1
|
Belay DM, Erku D, Bayih WA, Kassie YT, Minuye Birhane B, Assefa Y. Improving the quality of neonatal health care in Ethiopia: a systematic review. Front Med (Lausanne) 2024; 11:1293473. [PMID: 38841585 PMCID: PMC11150606 DOI: 10.3389/fmed.2024.1293473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 04/19/2024] [Indexed: 06/07/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Demeke Mesfin Belay
- College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Daniel Erku
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- Centre for Applied Health Economics, Griffith University, Nathan, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Addis Consortium for Health Economics and Outcomes Research (AnCHOR)
| | - Wubet Alebachew Bayih
- College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | | | - Binyam Minuye Birhane
- College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
- School of Public Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| |
Collapse
|
2
|
Birhane BM, Assefa Y, Belay DM, Nibret G, Munye Aytenew T, Liyeh TM, Gelaw KA, Tiruneh YM. Interventions to improve the quality of maternal care in Ethiopia: a scoping review. Front Glob Womens Health 2024; 5:1289835. [PMID: 38694232 PMCID: PMC11061455 DOI: 10.3389/fgwh.2024.1289835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 03/25/2024] [Indexed: 05/04/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Binyam Minuye Birhane
- College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
- School of Public Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Demeke Mesfin Belay
- College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Gedefaye Nibret
- College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Tewachew Muche Liyeh
- College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
- School of Public Health, University of Technology Sydney, Sydney, NSW, Australia
| | | | | |
Collapse
|
3
|
Iroz CB, Ramaswamy R, Bhutta ZA, Barach P. Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review. BMC Health Serv Res 2024; 24:332. [PMID: 38481226 PMCID: PMC10935959 DOI: 10.1186/s12913-024-10802-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs. METHODS We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author. RESULTS We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change. CONCLUSIONS Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.
Collapse
Affiliation(s)
- Cassandra B Iroz
- Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
| | - Rohit Ramaswamy
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Institute for Global Health & Development, The Aga Khan University, South Central Asia, East Africa, UK
| | - Paul Barach
- Thomas Jefferson University, Philadelphia, PA, USA
- Imperial College, London, UK
| |
Collapse
|
4
|
Musie MR, Mulaudzi FM, Anokwuru R, Sepeng NV. An Inclusive Framework for Collaboration between Midwives and Traditional Birth Attendants and Optimising Maternal and Child Healthcare in Restricted Rural Communities in South Africa: Policy Considerations. Healthcare (Basel) 2024; 12:363. [PMID: 38338248 PMCID: PMC10855344 DOI: 10.3390/healthcare12030363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024] Open
Abstract
Collaboration between midwives and traditional birth attendants for maternal and child healthcare is a challenge in rural South African communities due to the absence of a guiding framework. To address this, this study sought to develop and validate an inclusive framework informed by the Donabedian structure-process-outcome (SPO) framework for collaboration between these healthcare professionals. METHOD Key stakeholders were invited to participate in a co-creation workshop to develop the framework. Twenty (20) participants were purposively sampled based on their maternal and child healthcare expertise. A consensus design using the nominal group technique was followed. RESULTS Participants identified the components needed in the framework, encompassing (i) objectives, (ii) structures, (iii) processes, and (iv) outcomes. CONCLUSION This paper will contribute to the development of an inclusive healthcare framework, providing insights for stakeholders, policymakers, and practitioners seeking to improve maternal and child healthcare outcomes in resource-constrained, rural settings. Ultimately, the proposed framework will create a sustainable and culturally sensitive model that optimises the strengths of midwives and TBAs and fosters improved healthcare delivery to rural South African communities.
Collapse
Affiliation(s)
- Maurine Rofhiwa Musie
- Department of Nursing Sciences, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa (N.V.S.)
| | - Fhumulani Mavis Mulaudzi
- Department of Nursing Sciences, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa (N.V.S.)
| | - Rafiat Anokwuru
- Department of Maternal and Child Health, llishan School of Nursing, Babcock University Remo, Ilishan-Remo 121003, Nigeria;
| | - Nombulelo Veronica Sepeng
- Department of Nursing Sciences, Faculty of Health Sciences, University of Pretoria, Pretoria 0084, South Africa (N.V.S.)
