Methodology and tools for quality improvement in maternal and newborn health care

Improving the quality of neonatal health care in Ethiopia: a systematic review

Background

Ensuring high-quality healthcare for newborns is essential for improving their chances of survival within Ethiopia's healthcare system. Although various intervention approaches have been implemented, neonatal mortality rates remain stable. Therefore, the present review seeks to identify initiatives for enhancing healthcare quality, their effects on neonatal wellbeing, and the factors hindering or supporting these Quality Improvement (QI) efforts' success in Ethiopia.

Methods

We searched for original research studies up to June 23, 2023, using PubMed/Medline, WHO-Global Health Library, Cochrane, Clinical Trials.gov, and Hinari. After selecting eligible studies, we assessed their quality using a mixed-method appraisal tool. Quality of care refers to how healthcare services effectively improve desired outcomes for individuals and patient populations. It encompasses vital principles such as safety, effectiveness, timeliness, efficiency, equity, and patient-centeredness.

Results

We found 3,027 publication records and included 13 studies during our search. All these interventions primarily aimed to provide safe healthcare, with a strong focus on Domain One, which deals with the evidence-based routine upkeep and handling of complications, and Domain Seven, which revolves around ensuring staff competency, emerged as a frequent target for intervention. Many interventions aimed at improving quality also concentrate on essential quality measure elements such as processes, focusing on the activities that occur during care delivery, and quality planning, involving distributing resources, such as basic medicine and equipment, and improving infrastructure. Moreover, little about the facilitators and barriers to QI interventions is investigated.

Conclusions

This review highlights the significance of introducing QI initiatives in Ethiopia, enhancing the healthcare system's capabilities, engaging the community, offering financial incentives, and leveraging mobile health technologies. Implementing QI interventions in Ethiopia poses difficulties due to resource constraints, insufficient infrastructure, and medical equipment and supplies shortages. It necessitates persistent endeavors to improve neonatal care quality, involving ongoing training, infrastructure enhancement, the establishment of standardized protocols, and continuous outcome monitoring. These efforts are crucial to achieving the optimal outcomes for newborns and their families.

Quality improvement in maternal and reproductive health services

As maternal mortality and morbidity rates stagnate or increase worldwide, there is an urgent need to address health system issues that impede access to high-quality care. Learning from efforts to address the value, safety, and effectiveness of reproductive and maternal health care is essential to advancing quality improvement efforts.

Auditing the readiness of healthcare facilities for referral and management of pre-eclampsia cases in Zanzibar- a study protocol

Hypertensive disorders of pregnancy are reported as the second leading root of maternal morbidity and mortality in Zanzibar. Evidence shows that the majority of pregnant women in Zanzibar are referred late from lower-level healthcare facilities, and majority develop complications of eclampsia. This study's goal is to determine if all public healthcare facilities in Zanzibar are prepared to manage pre-eclampsia cases and if lower-levels public healthcare facilities are ready to refer pre-eclampsia cases. This will be a descriptive cross-sectional study that will involve a total of 54 healthcare facilities and 176 health care providers working in antenatal clinics. All public health care facilities will be stratified into tertiary, secondary, and primary strata. A simple random sampling will be used to select 46 healthcare facilities in the primary stratum while all healthcare facilities within the tertiary and secondary strata will be selected. In each healthcare facility, a physical observation will be performed to assess the availability of equipment and supplies, medications, and lab tests, while a self-administered questionnaire will be used to assess the knowledge level and skills of healthcare providers for the management of pre-eclampsia and eclampsia. Patient's case files in the tertiary and secondary strata will be reviewed to assess the quality of management of pre-eclampsia while the service records of the primary stratum will be assessed for compliance status with referral guidelines. Data will be analyzed using SPSS version 25. Descriptive statistics will be used to describe the frequency distribution of the study variables, and results will be presented in terms of frequency and percentage. The Chi-square test will be used to describe the relationship between variables, and a p-value of < 0.05 will be regarded as a statistically significant difference.

Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda

Background: Preventable maternal and newborn deaths remain a global concern, particularly in low- and- middle-income countries (LMICs) Timely maternal death surveillance and response (MDSR) is a recommended strategy to account for such deaths through identifying contextual factors that contributed to the deaths to inform recommendations to implement in order to reduce future deaths. Implementation of MDSR is still suboptimal due to barriers such as inadequate skills and leadership to support MDSR. With the leadership of WHO and UNFPA, there is momentum to roll out MDSR, however, the barriers and enablers for implementation have received limited attention. These have  implications for successful implementation. The aim of this study was: To assess barriers and facilitators to implementation of MDSR at a busy urban National Referral Hospital as perceived by health workers, administrators, and other partners in Reproductive Health. Methods: Qualitative study using in-depth interviews (24), 4 focus-group discussions with health workers, 15 key-informant interviews with health sector managers and implementing partners in Reproductive-Health. We conducted thematic analysis drawing on the Theory of Planned Behaviour (TPB).   Results: The major barriers to implementation of MDSR were: inadequate knowledge and skills; fear of blame / litigation; failure to implement recommendations; burn out because of workload   and inadequate leadership- to support health workers. Major facilitators were involving all health workers in the MDSR process, eliminate blame, strengthen leadership, implement recommendations from MDSR and functionalize lower health facilities (especially Health Centre -IVs). Conclusions: The barriers of MDSR include knowledge and skills gaps, fear of blame and litigation, and other health system factors such as erratic emergency supplies, and leadership/governance challenges. Recommendation: Efforts to strengthen MDSR for impact should use health system responsiveness approach to address the barriers identified, constructive participation of health workers to harness the facilitators and addressing the required legal framework.

A qualitative assessment of facility readiness and barriers to the facility-based management of childhood severe acute malnutrition in the public healthcare settings in Bangladesh

OBJECTIVE

To assess facility readiness and identify barriers to the facility-based management of childhood severe acute malnutrition (SAM) in public healthcare settings.

DESIGN

Qualitative methods were applied to assess readiness and identify different perspectives on barriers to the facility-based management of children with SAM. Data collection was done using in-depth interviews, key informant interviews, exit interviews and pre-tested observation tools.

SETTINGS

Two tertiary care and four district hospitals in Rangpur and Sylhet Divisions of Bangladesh.

PARTICIPANTS

Healthcare professionals and caregivers of children with SAM.

RESULTS

Anthropometric tools, glucometer, medicines, F-75, F-100 and national guidelines for facility-based management of childhood SAM were found unavailable in some of the hospitals. Sitting and sleeping arrangements for the caregivers were absent in all of the chosen facilities. We identified a combination of health system and contextual barriers that inhibited the facility-based management of SAM. The health system barriers include inadequate manpower, rapid turnover of staff, increased workload, lack of training and lack of adherence to management protocol. The major facility barriers were insufficient space and unavailability of required equipment, medicines and foods for hospitalised children with SAM. The reluctance of caregivers to complete the treatment regimen, their insufficient knowledge regarding proper feeding, increased number of attendants and poverty of parents were the principal contextual barriers.

CONCLUSIONS

The study findings provide insights on barriers that are curbing the facility-based management of SAM and emphasise policy efforts to develop feasible interventions to reduce the barriers and ensure the preparedness of the facilities for effective service delivery.

Combined Clinical Audits and Low-Dose, High-frequency, In-service Training of Health Care Providers and Community Health Workers to Improve Maternal and Newborn Health in Mali: Protocol for a Pragmatic Cluster Randomized Trial

Background

Although most births in Mali occur in health facilities, a substantial number of newborns still die during delivery and within the first 7 days of life, mainly because of existing training deficiencies and the challenges of maintaining intrapartum and postpartum care skills.

