Impact of financial and educational interventions on maternity care: results of cluster randomized trials in rural China, CHIMACA

Interventions to improve the quality of maternal care in Ethiopia: a scoping review

Introduction

Quality improvement interventions have been part of the national agenda aimed at reducing maternal and neonatal morbidities and mortality. Despite different interventions, neonatal mortality and morbidity rates remain steady. This review aimed to map and synthesize the evidence of maternal and newborn quality improvement interventions in Ethiopia.

Methods

A scoping review was reported based on the reporting items for systematic reviews and meta-analysis extensions for the scoping review checklist. Data extraction, collation, and organization were based on the Joanna Briggs Institute manual of the evidence synthesis framework for a scoping review. The maternal and neonatal care standards from the World Health Organization and the Donabedian quality of health framework were used to summarize the findings.

Results

Nineteen articles were included in this scoping review. The review found that the studies were conducted across various regions of Ethiopia, with the majority published after 2013. The reviewed studies mainly focused on three maternal care quality interventions: mobile and electronic health (eHealth), quality improvement standards, and human resource mobilization. Moreover, the reviewed studies explored various approaches to quality improvement, such as providing training to healthcare workers, health extension workers, traditional birth attendants, the community health development army, and mothers and supplying resources needed for maternal and newborn care.

Conclusion

In conclusion, quality improvement strategies encompass community involvement, health education, mHealth, data-driven approaches, and health system strengthening. Future research should focus on the impact of physical environment, culture, sustainability, cost-effectiveness, and long-term effects of interventions. Healthcare providers' knowledge, skills, attitudes, satisfaction, and adherence to guidelines should also be considered.

Tuberculosis treatment management in primary healthcare sectors: a mixed-methods study investigating delivery status and barriers from organisational and patient perspectives

OBJECTIVE

Tuberculosis (TB) treatment management services (TTMSs) are crucial for improving patient treatment adherence. Under the TB integrated control model in China, healthcare workers (HCWs) in the primary healthcare (PHC) sectors are responsible for TTMS delivery. This mixed-method study aimed to explore the status of and barriers to TTMS delivery faced by HCWs in PHC sectors from the health organisational and patient perspectives.

DESIGN

We completed a questionnaire survey of 261 TB healthcare workers (TB HCWs) and 459 patients with TB in the PHC sector and conducted 20 semistructured interviews with health organisational leaders, TB HCWs and patients with TB. SPSS V.22.0 and the framework approach were used for data analysis.

SETTING

PHC sectors in Southwest China.

RESULTS

Our results showed that TTMS delivery rate by HCWs in PHC sectors was <90% (88.4%) on average, and the delivery rates of intensive and continuation phase directly observed therapy (DOT) were only 54.7% and 53.0%, respectively. HCWs with high work satisfaction and junior titles were more likely to deliver first-time home visits and DOT services. Our results suggest that barriers to TTMS delivery at the organisational level include limited patient-centred approaches, inadequate resources and incentives, insufficient training, poor cross-sectional coordination, and strict performance assessment. At the patient level, barriers include low socioeconomic status, poor health literacy and TB-related social stigma.

CONCLUSION

TTMSs in Southwest China still need further improvement, and this study highlighted specific barriers to TTMS delivery in the PHC sector. Comprehensive measures are urgently needed to address these barriers at the organisational and patient levels to promote TB control in Southwest China.

Training primary healthcare workers in China's township hospitals: a mixed methods study

Background

Primary health care (PHC) was a keystone toward achieving universal health coverage and Sustainable Development Goals (SDGs). China has made efforts to strengthen its PHC institutions. As part of such efforts, regular in-service training is crucial for primary healthcare workers (PHWs) to strengthen their knowledge and keep their skills up to date.

Objective

To investigate if and how the existing training arrangements influenced the competence and job satisfaction of PHWs in township hospitals (THs).

Methods

A mixed method approach was employed. We analyzed the associations between in-service training and competence, as well as between in-service training and job satisfaction of PHWs using logistic regression. Interviews were recorded, transcribed, and analyzed using NVivo12 to better understand the trainings and the impacts on PHWs.

Results

The study found that training was associated with competence for all the types of PHWs except nurses. The odds of higher competence for physicians who received long-term training were 3.60 (p < 0.01) and that of those who received both types of training was 2.40 (p < 0.01). PHWs who received short-term training had odds of higher competence significantly (OR = 1.710, p < 0.05). PHWs who received training were more satisfied than their untrained colleagues in general (OR = 1.638, p < 0.01). Specifically, physicians who received short-term training (OR = 1.916, p < 0.01) and who received both types of training (OR = 1.941, p < 0.05) had greater odds of general job satisfaction. The odds ratios (ORs) of general job satisfaction for nurses who received short-term training was 2.697 (p < 0.01), but this association was not significant for public health workers. The interview data supported these results, and revealed how training influenced competence and satisfaction.