| |
Collapse
|
5
|
Gwacham-Anisiobi U, Boo YY, Oladimeji A, Kurinczuk JJ, Roberts N, Opondo C, Nair M. Types, reporting and acceptability of community-based interventions for stillbirth prevention in sub-Saharan Africa (SSA): a systematic review. EClinicalMedicine 2023; 62:102133. [PMID: 37593225 PMCID: PMC10430180 DOI: 10.1016/j.eclinm.2023.102133] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Background Community-based interventions are increasingly being implemented in Sub-Saharan Africa (SSA) for stillbirth prevention, but the nature of these interventions, their reporting and acceptability are poorly assessed. In addition to understanding their effectiveness, complete reporting of the methods, results and intervention acceptability is essential as it could potentially reduce research waste from replication of inadequately implemented and unacceptable interventions. We conducted a systematic review to investigate these aspects of community-based interventions for preventing stillbirths in SSA. Methods In this systematic review, eight databases (MEDLINE(OvidSP), Embase (OvidSP), Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index (Web of Science Core Collection), CINAHL (EBSCOhost) and Global Index Medicus) and four grey literature sources were searched from January 1, 2000 to July 7, 2023 for relevant quantitative and qualitative studies from SSA (PROSPERO-CRD42021296623). Following deduplication, abstract screening and full-text review, studies were included if the interventions were community-based with or without a health facility component. The main outcomes were types of community-based interventions, completeness of intervention reporting using the TIDier (Template for Intervention Description and replication) checklist, and themes related to intervention acceptability identified using a theoretical framework. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools. Findings Thirty-nine reports from thirty-four studies conducted in 18 SSA countries were eligible for inclusion. Four types of interventions were identified: nutritional, infection prevention, access to skilled childbirth attendants and health knowledge/behaviour of women. These interventions were implemented using nine strategies: mHealth (defined as the use of mobile and wireless technologies to support the achievement of health objectives), women's groups, community midwifery, home visits, mass media sensitisation, traditional birth attendant and community volunteer training, community mobilisation and transport vouchers. The completeness of reporting using the TIDier checklist varied across studies with a very low proportion of the included studies reporting the intervention intensity, dosing, tailoring and modification. The quality of the included studies were graded as poor (n = 6), fair (n = 14) and good (n = 18). Though interventions were acceptable, only 4 (out of 7) studies explored women's perceptions, mostly focusing on perceived intervention effects and how they felt, omitting key constructs like ethicality, opportunity cost and burden of participation. Interpretation Different community-based interventions have been tried and evaluated for stillbirth prevention in SSA. The reproducibility and implementation scale-up of these interventions may be limited by incomplete intervention descriptions in the published literature. To strengthen impact, it is crucial to holistically explore the acceptability of these interventions among women and their families. Funding Clarendon/Balliol/NDPH DPhil scholarship for UGA. MN is funded by a Medical Research Council Transition Support Award (MR/W029294/1).
Collapse
Affiliation(s)
- Uchenna Gwacham-Anisiobi
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Yebeen Ysabelle Boo
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | - Jennifer J. Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | - Charles Opondo
- London Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
6
|
Westercamp N, Staedke SG, Maiteki-Sebuguzi C, Ndyabakira A, Okiring JM, Kigozi SP, Dorsey G, Broughton E, Hutchinson E, Massoud MR, Rowe AK. Effectiveness of in-service training plus the collaborative improvement strategy on the quality of routine malaria surveillance data: results of a pilot study in Kayunga District, Uganda. Malar J 2021; 20:290. [PMID: 34187489 PMCID: PMC8243434 DOI: 10.1186/s12936-021-03822-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 06/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surveillance data are essential for malaria control, but quality is often poor. The aim of the study was to evaluate the effectiveness of the novel combination of training plus an innovative quality improvement method-collaborative improvement (CI)-on the quality of malaria surveillance data in Uganda. METHODS The intervention (training plus CI, or TCI), including brief in-service training and CI, was delivered in 5 health facilities (HFs) in Kayunga District from November 2015 to August 2016. HF teams monitored data quality, conducted plan-do-study-act cycles to test changes, attended periodic learning sessions, and received CI coaching. An independent evaluation was conducted to assess data completeness, accuracy, and timeliness. Using an interrupted time series