Objective

This trial aims to assess the effectiveness and cost-effectiveness of an intervention combining clinical audits and low-dose, high-frequency (LDHF) in-service training of health care providers and community health workers to reduce perinatal mortality.

Methods

The study is a three-arm cluster randomized controlled trial in the Koulikoro region in Mali. The units of randomization are each of 84 primary care facilities. Each trial arm will include 28 facilities. The facilities in the first intervention arm will receive support in implementing mortality and morbidity audits, followed by one-day LDHF training biweekly, for 6 months. The health workers in the second intervention arm (28 facilities) will receive a refresher course in maternal neonatal and child health (MNCH) for 10 days in a classroom setting, in addition to mortality and morbidity audits and LDHF hands-on training for 6 months. The control arm, also with 28 facilities, will consist solely of the standard MNCH refresher training delivered in a classroom setting. The main outcomes are perinatal deaths in the intervention arms compared with those in the control arm. A final sample of approximately 600 deliveries per cluster was expected for a total of 30,000 newborns over 14 months. Data sources included both routine health records and follow-up household surveys of all women who recently gave birth in the study facility 7 days postdelivery. Data collection tools will capture perinatal deaths, complications, and adverse events, as well as the status of the newborn during the perinatal period. A full economic evaluation will be conducted to determine the incremental cost-effectiveness of each of the case-based focused LDHF hands-on training strategies in comparison to MNCH refresher training in a classroom setting.

Results

The trial is complete. The recruitment began on July 15, 2019, and data collection began on July 23, 2019, and was completed in November 2020. Data cleaning or analyses began at the time of submission of the protocol.

Conclusions

The results will provide policy makers and practitioners with crucial information on the impact of different health care provider training modalities on maternal and newborn health outcomes and how to successfully implement these strategies in resource-limited settings.

Trial Registration

ClinicalTrials.gov NCT03656237; https://clinicaltrials.gov/ct2/show/NCT03656237

International Registered Report Identifier (IRRID)

DERR1-10.2196/28644

Culture's Place in Quality of Care in a Resource-Constrained Health System: Comparison Between Three Malawi Districts

Public health scholars describe "culture of quality" in terms of desired values, attitudes, and practices, but this literature rarely includes explicitly stated theories of culture formation. In this article, we apply Fredrik Barth's transactional model to demonstrate how taking a theory-centered approach can help to identify what would be necessary to foster "cultures of quality" outlined in the public health literature. We draw on data from a study of the Republic of Malawi's Performance and Quality Improvement for Reproductive Health initiative. These data were generated in 2017-2018 through a 6-month organizational ethnography in three facilities selected to represent a range of districts with differing social and economic contexts. Our analysis revealed facility-level organizational cultures in which staff valued providing care, but responded to structural constraints by normalizing divergence from quality-of-care protocols. These findings indicate that sustaining a quality-oriented organizational culture requires addressing underlying conditions that generate routine experiences and practices.

Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors

Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.

Essential Newborn Care Service Readiness and Barriers in Northwest Ethiopia: A Descriptive Survey and Qualitative Study

Background

Despite the efforts put forth in improving neonatal survival, there is still a high rate of neonatal morbidity and mortality in northwest Ethiopia. Therefore, this study aimed to determine the essential newborn care service readiness scores and explore the health facility-related barriers in North Gondar Zone, Northwest Ethiopia.

Methods

A cross-sectional survey of 16 health facilities (14 health centers and two hospitals) and twelve in-depth interviews were included in the study in three randomly selected districts of North Gondar Zone. A pretested health facility inventory questionnaire customized from the World Health Organization (WHO) service readiness assessment tool was used for a facility audit. Basic emergency and essential obstetric and newborn care (BEmONC), and child immunization service readiness scores were determined using unweighted averages according to the WHO guideline. Descriptive statistics were done for the quantitative data, and thematic content analysis was employed using NVivo 12 software for the qualitative data.

Results

All the surveyed health facilities had no specialist medical doctors, and 50% (8/16) of them had no inpatient beds. The overall BEmONC service readiness score was 62.7% (10/16) (95% CI: 34.8, 83.8) and only one facility had all the tracer items. Trained staff and guidelines had a 27.5% (4/16) readiness score, followed by 71.9% (12/16) readiness score for equipment, and 88.6% (14/16) readiness score for medicine and commodities. The overall child immunization service readiness score was 90.3% (15/16) (95% CI: 51.4, 94.7) and eleven facilities (68.8%) had all the tracer items. The immunization service readiness score was higher; 84.4% (14/16) for trained staff and guidelines, 92.8% (15/16) for equipment, and 93.8% (15/16) for medicines and commodities. Unavailability of equipment, shortage of supplies, and lack of respectful and compassionate healthcare practices were the key facility-related barriers compromising essential newborn care service readiness.

Conclusions for Practice

The survey revealed that the essential newborn care service readiness score of the health facilities was low, and it calls for improving BEmONC service readiness in particular. Provision of timely training for newly recruited staff, fulfilling essential equipment, and steady supply is imperative.

Addressing Quality of Care in Pediatric Units using a Digital Tool: Implementation Experience from 18 SNCU of India

Lack of quality care is associated with newborn mortality and stillbirth. India launched the Special newborn care unit (SNCU) Quality of Care Index (SQCI) for measuring quality indicators in SNCU. The USAID Vriddhi project provided support to the use of SQCI in 19 SNCU across aspirational districts of Jharkhand, Uttarakhand, Himachal Pradesh, Punjab and Haryana. The objective was to provide holistic support to quality care processes by generating analyzed quarterly reports for action with the goal toward sustainability by capacitating SNCU personnel and program officers to use SQCI, over a 1period from April 2019 to June 2020. The composite index has seven indicators and converts them into indices, each having a range from 0.1 to 1, to measure performance of SNCU.7 of the 18 SNCU improved their composite scores from the first to the last quarter. Rational use of antibiotics showed improvement in 12 SNCU. Survival in newborns >2500 g and <2500, low birth weight admission and optimal bed utilization had the most variations between and within facilities. Based on quarterly data analysis, all facilities introduced KMC, 10 facilities improved equipment and drug supply, 9 facilities launched in-house capacity building to improve asphyxia management. The SQCI implementation helped to show a process of using SQCI data for identifying bottlenecks and addressing quality concerns. The project has transitioned to complete responsibility of SQCI usage by the district and facility teams. Use of an existing mechanism of quality monitoring without any major external support makes the SQCI usable and doable.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 1: Review of implementation features and observed quality gaps in 25 countries

BACKGROUND

A substantial proportion of maternal and neonatal mortality and morbidity is attributable to gaps in quality of care. A systematic, standard-based tool for quality assessment and improvement for maternal and neonatal hospital care (QA/QI MN tool) was developed in 2009 by the World Health Organization (WHO). The tool guides the assessment process along the whole continuum from admission to discharge, collects the views of the recipients of care and engages hospital mangers and staff in identifying gaps and drafting an action plan.

METHODS

Publications describing use of the WHO QA/QI MN tool from 2009 to 2017 and reports retrievable from WHO or other development partners' websites were searched and considered for inclusion in the review. Only assessments of hospitals were considered. Quality gaps were classified as regarding case management in maternal care, case management in neonatal care, hospital infrastructure, hospital policies and according to severity and frequency. Quotations from women regarding key issues in effective communication, respect and dignity, emotional support and costs incurred were selected.