Conclusions

Considering existing evidence that competence and satisfaction serve as two major determinants of health workers’ performance, to further improve PHWs’ performance, it is necessary to provide sufficient training opportunities and improve the quality of training.

Non-clinical interventions for reducing unnecessary caesarean section

BACKGROUND

Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline.

OBJECTIVES

To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions).

MAIN RESULTS

We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.

Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996-2016)

BACKGROUND

Community Health Workers (CHWs) have been widely used in response to the shortage of skilled health workers especially in resource limited areas. China has a long history of involving CHWs in public health intervention project. CHWs in China called village doctors who have both treatment and public health responsibilities. This systematic review aimed to identify the types of public health services provided by CHWs and summarized potential barriers and facilitating factors in the delivery of these services.

METHODS

We searched studies published in Chinese or English, on Medline, PubMed, Cochrane, Google Scholar, and CNKI for public health services delivered by CHWs in China, during 1996-2016. The role of CHWs, training for CHWs, challenges, and facilitating factors were extracted from reviewed studies.

RESULTS

Guided by National Basic Public Health Service Standards, services provided by CHW covered five major areas of noncommunicable diseases (NCDs) including diabetes and/or hypertension, cancer, mental health, cardiovascular diseases, and common NCD risk factors, as well as general services including reproductive health, tuberculosis, child health, vaccination, and other services. Not many studies investigated the barriers and facilitating factors of their programs, and none reported cost-effectiveness of the intervention. Barriers challenging the sustainability of the CHWs led projects were transportation, nature of official support, quantity and quality of CHWs, training of CHWs, incentives for CHWs, and maintaining a good rapport between CHWs and target population. Facilitating factors included positive official support, integration with the existing health system, financial support, considering CHW's perspectives, and technology support.

CONCLUSION

CHWs appear to frequently engage in implementing diverse public health intervention programs in China. Facilitators and barriers identified are comparable to those identified in high income countries. Future CHWs-led programs should consider incorporating the common barriers and facilitators identified in the current study to maximize the benefits of these programs.

Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes?

BACKGROUND

Demand-side financing (DSF) interventions, including cash transfers and vouchers, have been introduced to promote maternal and newborn health in a range of low- and middle-income countries. These interventions vary in design but have typically been used to increase health service utilisation by offsetting some financial costs for users, or increasing household income and incentivising 'healthy behaviours'. This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health.

METHODS

A secondary analysis (using an adapted Supporting the Use of Research Evidence framework - SURE) was performed on studies that had previously been identified in a systematic review of evidence on DSF interventions in maternal and newborn health.

RESULTS

The article draws on findings from 49 quantitative and 49 qualitative studies. The studies give insights on difficulties with exclusion of migrants, young and multiparous women, with demands for informal fees at facilities, and with challenges maintaining quality of care under increasing demand. Schemes experienced difficulties if communities faced long distances to reach participating facilities and poor access to transport, and where there was inadequate health infrastructure and human resources, shortages of medicines and problems with corruption. Studies that documented improved care-seeking indicated the importance of adequate programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements) to address the issue of concern, concurrent investments in supply-side capacity to sustain and/or improve quality of care, and awareness generation using community-based workers, leaders and women's groups.

CONCLUSIONS

Evaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social, geographical and health systems factors as barriers to accessing care. Careful design of DSF programmes as part of broader maternal and newborn health initiatives would need to take into account these barriers, the behaviours of staff and the quality of care in health facilities. Research is still needed on the policy context for DSF schemes in order to understand how they become sustainable and where they fit, or do not fit, with plans to achieve equitable universal health coverage.

The effects of cash transfers and vouchers on the use and quality of maternity care services: A systematic review

BACKGROUND

Cash transfers and vouchers are forms of 'demand-side financing' that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years.

METHODS

This systematic review consolidates evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, and updates the systematic searches to June 2015 using the Joanna Briggs Institute approach for systematic reviewing. The review protocol for this update was registered with PROSPERO (CRD42015020637).

RESULTS

Data from 51 studies (15 more than previous reviews) and 22 cash transfer and voucher programmes suggest that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant. However, effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment. There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes.

CONCLUSION

Future research should use multiple intervention arms to compare cost-effectiveness with similar investment in public services, and should look beyond short- to medium-term service utilisation by examining programme costs, longer-term effects on service utilisation and health outcomes, and the equity of those effects.

A systematic review of implementation strategies to deliver guidelines on obstetric care practice in low- and middle-income countries

BACKGROUND

Healthcare measures to prevent maternal deaths are well known. However, effective implementation of this knowledge to change practice remains a challenge.

OBJECTIVES

To assess whether strategies to promote the use of guidelines can improve obstetric practices in low- and middle-income countries (LMICs).

SEARCH STRATEGY

Electronic databases were searched up to February 7, 2014, using relevant terms for implementation strategies (e.g. "audit," "education," "reminder"), and maternal mortality.