design without a separate control group, data were abstracted from 156,707 outpatient department (OPD) records, laboratory registers, and aggregated monthly reports (MR) for 4 time periods: baseline-12 months, TCI scale-up-5 months; CI implementation-9 months; post-intervention-4 months. Monthly OPD register completeness was measured as the proportion of patient records with a malaria diagnosis with: (1) all data fields completed, and (2) all clinically-relevant fields completed. Accuracy was the relative difference between: (1) number of monthly malaria patients reported in OPD register versus MR, and (2) proportion of positive malaria tests reported in the laboratory register versus MR. Data were analysed with segmented linear regression modelling. RESULTS Data completeness increased substantially following TCI. Compared to baseline, all-field completeness increased by 60.1%-points (95% confidence interval [CI]: 46.9-73.2%) at mid-point, and clinically-relevant completeness increased by 61.6%-points (95% CI: 56.6-66.7%). A relative - 57.4%-point (95% confidence interval: - 105.5, - 9.3%) change, indicating an improvement in accuracy of malaria test positivity reporting, but no effect on data accuracy for monthly malaria patients, were observed. Cost per additional malaria patient, for whom complete clinically-relevant data were recorded in the OPD register, was $3.53 (95% confidence interval: $3.03, $4.15). CONCLUSIONS TCI improved malaria surveillance completeness considerably, with limited impact on accuracy. Although these results are promising, the intervention's effectiveness should be evaluated in more HFs, with longer follow-up, ideally in a randomized trial, before recommending CI for wide-scale use.
Collapse
Affiliation(s)
- Nelli Westercamp
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA.
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Alex Ndyabakira
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - John Michael Okiring
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Simon P Kigozi
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Grant Dorsey
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
- Department of Medicine, University of California, San Francisco, USA
| | - Edward Broughton
- ASSIST Project, University Research Co., LLC, 5404 Wisconsin Avenue, Suite 600, Chevy Chase, MD, 20815, USA
| | - Eleanor Hutchinson
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - M Rashad Massoud
- ASSIST Project, University Research Co., LLC, 5404 Wisconsin Avenue, Suite 600, Chevy Chase, MD, 20815, USA
| | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| |
Collapse
|
7
|
Miller NP, Bagheri Ardestani F, Wong H, Stokes S, Mengistu B, Paulos M, Agonafir N, Sylla M, Ameha A, Birhanu BG, Khan S, Lemango ET. Barriers to the utilization of community-based child and newborn health services in Ethiopia: a scoping review. Health Policy Plan 2021; 36:1187-1196. [PMID: 33885143 PMCID: PMC8496769 DOI: 10.1093/heapol/czab047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/22/2021] [Accepted: 04/01/2021] [Indexed: 12/24/2022] Open
Abstract
The Ethiopian Federal Ministry of Health and partners have scaled up integrated
community case management (iCCM) and community-based newborn care (CBNC),
allowing health extension workers (HEWs) to manage the major causes of child and
newborn death at the community level. However, low service uptake remains a key
challenge. We conducted a scoping review of peer-reviewed and grey literature to
assess barriers to the utilization of HEW services and to explore potential
solutions. The review, which was conducted to inform the Optimizing the Health
Extension Program project, which aimed to increase the utilization of iCCM and
CBNC services, included 24 peer-reviewed articles and 18 grey literature
documents. Demand-side barriers to utilization included lack of knowledge about
the signs and symptoms of childhood illnesses and danger signs; low awareness of
curative services offered by HEWs; preference for home-based care, traditional
care, or religious intervention; distance, lack of transportation and cost of
care seeking; the need to obtain husband’s permission to seek care and
opposition of traditional or religious leaders. Supply-side barriers included
health post closures, drug stockouts, disrespectful care and limited skill and
confidence of HEWs, particularly with regard to the management of newborn
illnesses. Potential solutions included community education and demand
generation activities, finding ways to facilitate and subsidize transportation
to health facilities, engaging family members and traditional and religious
leaders, ensuring consistent availability of services at health posts and
strengthening supervision and supply chain management. Both demand generation
and improvement of service delivery are necessary to achieve the expected impact
of iCCM and CBNC. Key steps for improving utilization would be carrying out
multifaceted demand generation activities, ensuring availability of HEWs in
health posts and ensuring consistent supplies of essential commodities. The
Women’s Development Army has the potential to improving linkages between
HEWs and communities, but this strategy needs to be strengthened to be
effective.