RESULTS

In the period 2009-2017, use of the WHO QA/QI MN tool was documented in 25 countries, belonging to Central and Eastern Europe (8), Central Asia (4), Sub-Saharan Africa (11), Latin America (1) and Middle East (1). Overall, 133 hospitals were assessed. The tool allowed to identify in great detail serious quality gaps including: insufficient or incomplete adherence to recommended evidence-based procedures for normal childbirth and maternal and neonatal complications; excess of inappropriate or unnecessary interventions; insufficient infection control; failure to provide respectful care, adequate communication and emotional support to mothers and babies; poor use of information generated locally to analyse processes and outcomes. These gaps were observed in all countries. Significant differences were observed among facilities belonging to the same health systems, ie, with very similar staffing, infrastructure and equipment.

CONCLUSIONS

The experience made, the largest of this kind, provides comprehensive and detailed insight into the existing quality gaps in a wide variety of settings. QI cycles at facility level should be primarily based on assessments made by multidisciplinary teams of professionals to identify the parts of the care pathways which require improvement through a participatory approach involving managers, staff and patients.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 2: Review of the results of quality cycles and of factors influencing change

BACKGROUND

Information about the use of the findings of quality assessments in maternal and neonatal (MN) care is lacking and the development of tools capable to effectively address quality gaps is a key priority. Furthermore, little is known about factors that act as barriers or facilitators to change at facility level. Based on the extensive experience made with the WHO Quality Assessment and Improvement MN (QA/QI MN) tool, an overview is provided of the improvements in quality of care (QoC) which were obtained over time and of the factors influencing change.

METHODS

All documented reports on the implementation of the WHO QA/QI MN tool were searched and screened for inclusion. Reports were considered if bringing evidence from both the baseline assessment and the reassessment. Changes were considered in four domains: maternal care, neonatal care, infrastructure and policies, with reference made to WHO maternal and neonatal care standards. The observed improvements were categorized according to intensity and extent across the sample of health facilities. Factors influencing change were categorized into internal and external and further classified as barriers or facilitators.

RESULTS

Changes were documented after an average period of 1.2 years from first assessment in 27 facilities belonging to 9 different countries in Central and Eastern Europe (3), Central Asia (3), sub-Saharan Africa (2) and Latin America (1). Improvements were observed in all areas of care but were greater and more frequently observed in areas related to appropriate case management and respectful care for both mothers and newborns. Although widespread across most facilities and countries, the observed improvements were not covering all the quality gaps observed at the baseline assessment nor were always sufficient to achieve standard care. Factors facilitating change as well as barriers were mainly related to the capacity of the managers and head of units to involve and motivate their staff members.

CONCLUSIONS

The use of WHO QA/QI MN tool proved effective in promoting significant changes in quality of care. The review of observed improvements and of factors influencing change at facility level shows that participatory assessment tools that promote a constructive dialogue with hospital managers and staff and support them in acquiring capacity in this role are crucial to implement effective quality cycles.

Quality of Care for Maternal and Newborn Health in Health Facilities in Nepal

Introduction

Nepal has pledged to substantially reduce maternal and newborn death by 2030. Improving quality of intrapartum health services will be vital to reduce these deaths. This paper examines quality of delivery and newborn services in health facilities of Nepal.

Methods

Data were sourced from the Nepal Health Facility Survey 2015, which covered a national representative sample of health facilities. The datasets were analysed to assess service readiness, availability and quality of delivery and newborn care in a sample of 992 health facilities.

Results

Of the 992 facilities in the sample, 623 provided delivery and newborn care services. Of the 623 facilities offering delivery and newborn care services, 13.3% offered comprehensive emergency obstetric care (CEmONC), 19.6% provided basic emergency obstetric care (BEmONC) and 53.9% provided basic delivery and newborn service. The availability of essential equipment for delivery and newborn care was more than 80% in health facilities. Except for the coverage of vitamin K injection, the coverage of immediate newborn care was more than 85% in all health facilities. The coverage of use of chlorhexidine ointment to all newborns was more than 70% in government hospitals and primary health care centers (PHCCs) and only 32.3% in private hospitals.

Conclusions

These findings show gaps in equipment and drugs, especially in PHCCs and private health facilities. Improving readiness and availability of equipment and drugs in PHCCs and private health facility will help improve the quality of care to further reduce maternal and newborn mortality in Nepal.

Health workers' views on audit in maternal and newborn healthcare in LMICs: a qualitative evidence synthesis

OBJECTIVES

To identify and summarise health workers' views on the use of audit as a method to improve the quality of maternal and newborn healthcare in low- and middle-income countries (LMICs).

METHODS

We conducted a qualitative evidence synthesis. PubMed, CINAHL and Global Health databases were searched using keywords, synonyms and MeSH headings for 'audit', 'views' and 'health workers' to find papers that used qualitative methods to explore health workers' views on audit in LMICs. Titles and abstracts were then screened for inclusion. The remaining full-text papers were then screened. The final included papers were quality assessed using the Critical Appraisal Skills Programme tool for qualitative research. Data on audit type and health workers' perceptions were extracted and analysed using thematic synthesis.

RESULTS

Nineteen papers were included in the review, most from sub-Saharan Africa. Health workers generally held favourable views of audit and expressed dedication to the process. Similarly, they described positive experiences conducting audit. The main barriers to implementing audit were the presence of a blame culture, inadequate training and the lack of time and resources to conduct audit. Health workers' motivation and dedication to the audit process helped to overcome such barriers.

CONCLUSIONS

Health workers are dedicated to the process of audit, but must be supported with training, leadership and adequate resources to use it. Decision-makers and technical partners supporting audit should focus on improving audit training and finding ways to conduct audit without requiring too much staff time.

Training and mentorship of medical officers to improve MCH care in public health facilities: Lessons learned from eastern Uttar Pradesh

Introduction

To improve the quality of MCH services in high priority districts of eastern Uttar Pradesh, Regional Resource Training Center (RRTC) has been established in BRD Medical College Gorakhpur. Medical College faculties empanelled at RRTC Gorakhpur carried out the training and mentoring of medical officers of public health facilities.

Aims and Objectives

To study the role of training and mentoring of medical officers in terms of quality improvements of MCH services at public health facilities.

Materials and Methods

The present study was carried out in women hospitals of seven districts and one of their respective CHCs of eastern Uttar Pradesh from December 2017 to October 2018. Data was collected by direct observation and review of records of OPD/IPD, labor room, operation theaters, blood bank, and blood storage facilities by mentoring team. Findings of these observations were recorded in predesigned 50 point quality assurance, and facility score was calculated. Technical score was calculated from data collected during one-to-one interaction of mentor and mentees in a predesigned and tested proforma.

Result

Technical scores of medical officers showed marked improvement after mentoring visits in majority of facilities. Mentoring visits build the confidence of medical officers to deal with the complications like severe anemia, eclampsia, and postpartum hemorrhage as per latest guidelines and protocol. It also helped in the initiation and augmentation of LSCS at certain facilities. Technical scores at few facilities showed little improvement (DWH Sant Kabir Nagar, CHC Colonelganj). Mentoring visit also helped in overall facility improvement at these centers.

Conclusions

The whole training and mentorship program was found effective to improve the knowledge and skills of the medical officer with few exceptions of opposition/resistance. It was found useful in overall facility improvement up to some extent.