SELECTION CRITERIA

Randomized and non-randomized studies of implementation strategies targeting healthcare professionals within the formal health services in LMICs were included.

DATA COLLECTION AND ANALYSIS

Cochrane methodological guidance was followed. Because of heterogeneity in the interventions, a narrative synthesis was completed.

MAIN RESULTS

Nine studies met the inclusion criteria. Moderate-to-low-quality evidence was found to show improvement in the areas of doctor-patient communication (one study), analgesic provision (one study), the management of emergencies (two studies) and maternal and late neonatal mortality (one study each). Intervention effects were not consistent across studies.

CONCLUSIONS

Implementation strategies targeting health professionals could lead to improvement in obstetric care in LMICs. Future research should explore what feature of an intervention is effective in one context and how this could be translated into another context.

PROSPERO

CRD42014010310.

Innovative approaches for improving maternal and newborn health--A landscape analysis

Background

Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added value to health systems remains incompletely understood. This study’s aim was to analyze the landscape of innovative MNH approaches and related published evidence.

Methods

Systematic literature review and descriptive analysis based on the MNH continuum of care framework and the World Health Organization health system building blocks, analyzing the range and nature of currently published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science, CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source and extracted data according to our study protocol.

Results

Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in which they had not been applied previously. Many aim at the direct organization and delivery of maternal and newborn health services or are primarily health workforce interventions. Innovative approaches also include health technologies, interventions based on community ownership and participation, and novel models of financing and policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health care delivery.

Conclusions

Future implementation and evaluation efforts need to assess innovations’ effects on health outcomes and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability. Measuring equity is an important aspect to identify and target population groups at risk of service inequity. Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their sustainable integration into health systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0784-9) contains supplementary material, which is available to authorized users.

Cesarean section in the People's Republic of China: current perspectives

OBJECTIVE

To review the current knowledge on the prevalence, reasons, and consequences of cesarean sections in the People's Republic of China.

METHODS

Peer-reviewed articles were systematically searched on PubMed. The following Chinese databases were comprehensively searched: the China National Knowledge Infrastructure, Wanfang, and the VIP information. The databases were searched from inception to September 1, 2013. Two reviewers independently screened the titles and abstracts for eligibility. Full texts of eligible papers were reviewed, where relevant references were hand-searched and reviewed.

FINDINGS

Sixty articles were included from PubMed, 17 articles were intentionally picked out from Chinese journals, and five additional articles were added, for a total of 82 articles for the analysis. With a current national rate near 40%, the literature consistently reported a rapid rise of cesarean sections in the People's Republic of China in the past decades, irrespective of where people lived or their socioeconomic standing. Nonclinical factors were considered as the main drivers fueling the rise of cesareans in the People's Republic of China. There was a lively debate on whether women's preferences or providers' distorted financial incentives affected the rise in cesarean sections. However, recent evidence suggests that it might be the People's Republic of China's health development approach - focusing on specialized care and marginalizing primary care - that is playing a role. Although 30 articles were identified studying the consequences of cesareans, the methodologies are in general weak and the themes are out of focus.

CONCLUSION

The overuse of cesareans is rising alarmingly in the People's Republic of China and has become a real public health problem. No consensus has been made on the leverage factors that drive the cesarean epidemic, particularly for those nonclinical factors. The more macro level structural factors may have played a part, though further research is warranted to understand the mechanisms. Knowledge of the consequences of cesareans, particularly for women, is limited in the People's Republic of China, leaving a substantial literature gap.

Work behaviour during pregnancy in rural China in 2009

OBJECTIVES

To describe the pattern and determinants of working during pregnancy in rural China.

METHODS

A cross-sectional survey was carried out in 2009 in three provinces (Anhui, Chongqing and Shaanxi) in rural China among 3966 mothers who had recently given birth. Multilevel logistic regression was used to examine the determinants of work behaviour during pregnancy.

RESULTS

Overall, 39% of the women stopped working during early pregnancy, 32% worked the same throughout pregnancy and the rest decreased their work or stopped later in pregnancy. Women from Anhui (53%) and Chongqing (54%) provinces were more likely to stop work in early pregnancy than women from Shaanxi province (20%). Older women [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.56-0.99], those having two or more children (OR 0.55, 95% CI 0.43-0.69) and non-farmers (OR 0.50, 95% CI 0.65-0.99) were less likely to stop working on the first trimester, but those with higher education (high school OR 1.43, 95% CI 1.05-1.94) were more likely to stop working. Stopping work early was not related to household income and adequacy of prenatal care. Women with two or more children, non-farmers and those from Shaanxi province were more likely to continue to work to the same extent during pregnancy. But those with higher household income and middle and high school were less likely to work the same.

CONCLUSIONS

Women's working patterns during pregnancy in rural China were polarized: many women stopped working already in early pregnancy, but others continued to work as before. The key determinant of the working patterns was the province of residence.