Collapse
Affiliation(s)
- Nathan P Miller
- Health Section, UNICEF, 3 UN Plaza, New York, NY 10017, USA.,Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th St., New York, NY 10032, USA
| | | | - Hayes Wong
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th St., New York, NY 10032, USA
| | - Sonya Stokes
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th St., New York, NY 10032, USA
| | - Birkety Mengistu
- PATH Ethiopia, Bole Medhaniyalem Street #03, Bole, Addis Ababa, Ethiopia
| | - Meron Paulos
- PATH Ethiopia, Bole Medhaniyalem Street #03, Bole, Addis Ababa, Ethiopia
| | - Nesibu Agonafir
- PATH Ethiopia, Bole Medhaniyalem Street #03, Bole, Addis Ababa, Ethiopia
| | - Mariame Sylla
- Health Section, UNICEF Ethiopia, UNECA Compound, Zambezi Building, Addis Ababa, Ethiopia
| | - Agazi Ameha
- Health Section, UNICEF Ethiopia, UNECA Compound, Zambezi Building, Addis Ababa, Ethiopia
| | - Bizuhan Gelaw Birhanu
- Health Section, UNICEF Ethiopia, UNECA Compound, Zambezi Building, Addis Ababa, Ethiopia
| | - Sadaf Khan
- Maternal Newborn Child Health and Nutrition, PATH, 2201 Westlake Ave. Ste 200, Seattle, WA 98121, USA
| | - Ephrem Tekle Lemango
- Programs Section, Maternal, Child Health and Nutrition Directorate, Ministry of Health, Sudan Street, Addis Ababa, Ethiopia
| |
Collapse
|
8
|
Kumar MB, Madan JJ, Auguste P, Taegtmeyer M, Otiso L, Ochieng CB, Muturi N, Mgamb E, Barasa E. Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya. BMJ Glob Health 2021; 6:e002452. [PMID: 33658302 PMCID: PMC7931757 DOI: 10.1136/bmjgh-2020-002452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Improvements in maternal and infant health outcomes are policy priorities in Kenya. Achieving these outcomes depends on early identification of pregnancy and quality of primary healthcare. Quality improvement interventions have been shown to contribute to increases in identification, referral and follow-up of pregnant women by community health workers. In this study, we evaluate the cost-effectiveness of using quality improvement at community level to reduce maternal and infant mortality in Kenya. METHODS We estimated the cost-effectiveness of quality improvement compared with standard of care treatment for antenatal and delivering mothers using a decision tree model and taking a health system perspective. We used both process (antenatal initiation in first trimester and skilled delivery) and health outcomes (maternal and infant deaths averted, as well as disability-adjusted life years (DALYs)) as our effectiveness measures and actual implementation costs, discounting costs only. We conducted deterministic and probabilistic sensitivity analyses. RESULTS We found that the community quality improvement intervention was more cost-effective compared with standard community healthcare, with incremental cost per DALY averted of $249 under the deterministic analysis and 76% likelihood of cost-effectiveness under the probabilistic sensitivity analysis using a standard threshold. The deterministic estimate of incremental cost per additional skilled delivery was US$10, per additional early antenatal care presentation US$155, per maternal death averted US$5654 and per infant death averted US$37 536 (2017 dollars). CONCLUSIONS This analysis shows that the community quality improvement intervention was cost-effective compared with the standard community healthcare in Kenya due to improvements in antenatal care uptake and skilled delivery. It is likely that quality improvement interventions are a good investment and may also yield benefits in other health areas.