Quality improvement in maternal and newborn healthcare: lessons from programmes supported by the German development organisation in Africa and Asia

Improving the quality of maternal and child healthcare (MCH) is a mandatory step on the path to reaching the Sustainable Development Goals and Universal Health Coverage. Quality improvement (QI) in MCH is a strong focus of the bilateral development cooperation provided by Germany to help strengthen the health systems of countries with high maternal and child mortality rates and/or with high unmet needs for family planning. In this article, we report on the findings of an analysis commissioned by a community of practice on MCH, of Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). The objectives were to review the QI interventions implemented through programmes which have received technical assistance from GIZ on behalf of the German Federal Ministry for Economic Cooperation and Development in 14 Asian and African countries, to identify and describe the existing approaches and their results, and finally to draw lessons learnt from their implementation. Our analysis of the information contained in programme documents and reports identified five main methodologies used to improve the quality of care: capacity-building and supervision, governance and regulation, systemic QI at facility level, support to infrastructures, and community support. It is difficult to attribute the observed progresses in maternal and neonatal health to a particular agency, programme or intervention. We acknowledge that systemic implementation research embedded within the programmes would facilitate an understanding of the determinants of successful QI interventions, would better assess their effectiveness, and therefore better guide future bilateral aid programmatic decisions.

Technical quality of delivery care in private- and public-sector health facilities in Enugu and Lagos States, Nigeria

Private-sector providers are increasingly being recognized as important contributors to the delivery of healthcare. Countries with high disease burdens and limited public-sector resources are considering using the private sector to achieve universal health coverage. However, evidence for the technical quality of private-sector care is lacking. This study assesses the technical quality of maternal healthcare during delivery in public- and private-sector facilities in resource-limited settings, from a systems and programmatic perspective. A summary index (the skilled attendance index, SAI), was used. Two-staged cluster sampling with stratification was used to select representative samples of case records in public- and private-sector facilities in Enugu and Lagos States, Nigeria. Information to assess criteria was extracted, and the SAI calculated. Linear regression models examined the relationship between SAI and the private and public sectors, controlling for confounders. The median SAI was 54.8% in Enugu and 85.7% in Lagos. The private for-profit sector's SAI was lower than and the private not-for-profit sector's SAI was higher than the public sector in Enugu [coefficient = -3.6 (P = 0.018) and 12.6 (P < 0.001), respectively]. In Lagos, the private for-profit sector's SAI was higher and the private not-for-profit sector's SAI was lower than the public sector [3.71 (P = 0.005) and -3.92 (P < 0.001)]. Results indicate that the technical quality of private for-profit providers' care was poorer than public providers where the public provision of care was weak, while private for-profit facilities provided better technical quality care than public facilities where the public sector was strong and there was a relatively strong regulatory body. Our findings raise important considerations relating to the quality of maternity care, the public-private mix and needs for regulation in global efforts to achieve universal healthcare.

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.

[Assessment of adherence to the Safe Childbirth Checklist in a public maternity hospital in Northeast Brazil]

Decreasing childbirth-related mortality is a current global health priority. The World Health Organization developed the Safe Childbirth Checklist to reduce adverse events in maternal and perinatal care, using simple and effective practices. The current study aims to evaluate adherence to the checklist by professionals in a maternity hospital in Natal, Rio Grande do Norte State, Brazil. The study used an observational, cross-sectional approach to evaluate all births in three months, with data collected from patient charts. Adherence was described on the basis of presence and quality of the checklist's completion, and bivariate analysis was performed using the association with childbirth-related factors. Of 978 patient charts that were reviewed, 71% had the list, an average of 24% of the items were completed, but only 0.1% of the patient charts were totally completed; better completion was seen in vaginal deliveries and at the time of patient admission. Checklist adherence showed limitations that are inherent to the adoption of a new safety routine and requires continuous training of the health professionals to achieve better results.

Implementing the WHO integrated tool to assess quality of care for mothers, newborns and children: results and lessons learnt from five districts in Malawi

BACKGROUND

In 2014 the World Health Organization (WHO) developed a new tool to be used to assess the quality of care for mothers, newborns and children provided at healthcare facility level. This paper reports on the feasibility of using the tool, its limitations and strengths.

METHODS

Across 5 districts in Malawi, 35 healthcare facilities were assessed. The WHO tool includes checklists, interviews and observation of case management by which care is assessed against agreed standards using a Likert scale (1 lowest: not meeting standard, 5 highest: compliant with standard). Descriptive statistics were used to provide summary scores for each standard. A 'dashboard' system was developed to display the results.

RESULTS

For maternal care three areas met standards; 1) supportive care for admitted patients (71% of healthcare facilities scored 4 or 5); 2) prevention and management of infections during pregnancy (71% scored 4 or 5); and 3) management of unsatisfactory progress of labour (84% scored 4 or 5). Availability of essential equipment and supplies was noted to be a critical barrier to achieving satisfactory standards of paediatric care (mean score; standard deviation: 2.9; SD 0.95) and child care (2.7; SD 1.1). Infection control is inadequate across all districts for maternal, newborn and paediatric care. Quality of care varies across districts with a mean (SD) score for all standards combined of 3 (SD 0.19) for the worst performing district and 4 (SD 0.27) for the best. The best performing district has an average score of 4 (SD 0.27). Hospitals had good scores for overall infrastructure, essential drugs, organisation of care and management of preterm labour. However, health centres were better at case management of HIV/AIDS patients and follow-up of sick children.

CONCLUSIONS

There is a need to develop an expanded framework of standards which is inclusive of all areas of care. In addition, it is important to ensure structure, process and outcomes of health care are reflected.

Health providers' perception of quality of care for neonates in health facilities in a municipality in Southern Ghana

Purpose The purpose of this paper is to assess available human resources for neonatal care and their skills, in order to explore health providers' perceptions of quality of neonatal care in health facilities in Ghana. Design/methodology/approach Data were gathered using qualitative interviews with health providers working in the maternity and paediatric wards and midwives; direct observation; and documentary review at a regional hospital, a municipal hospital and four health centres in a municipality in a region in Southern Ghana. Data were analysed using thematic framework through the process of coding in six phases to create and establish meaningful patterns. Findings The study revealed that health providers were concerned about the number of staff available, their competence and also equipment available for them to work more efficiently. Some essential equipment for neonatal care was either not available or was non-functional where it was available, while aseptic procedures were not adhered to. Moreover, personal protective equipment such as facemask, caps, aprons were not used except in the labour wards where staff had to change their footwear before entering. Research limitations/implications Limited number of health providers and facilities used, lack of exploration of parents of neonates' perspective of quality of neonatal care in this study and other settings, including the teaching hospitals. The authors did not examine issues related to the ineffective use of IV cannulation for neonates by nurses as well as referral of neonates. Additionally, the authors did not explore the perspectives of management of the municipal and regional health directorates or policy makers of the Ministry of Health and Ghana Health Service regarding the shortage of staff, inadequate provision of medical equipment and infrastructure. Practical implications This paper suggests the need for policy makers to redirect their attention to the issues that would improve the quality of neonatal health care in health facilities in Ghana and in countries with similar challenges. Social implications The study found that the majority of nursing staff catering for sick newborns were not trained in neonatal nursing. Babies were found sleeping in separate cots but were mixed with older children. The study suggests that babies should be provided with a separate room and not mixed with older babies. Originality/value There seemed to be no defined policy framework for management of neonatal care in the country's health care facilities. The study recommends the adoption of paediatric and neonatal care nursing as a specialty in the curricula of health training institutions. In-service trainings should encompass issues related to management of sick babies, care of preterm babies, neonatal resuscitation and intravenouscannulation, among others.

