of 2164 labor and delivery observations were conducted at hospitals and health centers. Encouragingly, women overall were treated with dignity and in a supportive manner by providers, but many women experienced poor interactions with providers and were not well-informed about their care. Both physical and verbal abuse of women were observed during the study. The most frequently mentioned form of disrespect and abuse in the open-ended comments was abandonment and neglect.

Conclusions

Efforts to increase use of facility-based maternity care in low income countries are unlikely to achieve desired gains if there is no improvement in quality of care provided, especially elements of respectful care. This analysis identified insufficient communication and information sharing by providers as well as delays in care and abandonment of laboring women as deficiencies in respectful care. Failure to adopt a patient-centered approach and a lack of health system resources are contributing structural factors. Further research is needed to understand these barriers and develop effective interventions to promote respectful care in this context.

Responsive versus scheduled feeding for preterm infants

BACKGROUND

Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth, duration of hospital stay, and parental satisfaction.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2015), MEDLINE (1966 to September 2015), EMBASE (1980 to September 2015), and CINAHL (1982 to September 2015), conference proceedings, previous reviews, and trial registries.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses.

MAIN RESULTS

We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.4, 95% CI -2.4 to -0.3 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.5, 95% CI -6.8 to -4.2 days). The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views.

AUTHORS' CONCLUSIONS

Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. However, this finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.

Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby

BACKGROUND

While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking.

METHODS

We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality.

RESULTS

Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed.

CONCLUSIONS

Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

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.

Improving the Quality of Health Care Services for Adolescents, Globally: A Standards-Driven Approach

PURPOSE

The World Health Organization (WHO) undertook an extensive and elaborate process to develop eight Global Standards to improve quality of health care services for adolescents. The objectives of this article are to present the Global Standards and their method of development.

METHODS

The Global Standards were developed through a four-stage process: (1) conducting needs assessment; (2) developing the Global Standards and their criteria; (3) expert consultations; and (4) assessing their usability. Needs assessment involved conducting a meta-review of systematic reviews and two online global surveys in 2013, one with primary health care providers and another with adolescents. The Global Standards were developed based on the needs assessment in conjunction with analysis of 26 national standards from 25 countries. The final document was reviewed by experts from the World Health Organization regional and country offices, governments, academia, nongovernmental organizations, and development partners. The standards were subsequently tested in Benin and in a regional expert consultation of Latin America and Caribbean countries for their usability.

RESULTS

The process resulted in the development of eight Global Standards and 79 criteria for measuring them: (1) adolescents' health literacy; (2) community support; (3) appropriate package of services; (4) providers' competencies; (5) facility characteristics; (6) equity and nondiscrimination; (7) data and quality improvement; and (8) adolescents' participation.

CONCLUSIONS

The eight standards are intended to act as benchmarks against which quality of health care provided to adolescents could be compared. Health care services can use the standards as part of their internal quality assurance mechanisms or as part of an external accreditation process.

Does the Janani Suraksha Yojana cash transfer programme to promote facility births in India ensure skilled birth attendance? A qualitative study of intrapartum care in Madhya Pradesh

BACKGROUND

Access to facility delivery in India has significantly increased with the Janani Suraksha Yojana (JSY) cash transfer programme to promote facility births. However, a decline in maternal mortality has only followed secular trends as seen from the beginning of the decade well before the programme began. We, therefore, examined the quality of intrapartum care provided in facilities under the JSY programme to study whether it ensures skilled attendance at birth.

DESIGN

1) Non-participant observations (n=18) of intrapartum care during vaginal deliveries at a representative sample of 11 facilities in Madhya Pradesh to document what happens during intrapartum care. 2) Interviews (n=10) with providers to explore reasons for this care. Thematic framework analysis was used.

RESULTS

Three themes emerged from the data: 1) delivery environment is chaotic: delivery rooms were not conducive to safe, women-friendly care provision, and coordination between providers was poor. 2) Staff do not provide skilled care routinely: this emerged from observations that monitoring was limited to assessment of cervical dilatation, lack of readiness to provide key elements of care, and the execution of harmful/unnecessary practices coupled with poor techniques. 3) Dominant staff, passive recipients: staff sometimes threatened, abused, or ignored women during delivery; women were passive and accepted dominance and disrespect. Attendants served as 'go-betweens' patients and providers. The interviews with providers revealed their awareness of the compromised quality of care, but they were constrained by structural problems. Positive practices were also observed, including companionship during childbirth and women mobilising in the early stages of labour.

CONCLUSIONS

Our observational study did not suggest an adequate level of skilled birth attendance (SBA). The findings reveal insufficiencies in the health system and organisational structures to provide an 'enabling environment' for SBA. We highlight the need to ensure quality obstetric care prior to increasing coverage of facility births if cash transfer programmes like the JSY are to improve health outcomes.

Utilization of maternal healthcare among adolescent mothers in urban India: evidence from DLHS-3

Background. Low use of maternal healthcare services is one of the reasons why maternal mortality is still considerably high among adolescents mothers in India. To increase the utilization of these services, it is necessary to identify factors that affect service utilization. To our knowledge, no national level study in India has yet examined the issue in the context urban adolescent mothers. The present study is an attempt to fill this gap. Data and Methods. Using information from the third wave of District Level Household Survey (2007-08), we have examined factors associated with the utilization of maternal healthcare services among urban Indian married adolescent women (aged 13-19 years) who have given live/still births during last three years preceding the survey. The three outcome variables included in the analyses are 'full antenatal care (ANC)', 'safe delivery' and 'postnatal care within 42 days of delivery'. We have used Chi-square test to determine the difference in proportion and the binary logistic regression to understand the net effect of predictor variables on the utilization of maternity care. Results. About 22.9% of mothers have received full ANC, 65.1% of mothers have had at least one postnatal check-up within 42 days of pregnancy. The proportion of mother having a safe delivery, i.e., assisted by skilled personnel, is about 70.5%. Findings indicate that there is considerable amount of variation in use of maternity care by educational attainment, household wealth, religion, parity and region of residence. Receiving full antenatal care is significantly associated with mother's education, religion, caste, household wealth, parity, exposure to healthcare messages and region of residence. Mother's education, full antenatal care, parity, household wealth, religion and region of residence are also statistically significant in case of safe delivery. The use of postnatal care is associated with household wealth, woman's education, full antenatal care, safe delivery care and region of residence. Conclusion. Several socioeconomic and demographic factors affect the utilization of maternal healthcare services among urban adolescent women in India. Promoting the use of family planning, female education and higher age at marriage, targeting vulnerable groups such as poor, illiterate, high parity women, involving media and grass root level workers and collaboration between community leaders and health care system could be some important policy level interventions to address the unmet need of maternity services among urban adolescents.