Collapse
Affiliation(s)
- Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jason J Madan
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Peter Auguste
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | | | | | - Nelly Muturi
- Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Elizabeth Mgamb
- Department of Health, Migori County Government, Migori, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| |
Collapse
|
9
|
Demis A, Gedefaw G, Wondmieneh A, Getie A, Alemnew B. Women's knowledge towards neonatal danger signs and its associated factors in Ethiopia: a systematic review and meta-analysis. BMC Pediatr 2020; 20:217. [PMID: 32408874 PMCID: PMC7222534 DOI: 10.1186/s12887-020-02098-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 04/22/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Reducing neonatal mortality is an essential part of the third Sustainable Development Goal, to end preventable child deaths. Neonatal danger signs are the most common cause of neonatal mortality and morbidity. In Ethiopia, most babies are born at home or are discharged from the health institutions in the first 24 h, as a result enhancing women’s knowledge towards neonatal danger signs and its complication might reduce neonatal morbidity and mortality. Therefore, this systematic review and meta-analysis aimed to assess the women knowledge towards neonatal danger signs in Ethiopia. Method MEDLINE/PubMed, Scopus, Hinari, Google scholar, web of science electronic databases and grey literature from repository were searched for all the available studies. Fourteen cross sectional studies were included in this systematic review and meta-analysis. Subgroup analysis was conducted for the evidence of heterogeneity. Cochrane I2 statistics were used to check the heterogeneity of the studies. Egger test with funnel plot were used to investigate publication bias. Result Fourteen cross-sectional studies with a total of 6617 study participants were included for this study. The overall pooled prevalence of women’s knowledge towards neonatal danger sign was 40.7% (95%CI, 25.72, 55.67). Having higher educational status of the women (AOR = 3.86, 95%CI: 2.3–6.5), having higher educational status of the husband (AOR = 4.57, 95%CI: 3.29–6.35), access to mass media (AOR = 1.69, 95%CI: 1.17–2.23), having antenatal care visits (AOR = 2.63, 95%CI: 1.13–4.67), having postnatal care follow up (AOR = 2.55, 95%CI; 1.72–3.79) and giving birth at health institutions (AOR = 2.51, 95%CI:1.68–3.74) were factors associated with knowledge of the women towards danger sign of the neonate. Conclusion In this systematic review and meta-analysis the pooled prevalence of maternal knowledge towards neonatal danger sign was low. Educational status of the mother, educational status of the husband, access to mass media, antenatal care follow-up, postnatal care follow-up and place of delivery were factors associated with knowledge of the mother towards danger sign of the newborn. Promoting antenatal care, postnatal care follow-up and community-based health information dissemination about neonatal danger signs should be strengthened. Systematic review registration PROSPERO CRD42019132179.
Collapse
Affiliation(s)
- Asmamaw Demis
- Department of Nursing, College of Health Sciences, Woldia University, P.O. Box:400, Woldia, Ethiopia.
| | - Getnet Gedefaw
- Department of Midwifery, College of Health Sciences, Woldia University, P.O.Box:400, Woldia, Ethiopia
| | - Adam Wondmieneh
- Department of Nursing, College of Health Sciences, Woldia University, P.O. Box:400, Woldia, Ethiopia
| | - Addisu Getie
- Department of Nursing, College of Health Sciences, Woldia University, P.O. Box:400, Woldia, Ethiopia
| | - Birhan Alemnew
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, P.O.Box:400, Woldia, Ethiopia
| |
Collapse
|
10
|
Hanson C, Zamboni K, Prabhakar V, Sudke A, Shukla R, Tyagi M, Singh S, Schellenberg J. Evaluation of the Safe Care, Saving Lives (SCSL) quality improvement collaborative for neonatal health in Telangana and Andhra Pradesh, India: a study protocol. Glob Health Action 2019; 12:1581466. [PMID: 30849300 PMCID: PMC6419630 DOI: 10.1080/16549716.2019.1581466] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The collaborative quality improvement approach proposed by the Institute for Healthcare Improvement has the potential to improve coverage of evidence-based maternal and newborn health practices. The Safe Care, Saving Lives initiative supported the implementation of 20 evidence-based maternal and newborn care practices, targeting labour wards and neonatal care units in 85 public and private hospitals in Telangana and Andhra Pradesh, India. Objective: We present a protocol for the evaluation of this programme which aims to (a) estimate the effect of the initiative on evidence-based care practices and mortality; (b) evaluate the mechanisms leading to changes in adherence to evidence-based practices, and their relationship with contextual factors; (c) explore the feasibility of scaling-up the approach. Methods: The mixed-method evaluation is based on a plausibility design nested within a phased implementation. The 29 non-randomly selected hospitals comprising wave II of the programme were compared to the 31 remaining hospitals where the quality improvement approach started later. We assessed mortality and adherence to evidence-based practices at baseline and endline using abstraction of registers, checklists, observations and interviews in intervention and comparison hospitals. We also explored the mechanisms and drivers of change in adherence to evidence-based practices. Qualitative methods investigated the mechanisms of change in purposefully selected case study hospitals. A readiness assessment complemented the analysis of what works and why. We used a difference-in-difference approach to estimate the effects of the intervention on mortality and coverage. Thematic analysis was used for the qualitative data. Discussion: This is the first quality improvement collaborative targeting neonatal health in secondary and tertiary hospitals in a middle-income country linked to a government health insurance scheme. Our process evaluation is theory driven and will refine hypotheses about how this quality improvement approach contributes to institutionalization of evidence-based practices.