Evaluation of a quality improvement intervention for obstetric and neonatal care in selected public health facilities across six states of India

Background

While increase in the number of women delivering in health facilities has been rapid, the quality of obstetric and neonatal care continues to be poor in India, contributing to high maternal and neonatal mortality.

Methods

The USAID ASSIST Project supported health workers in 125 public health facilities (delivering approximately 180,000 babies per year) across six states to use quality improvement (QI) approaches to provide better care to women and babies before, during and immediately after delivery. As part of this intervention, each month, health workers recorded data related to nine elements of routine care alongside data on perinatal mortality. We aggregated facility level data and conducted segmented regression to analyse the effect of the intervention over time.

Results

Care improved to 90–99% significantly (p < 0.001) for eight of the nine process elements. A significant (p < 0.001) positive change of 30–70% points was observed during post intervention for all the indicators and 3–17% points month-to-month progress shown from the segmented results. Perinatal mortality declined from 26.7 to 22.9 deaths/1000 live births (p < 0.01) over time, however, it is not clear that the intervention had any significant effect on it.

Conclusion

These results demonstrate the effectiveness of QI approaches in improving provision of routine care, yet these approaches are underused in the Indian health system. We discuss the implications of this for policy makers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1318-4) contains supplementary material, which is available to authorized users.

Effectiveness of Onsite Nurse Mentoring in Improving Quality of Institutional Births in the Primary Health Centres of High Priority Districts of Karnataka, South India: A Cluster Randomized Trial

Background

In India, although the proportion of institutional births is increasing, there are concerns regarding quality of care. We assessed the effectiveness of a nurse-led onsite mentoring program in improving quality of care of institutional births in 24/7 primary health centres (PHCs that are open 24 hours a day, 7 days a week) of two high priority districts in Karnataka state, South India. Primary outcomes were improved facility readiness and provider preparedness in managing institutional births and associated complications during child birth.

Methods

All functional 24/7 PHCs in the two districts were included in the study. We used a parallel, cluster randomized trial design in which 54 of 108 facilities received six onsite mentoring visits, along with an initial training update and specially designed case sheets for providers; the control arm received just the initial training update and the case sheets. Pre- and post-intervention surveys were administered in April-2012 and August-2013 using facility audits, provider interviews and case sheet audits. The provider interviews were administered to all staff nurses available at the PHCs and audits were done of all the filled case sheets during the month prior to data collection. In addition, a cost analysis of the intervention was undertaken.

Results

Between the surveys, we achieved coverage of 100% of facilities and 91.2% of staff nurse interviews. Since the case sheets were newly designed, case-sheet audit data were available only from the end line survey for about 80.2% of all women in the intervention facilities and 57.3% in the control facilities. A higher number of facilities in the intervention arm had all appropriate drugs, equipment and supplies to deal with gestational hypertension (19 vs.3, OR (odds ratio) 9.2, 95% C.I 2.5 to33.6), postpartum haemorrhage (29 vs. 12, OR 3.7, 95% C.I 1.6 to8.3); and obstructed labour (25 vs.9, OR 3.4, 95% CI 1.6 to8.3). The providers in the intervention arm had better knowledge of active management of the third stage of labour (82.4% vs.35.8%, AOR (adjusted odds ratio) 10, 95% C.I 5.5 to 18.2); management of maternal sepsis (73.5% vs. 10.9%, AOR 36.1, 95% C.I 13.6 to 95.9); neonatal resuscitation (48.5% vs.11.7%, AOR 10.7, 95% C.I 4.6 to 25.0) and low birth weight newborn care (58.1% vs. 40.9%, AOR 2.4, 95% C.I 1.2 to 4.7). The case sheet audits revealed that providers in the intervention arm showed greater compliance with the protocols during labour monitoring (77.3% vs. 32.1%, AOR 25.8, 95% C.I 9.6 to 69.4); delivery and immediate post-partum care for mothers (78.6% vs. 31.8%, AOR 22.1, 95% C.I 8.0 to 61.4) and for newborns (73.9% vs. 32.8%, AOR 24.1, 95% C.I 8.1 to 72.0). The cost analysis showed that the intervention cost an additional $5.60 overall per delivery.

Conclusions

The mentoring program successfully improved provider preparedness and facility readiness to deal with institutional births and associated complications. It is feasible to improve the quality of institutional births at a large operational scale, without substantial incremental costs.

Trial Registration

ClinicalTrials.gov NCT02004912

Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review

BACKGROUND

Many interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA.

METHODS

African Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability).

RESULTS

Seventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess.

CONCLUSIONS

Many non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015023750.

Monitoring maternal and newborn health outcomes in Bauchi State, Nigeria: an evaluation of a standards-based quality improvement intervention

Objective

This study assessed the correlation between compliance with set performance standards and maternal and neonatal deaths in health facilities.

Design

Baseline and three annual follow-up assessments were conducted, and each was followed by a quality improvement initiative using the Standards Based Management and Recognition (SBM-R) approach.

Setting

Twenty-three secondary health facilities of Bauchi state, Nigeria.

Participants

Health care workers and maternity unit patients.

Main outcome measures

We examined trends in: (i) achievement of SBM-R set performance standards based on annual assessment data, (ii) the use of maternal and newborn health (MNH) service delivery practices based on data from health facility registers and supportive supervision and (iii) MNH outcomes based on routine service statistics.

Results

At the baseline assessment in 2010, the facilities achieved 4% of SBM-R standards for MNH, on average, and this increased to 86% in 2013. Over the same time period, the study measured an increase in the administration of uterotonic for active management of third stage of labor from 10% to 95% and a decline in the incidence of postpartum hemorrhage from 3.3% to 1.9%. Institutional neonatal mortality rate decreased from 9 to 2 deaths per 1000 live births, while the institutional maternal mortality ratio dropped from 4113 to 1317 deaths per 100 000 live births.

Conclusion

Scaling up SBM-R for quality improvement has the potential to prevent maternal and neonatal deaths in Nigeria and similar settings.

Improving the Standards-Based Management-Recognition initiative to provide high-quality, equitable maternal health services in Malawi: an implementation research protocol

BACKGROUND

The Government of Malawi is seeking evidence to improve implementation of its flagship quality of care improvement initiative-the Standards Based Management-Recognition for Reproductive Health (SBM-R(RH)).

OBJECTIVE

This implementation study will assess the quality of maternal healthcare in facilities where the SBM-R(RH) initiative has been employed, identify factors that support or undermine effectiveness of the initiative and develop strategies to further enhance its operation.

METHODS

Data will be collected in 4 interlinked modules using quantitative and qualitative research methods. Module 1 will develop the programme theory underlying the SBM-R(RH) initiative, using document review and in-depth interviews with policymakers and programme managers. Module 2 will quantitatively assess the quality and equity of maternal healthcare provided in facilities where the SBM-R(RH) initiative has been implemented, using the Malawi Integrated Performance Standards for Reproductive Health. Module 3 will conduct an organisational ethnography to explore the structures and processes through which SBM-R(RH) is currently operationalised. Barriers and facilitators will be identified. Module 4 will involve coordinated co-production of knowledge by researchers, policymakers and the public, to identify and test strategies to improve implementation of the initiative.

POTENTIAL IMPACT

The research outcomes will provide empirical evidence of strategies that will enhance the facilitators and address the barriers to effective implementation of the initiative. It will also contribute to the theoretical advances in the emerging science of implementation research.

Implementation of the Standards-Based Management and Recognition approach to quality improvement in maternal, newborn, and child health programs in low-resource countries

The Standards-Based Management and Recognition (SBM-R; Jhpiego, Baltimore, MD, USA) approach to quality improvement was developed by Jhpiego to respond to common challenges faced by health systems in low-resource settings, including poor pre-service education, lack of resources for conventional supervisory models, and weak health information systems. Since its introduction in Brazil in 1997, SBM-R has been implemented in approximately 30 countries and continues expanding to new places and service delivery areas. The present article: (1) describes key steps in the SBM-R methodology focusing on provider performance assessment using evidence-based standards; and (2) presents examples of improvements in provider performance in maternal, newborn, and child health care following SBM-R implementation derived from routine program data, quasi-experimental evaluations, and in-depth case studies. SBM-R incorporates evidence-based methods that are known to have positive effects on healthcare quality, including audit and feedback, educational outreach visits, and checklist usage; however, further rigorous research is needed to document the population-level impacts of the SBM-R approach.

Nurse Mentors to Advance Quality Improvement in Primary Health Centers: Lessons From a Pilot Program in Northern Karnataka, India

Trained nurse mentors catalyzed quality improvements in facility-based maternal and newborn care by: (1) encouraging use of self-assessment checklists and team-based problem solving, (2) introducing case sheets to ensure adherence to clinical guidelines, and (3) strengthening clinical skills through on-site demonstrations and bedside teaching. Inadequate leadership and staffing were challenges in some facilities. Some social norms, such as client resistance to referral and to staying 48 hours after delivery, also impact quality and mandate community mobilization efforts.

High-quality care during labor, delivery, and the postpartum period is critically important since maternal and child morbidity and mortality are linked to complications that arise during these stages. A nurse mentoring program was implemented in northern Karnataka, India, to improve quality of services at primary health centers (PHCs), the lowest level in the public health system that offers basic obstetric care. The intervention, conducted between August 2012 and July 2014, employed 53 full-time nurse mentors and was scaled-up in 385 PHCs in 8 poor rural districts. Each mentor was responsible for 6 to 8 PHCs and conducted roughly 6 mentoring visits per PHC in the first year. This paper reports the results of a qualitative inquiry, conducted between September 2012 and April 2014, assessing the program's successes and challenges from the perspective of mentors and PHC teams. Data were gathered through 13 observations, 9 focus group discussions with mentors, and 25 individual and group interviews with PHC nurses, medical officers, and district health officers. Mentors and PHC staff and leaders reported a number of successes, including development of rapport and trust between mentors and PHC staff, introduction of team-based quality improvement processes, correct and consistent use of a new case sheet to ensure adherence to clinical guidelines, and increases in staff nurses’ knowledge and skills. Overall, nurses in many PHCs reported an increased ability to provide care according to guidelines and to handle maternal and newborn complications, along with improvements in equipment and supplies and referral management. Challenges included high service delivery volumes and/or understaffing at some PHCs, unsupportive or absent PHC leadership, and cultural practices that impacted quality. Comprehensive mentoring can build competence and improve performance by combining on-the-job clinical and technical support, applying quality improvement principles, and promoting team-based problem solving.

Facility-based active management of the third stage of labour: assessment of quality in six countries in sub-Saharan Africa

OBJECTIVE

To assess the quality of facility-based active management of the third stage of labour in Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and the United Republic of Tanzania.

METHODS

Between 2009 and 2012, using a cross-sectional design, 2317 women in 390 health facilities were directly observed during the third stage of labour. Observers recorded the use of uterotonic medicines, controlled cord traction and uterine massage. Facility infrastructure and supplies needed for active management were audited and relevant guidelines reviewed.

FINDINGS

Most (94%; 2173) of the women observed were given oxytocin (2043) or another uterotonic (130). The frequencies of controlled cord traction and uterine massage and the timing of uterotonic administration showed considerable between-country variation. Of the women given a uterotonic, 1640 (76%) received it within three minutes of the birth. Uterotonics and related supplies were generally available onsite. Although all of the study countries had national policies and/or guidelines that supported the active management of the third stage of labour, the presence of guidelines in facilities varied across countries and only 377 (36%) of 1037 investigated providers had received relevant training in the previous three years.

CONCLUSION

In the study countries, quality and coverage of the active management of the third stage of labour were high. However, to improve active management, there needs to be more research on optimizing the timing of uterotonic administration. Training on the use of new clinical guidelines and implementation research on the best methods to update such training are also needed.

Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions

BACKGROUND

Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth.

METHODS

The bottleneck analysis tool was applied in 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", factors 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 skilled birth attendance and basic and comprehensive emergency obstetric care.

RESULTS

Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships.

CONCLUSIONS

Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.

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.

Improving maternal and child health systems in Fiji through a perinatal mortality audit

OBJECTIVE

To develop a standardized process of perinatal mortality audit (PMA) and improve the capacity of health workers to identify and correct factors underlying preventable deaths in Fiji.

METHODS

In a pilot study, clinicians and healthcare managers in obstetrics and pediatrics were trained to investigate stillbirths and neonatal deaths according to current guidelines. A pre-existing PMA datasheet was refined for use in Fiji and trialed in three divisional hospitals in 2011-12. Key informant interviews identified factors influencing PMA uptake.

RESULTS

Overall, 141 stillbirths and neonatal deaths were analyzed (57 from hospital A and 84 from hospital B; forms from hospital C excluded because incomplete/illegible). Between-site variations in mortality were recorded on the basis of the level of tertiary care available; 28 (49%) stillbirths were recorded in hospital A compared with 53 (63%) in hospital B. Substantial health system factors contributing to preventable deaths were identified, and included inadequate staffing, problems with medical equipment, and lack of clinical skills. Leadership, teamwork, communication, and having a standardized process were associated with uptake of PMA.

CONCLUSION

The use of PMAs by health workers in Fiji and other Pacific island countries could potentially rectify gaps in maternal and neonatal service delivery.

Establishing cause of maternal death in Malawi via facility-based review and application of the ICD-MM classification

Maternal death review (MDR) is an accepted process that is implemented across Malawi and 'underlying cause of death' is assigned by healthcare providers using a standard MDR form. Mixed-methods approach. Key informant interviews with eight stakeholders involved in MDR. Secondary analysis of MDR forms for 54 maternal deaths. Comparison of assigned cause of death by healthcare providers conducting MDR at health facility level with cause assigned by researchers using the International Classification of Diseases Maternal Mortality (ICD-MM) classification. MDR teams, analysts and policymakers reported facing challenges in completing the forms, analysing and using information. The concepts of underlying (primary) and contributing (secondary) causes of death are often misunderstood. Healthcare providers using only MDR forms reported cause of death as non-obstetric complications in 39.6% and pregnancy-related infection in 11.3% of cases. For 30.2% of cases, no clear clinical cause of death was recorded. The most commonly assigned underlying cause of death using ICD-MM was obstetric haemorrhage (32.1%), non-obstetric complications (24.5%) and pregnancy-related infection (22.6%). There was poor agreement between cause(s) of maternal death assigned by healthcare providers in the field and trained researchers using the new ICD-MM classification (κ statistic; 0.219). The majority of cases could be reclassified using the ICD-MM and this provided a more specific cause of death. A more structured and user-friendly MDR form is required. Accurate classification of cause of death is important. Dissemination of, and training in the use of the new ICD-MM classification system will be helpful to healthcare providers conducting MDR in Malawi.