Collapse
Affiliation(s)
- Claudia Hanson
- a Department of Disease Control , London School of Hygiene and Tropical Medicine , London , UK.,b Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Karen Zamboni
- a Department of Disease Control , London School of Hygiene and Tropical Medicine , London , UK
| | - Vikrant Prabhakar
- c Department of Community Medicine , Adesh Medical College and Hospital , Kurukshetra , India
| | | | - Rajan Shukla
- e Public Health Foundation of India , Kavuri Hills, Madhapur , Hyderabad , India
| | - Mukta Tyagi
- e Public Health Foundation of India , Kavuri Hills, Madhapur , Hyderabad , India
| | - Samiksha Singh
- e Public Health Foundation of India , Kavuri Hills, Madhapur , Hyderabad , India
| | - Joanna Schellenberg
- a Department of Disease Control , London School of Hygiene and Tropical Medicine , London , UK
| |
Collapse
|
11
|
Kumar MB, Madan JJ, Achieng MM, Limato R, Ndima S, Kea AZ, Chikaphupha KR, Barasa E, Taegtmeyer M. Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries. BMJ Glob Health 2019; 4:e001390. [PMID: 31354971 PMCID: PMC6626522 DOI: 10.1136/bmjgh-2019-001390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/22/2019] [Accepted: 05/25/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Countries aspiring to universal health coverage view close-to-community (CTC) providers as a low-cost means of increasing coverage. However, due to lack of coordination and unreliable funding, the quality of large-scale CTC healthcare provision is highly variable and routine data about service quality are not trustworthy. Quality improvement (QI) approaches are a means of addressing these issues, yet neither the costs nor the budget impact of integrating QI approaches into CTC programme costs have been assessed. Methods This paper examines the costs and budget impact of integrating QI into existing CTC health programmes in five countries (Ethiopia, Indonesia, Kenya, Malawi, Mozambique) between 2015 and 2017. The intervention involved: (1) QI team formation; (2) Phased training interspersed with supportive supervision; which resulted in (3) QI teams independently collecting and analysing data to conduct QI interventions. Project costs were collected using an ingredients approach from a health systems perspective. Based on project costs, costs of local adoption of the intervention were modelled under three implementation scenarios. Results Annualised economic unit costs ranged from $62 in Mozambique to $254 in Ethiopia per CTC provider supervised, driven by the context, type of community health model and the intensity of the intervention. The budget impact of Ministry-led QI for community health is estimated at 0.53% or less of the general government expenditure on health in all countries (and below 0.03% in three of the five countries). Conclusion CTC provision is a key component of healthcare delivery in many settings, so QI has huge potential impact. The impact is difficult to establish conclusively, but as a first step we have provided evidence to assess affordability of QI for community health. Further research is needed to assess whether QI can achieve the level of benefits that would justify the required investment.