Improvements in newborn care and newborn resuscitation following a quality improvement program at scale: results from a before and after study in Tanzania

BACKGROUND

Every year, more than a million of the world's newborns die on their first day of life; as many as two-thirds of these deaths could be saved with essential care at birth and the early newborn period. Simple interventions to improve the quality of essential newborn care in health facilities - for example, improving steps to help newborns breathe at birth - have demonstrated up to 47% reduction in newborn mortality in health facilities in Tanzania. We conducted an evaluation of the effects of a large-scale maternal-newborn quality improvement intervention in Tanzania that assessed the quality of provision of essential newborn care and newborn resuscitation.

METHODS

Cross-sectional health facility surveys were conducted pre-intervention (2010) and post intervention (2012) in 52 health facilities in the program implementation area. Essential newborn care provided by health care providers immediately following birth was observed for 489 newborns in 2010 and 560 in 2012; actual management of newborns with trouble breathing were observed in 2010 (n = 18) and 2012 (n = 40). Assessments of health worker knowledge were conducted with case studies (2010, n = 206; 2012, n = 217) and a simulated resuscitation using a newborn mannequin (2010, n = 299; 2012, n = 213). Facility audits assessed facility readiness for essential newborn care.

RESULTS

Index scores for quality of observed essential newborn care showed significant overall improvement following the quality-of-care intervention, from 39% to 73% (p <0.0001). Health worker knowledge using a case study significantly improved as well, from 23% to 41% (p <0.0001) but skills in resuscitation using a newborn mannequin were persistently low. Availability of essential newborn care supplies, which was high at baseline in the regional hospitals, improved at the lower-level health facilities.

CONCLUSIONS

Within two years, the quality improvement program was successful in raising the quality of essential newborn care services in the program facilities. Some gaps in newborn care were persistent, notably practical skills in newborn resuscitation. Continued investment in life-saving improvements to newborn care through the health services is a priority for reduction of newborn mortality in Tanzania.

Approaches to improve the quality of maternal and newborn health care: an overview of the evidence

Despite progress in recent years, an estimated 273,500 women died as a result of maternal causes in 2010. The burden of these deaths is disproportionately bourne by women who reside in low income countries or belong to the poorest sectors of the population of middle or high income ones, and it is particularly acute in regions where access to and utilization of facility-based services for childbirth and newborn care is lowest. Evidence has shown that poor quality of facility-based care for these women and newborns is one of the major contributing factors for their elevated rates of morbidity and mortality. In addition, women who perceive the quality of facilty-based care to be poor,may choose to avoid facility-based deliveries, where life-saving interventions could be availble. In this context, understanding the underlying factors that impact the quality of facility-based services and assessing the effectiveness of interventions to improve the quality of care represent critical inputs for the improvement of maternal and newborn health. This series of five papers assesses and summarizes information from relevant systematic reviews on the impact of various approaches to improve the quality of care for women and newborns. The first paper outlines the conceptual framework that guided this study and the methodology used for selecting the reviews and for the analysis. The results are described in the following three papers, which highlight the evidence of interventions to improve the quality of maternal and newborn care at the community, district, and facility level. In the fifth and final paper of the series, the overall findings of the review are discussed, research gaps are identified, and recommendations proposed to impove the quality of maternal and newborn health care in resource-poor settings.

Assessment of facility readiness and provider preparedness for dealing with postpartum haemorrhage and pre-eclampsia/eclampsia in public and private health facilities of northern Karnataka, India: a cross-sectional study

BACKGROUND

The maternal mortality ratio in India has been declining over the past decade, but remains unacceptably high at 212 per 100,000 live births. Postpartum haemorrhage (PPH) and pre- eclampsia/eclampsia contribute to 40% of all maternal deaths. We assessed facility readiness and provider preparedness to deal with these two maternal complications in public and private health facilities of northern Karnataka state, south India.

METHODS

We undertook a cross-sectional study of 131 primary health centres (PHCs) and 148 higher referral facilities (74 public and 74 private) in eight districts of the region. Facility infrastructure and providers' knowledge related to screening and management of complications were assessed using facility checklists and test cases, respectively. We also attempted an audit of case sheets to assess provider practice in the management of complications. Chi square tests were used for comparing proportions.

RESULTS

84.5% and 62.9% of all facilities had atleast one doctor and three nurses, respectively; only 13% of higher facilities had specialists. Magnesium sulphate, the drug of choice to control convulsions in eclampsia was available in 18% of PHCs, 48% of higher public facilities and 70% of private facilities. In response to the test case on eclampsia, 54.1% and 65.1% of providers would administer anti-hypertensives and magnesium sulphate, respectively; 24% would administer oxygen and only 18% would monitor for magnesium sulphate toxicity. For the test case on PPH, only 37.7% of the providers would assess for uterine tone, and 40% correctly defined early PPH. Specialists were better informed than the other cadres, and the differences were statistically significant. We experienced generally poor response rates for audits due to non-availability and non-maintenance of case sheets.

CONCLUSIONS

Addressing gaps in facility readiness and provider competencies for emergency obstetric care, alongside improving coverage of institutional deliveries, is critical to improve maternal outcomes. It is necessary to strengthen providers' clinical and problem solving skills through capacity building initiatives beyond pre-service training, such as through onsite mentoring and supportive supervision programs. This should be backed by a health systems response to streamline staffing and supply chains in order to improve the quality of emergency obstetric care.

Applying the maternal near miss approach for the evaluation of quality of obstetric care: a worked example from a Multicenter Surveillance Study

Objective. To assess quality of care of women with severe maternal morbidity and to identify associated factors. Method. This is a national multicenter cross-sectional study performing surveillance for severe maternal morbidity, using the World Health Organization criteria. The expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed. Results. 17 hospitals were classified as providing adequate and 10 as nonadequate care. Besides almost twofold increase in maternal mortality ratio, the main factors associated with nonadequate performance were geographic difficulty in accessing health services (P < 0.001), delays related to quality of medical care (P = 0.012), absence of blood derivatives (P = 0.013), difficulties of communication between health services (P = 0.004), and any delay during the whole process (P = 0.039). Conclusions. This is an example of how evaluation of the performance of health services is possible, using a benchmarking tool specific to Obstetrics. In this study the MSI was a useful tool for identifying differences in maternal mortality ratios and factors associated with nonadequate performance of care.

Is essential newborn care provided by institutions and after home births? Analysis of prospective data from community trials in rural South Asia

Background

Provision of essential newborn care (ENC) can save many newborn lives in poor resource settings but coverage is far from universal and varies by country and place of delivery. Understanding gaps in current coverage and where coverage is good, in different contexts and places of delivery, could make a valuable contribution to the future design of interventions to reduce neonatal mortality. We sought to describe the coverage of essential newborn care practices for births in institutions, at home with a skilled birth attendant, and at home without a skilled birth attendant (SBA) in rural areas of Bangladesh, Nepal, and India.

Methods

We used data from the control arms of four cluster randomised controlled trials in Bangladesh, Eastern India and from Makwanpur and Dhanusha districts in Nepal, covering periods from 2001 to 2011. We used these data to identify essential newborn care practices as defined by the World Health Organization. Each birth was allocated to one of three delivery types: home birth without an SBA, home birth with an SBA, or institutional delivery. For each study, we calculated the observed proportion of births that received each care practice by delivery type with 95% confidence intervals, adjusted for clustering and, where appropriate, stratification.

Results

After exclusions, we analysed data for 8939 births from Eastern India, 27 553 births from Bangladesh, 6765 births from Makwanpur and 15 344 births from Dhanusha. Across all study areas, coverage of essential newborn care practices was highest in institutional deliveries, and lowest in home non-SBA deliveries. However, institutional deliveries did not provide universal coverage of the recommended practices, with relatively low coverage (20%-70%) across all study areas for immediate breastfeeding and thermal care. Institutions in Bangladesh had the highest coverage for almost all care practices except thermal care. Across all areas, fewer than 20% of home non-SBA deliveries used a clean delivery kit, the use of plastic gloves was very low and coverage of recommended thermal care was relatively poor. There were large differences between study areas in handwashing, immediate breastfeeding and delayed bathing.

Conclusions

There remains substantial scope for health facilities to improve thermal care for the newborn and to encourage immediate and exclusive breastfeeding. For unattended home deliveries, increased handwashing, use of clean delivery kits and basic thermal care offer great scope for improvement.

Do strategies to improve quality of maternal and child health care in lower and middle income countries lead to improved outcomes? A review of the evidence

OBJECTIVES

Efforts to scale-up maternal and child health services in lower and middle income countries will fail if services delivered are not of good quality. Although there is evidence of strategies to increase the quality of health services, less is known about the way these strategies affect health system goals and outcomes. We conducted a systematic review of the literature to examine this relationship.

METHODS

We undertook a search of MEDLINE, SCOPUS and CINAHL databases, limiting the results to studies including strategies specifically aimed at improving quality that also reported a measure of quality and at least one indicator related to health system outcomes. Variation in study methodologies prevented further quantitative analysis; instead we present a narrative review of the evidence.

FINDINGS

Methodologically, the quality of evidence was poor, and dominated by studies of individual facilities. Studies relied heavily on service utilisation as a measure of strategy success, which did not always correspond to improved quality. The majority of studies targeted the competency of staff and adequacy of facilities. No strategies addressed distribution systems, public-private partnership or equity. Key themes identified were the conflict between perceptions of patients and clinical measures of quality and the need for holistic approaches to health system interventions.

CONCLUSION

Existing evidence linking quality improvement strategies to improved MNCH outcomes is extremely limited. Future research would benefit from the inclusion of more appropriate indicators and additional focus on non-facility determinants of health service quality such as health policy, supply distribution, community acceptability and equity of care.

Improving performance of Zambia Defence Force antiretroviral therapy providers: evaluation of a standards-based approach

A detailed standards-based performance approach modestly improved providers' performance and facility readiness to offer antiretroviral therapy. The approach included mutually reinforcing activities: (1) training, (2) supportive supervision, (3) assessments of service quality, and (4) facility-based action plans.

Background:

The Zambia Defence Force (ZDF) has applied the Standards-Based Management and Recognition (SBM-R®) approach, which uses detailed performance standards, at some health facilities to improve HIV-related services offered to military personnel and surrounding civilian communities. This study examines the effectiveness of the SBM-R approach in improving facility readiness and provider performance at ZDF facilities.

Methods:

We collected data on facility readiness and provider performance before and after the 2010–2012 intervention at 4 intervention sites selected for their relatively poor performance and 4 comparison sites. Assessors observed whether each facility met 16 readiness standards and whether providers met 9 performance standards during consultations with 354 returning antiretroviral therapy (ART) clients. We then calculated the percentages of criteria achieved for each readiness and performance standard and conducted bivariate and multivariate analyses of provider performance data.

Results:

Facilities' ART readiness scores exceeded 80% before the intervention at both intervention and comparison sites. At endline, scores improved on 4 facility readiness standards in the intervention group but on only 1 standard in the comparison group. Multivariate analysis found that the overall provider performance score increased significantly in the intervention group (from 58% to 84%; P<.01) but not in the comparison group (from 62% to 70%). The before-and-after improvement in scores was significantly greater among intervention sites than among comparison sites for 2 standards—initial assessment of the client's condition and nutrition counseling.

Conclusion:

The standards-based approach, which involved intensive and mutually reinforcing intervention activities, showed modest improvements in some aspects of providers' performance during ART consultations. Further research is needed to determine whether improvements in provider performance affect client outcomes such as adherence to ART.

Clean birth kits to improve birth practices: development and testing of a country level decision support tool

Background

Clean birth practices can prevent sepsis, one of the leading causes of both maternal and newborn mortality. Evidence suggests that clean birth kits (CBKs), as part of package that includes education, are associated with a reduction in newborn mortality, omphalitis, and puerperal sepsis. However, questions remain about how best to approach the introduction of CBKs in country. We set out to develop a practical decision support tool for programme managers of public health systems who are considering the potential role of CBKs in their strategy for care at birth.

Methods

Development and testing of the decision support tool was a three-stage process involving an international expert group and country level testing. Stage 1, the development of the tool was undertaken by the Birth Kit Working Group and involved a review of the evidence, a consensus meeting, drafting of the proposed tool and expert review. In Stage 2 the tool was tested with users through interviews (9) and a focus group, with federal and provincial level decision makers in Pakistan. In Stage 3 the findings from the country level testing were reviewed by the expert group.

Results

The decision support tool comprised three separate algorithms to guide the policy maker or programme manager through the specific steps required in making the country level decision about whether to use CBKs. The algorithms were supported by a series of questions (that could be administered by interview, focus group or questionnaire) to help the decision maker identify the information needed. The country level testing revealed that the decision support tool was easy to follow and helpful in making decisions about the potential role of CBKs. Minor modifications were made and the final algorithms are presented.

Conclusion

Testing of the tool with users in Pakistan suggests that the tool facilitates discussion and aids decision making. However, testing in other countries is needed to determine whether these results can be replicated and to identify how the tool can be adapted to meet country specific needs.

Status of emergency obstetric care in six developing countries five years before the MDG targets for maternal and newborn health

Background

Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population.

Methods and Findings

A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%.

Conclusions

Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.

Assessing skilled birth attendants and emergency obstetric care in rural Tanzania: the inadequacy of using global standards and indicators to measure local realities

Current efforts to reduce maternal mortality and morbidity in low-resource settings often depend on global standards and indicators to assess obstetric care, particularly skilled birth attendants and emergency obstetric care. This paper describes challenges in using these standards to assess obstetric services in the Kilombero Valley of Tanzania. A health facility survey and extensive participant observation showed existing services to be complicated and fluid, involving a wide array of skills, resources, and improvisations. Attempts to measure these services against established standards and indicators were not successful. Some aspects of care were over-valued while others were under-valued, with significant neglect of context and quality. This paper discusses the implications of these findings for ongoing maternal health care efforts in unique and complex settings, questioning the current reliance on generic (and often obscure) archetypes of obstetric care in policy and programming. It suggests that current indicators may be insufficient to assess services in low-resource settings, but not that these settings should settle for lower standards of care. In addition to global benchmarks, assessment approaches that emphasize quality of care and recognize available resources might better account for local realities, leading to more effective, more sustainable service delivery.

Improving global maternal health: progress, challenges, and promise

PURPOSE OF REVIEW

This review discusses the unprecedented global commitment to improve maternal health and scientific advancements in the field achieved during the last year.

RECENT FINDINGS

Achievements at political, scientific, and programmatic levels targeted at improving maternal health, especially in low-resource settings, are described. Remaining challenges are discussed and the most promising areas of research and practice aimed at addressing these challenges are identified.

SUMMARY

For the first time in decades, it is evident that progress in reducing mortality on a global scale is possible. Results showing increases in coverage of key maternal health interventions and the establishment of a system for promoting accountability are key determinants of that progress.