Collapse
Affiliation(s)
- Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Center for Humanitarian Emergencies, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jason J Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Ralalicia Limato
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Sozinho Ndima
- Community Health Department, University of Eduardo Mondlane, Faculty of Medicine, Maputo, Mozambique
| | - Aschenaki Z Kea
- School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia
| | - Kingsley Rex Chikaphupha
- Health Systems & HIV/AIDS Dept, Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
12
|
Nichols EK, Ragunanthan NW, Ragunanthan B, Gebrehiwet H, Kamara K. A systematic review of vital events tracking by community health agents. Glob Health Action 2019; 12:1597452. [PMID: 31179875 PMCID: PMC6566585 DOI: 10.1080/16549716.2019.1597452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Efforts to improve national civil registration and vital statistics (CRVS) systems are focusing on transforming traditionally passive systems into active systems that have the ability to reach the household level. While community health agents remain at the core of many birth and death reporting efforts, previous literature has not explored elements for their successful integration into CRVS efforts. Objective: To inform future efforts to improve CRVS systems, we conducted a systematic review of literature to understand and describe the design features, resulting data quality, and factors impacting the performance of community health agents involved in tracking vital events. Methods: We reviewed 393 articles; reviewers extracted key information from 58 articles meeting the eligibility criteria: collection of birth and/or death information outside of a clinic environment by a community agent. Reviewers recorded information in an Excel database on various program aspects, and results were summarized into key themes and topic areas. Results: The majority of articles described work in rural areas of Africa or South-East Asia. Nearly all articles (86%) cited some form of household visitation by community health agents. Only one article described a process in which vital events tracking activities were linked to official vital events registers. Other factors commonly described included program costs, relationship of community agents to community, and use of mobile devices. About 1/3 of articles reported quantitative information on performance and quality of vital events data tracked; various methods were described for measuring completeness of reporting, which varied greatly across articles. Conclusions: The multitude of articles on this topic attests to the availability of community health agents to track vital events. Creating a programmatic norm of integrating with CRVS systems the vital events information collected from existing community health programs has the potential to provide governments with information essential for public health decision-making.
Collapse
Affiliation(s)
- Erin K Nichols
- a National Center for Health Statistics , Centers for Disease Control and Prevention , Hyattsville , MD , USA.,b Department of Health and Human Services , United States Public Health Service , Washington, DC , USA
| | - Nina W Ragunanthan
- c Department of Obstetrics, Gynecology, and Reproductive Sciences , University of Pittsburgh Medical Center Magee-Womens Hospital , Pittsburgh , PA , USA
| | - Braveen Ragunanthan
- d Department of Pediatrics , University of Pittsburgh Medical Center Children's Hospital of Pittsburgh , Pittsburgh , PA , USA
| | - Hermon Gebrehiwet
- e Health Sciences Program , Argosy University , Arlington , VA , USA
| | - Karim Kamara
- f School of Health Professions , Shenandoah University , Winchester , VA , USA
| |
Collapse
|
13
|
Assefa Y, Gelaw YA, Hill PS, Taye BW, Van Damme W. Community health extension program of Ethiopia, 2003-2018: successes and challenges toward universal coverage for primary healthcare services. Global Health 2019; 15:24. [PMID: 30914055 PMCID: PMC6434624 DOI: 10.1186/s12992-019-0470-1] [Citation(s) in RCA: 171] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ethiopia has been implementing a community health extension program (HEP) since 2003. We aimed to assess the successes and challenges of the HEP over time, and develop a framework that may assist the implementation of the program toward universal primary healthcare services. METHODS We conducted a systematic review and synthesis of the literature on the HEP in Ethiopia between 2003 and 2018. Literature search was accomplished in PubMed, Embase and Google scholar databases. Literature search strategies were developed using medical subject headings (MeSH) and text words related to the aim of the review. We used a three-stage screening process to select the publications. Data extraction was conducted by three reviewers using pre-prepared data extraction form. We conducted an interpretive (not aggregative) synthesis of studies. FINDINGS The HEP enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge and health care seeking. The HEP has been a learning organization that adapts itself to community demands. The program is also dynamic enough to shift tasks between health centers and community. The community has been a key player in the successful implementation of the HEP. In spite of these successes, the program is currently facing challenges that remain to be addressed. These challenges are related to productivity and efficiency of health extension workers (HEWs); working and living conditions of HEWs; capacity of health posts; and, social determinants of health. These require a systemic approach that involves the wider health system, community, and sectors responsible for social determinants of health. We developed a framework that may assist in the implementation of the HEP. CONCLUSION The HEP has enabled Ethiopia to achieve significant improvements. However, several challenges remain to be addressed. The framework can be utilized to improve community health programs toward universal coverage for primary healthcare services.
Collapse
Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia.
| | | | - Peter S Hill
- School of Public Health, the University of Queensland, Brisbane, Australia
| | | | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
14
|
Asefa A, Gebremedhin S, Messele T, Letamo Y, Shibru E, Alano A, Morgan A, Kermode M. Mismatch between antenatal care attendance and institutional delivery in south Ethiopia: A multilevel analysis. BMJ Open 2019; 9:e024783. [PMID: 30898814 PMCID: PMC6527994 DOI: 10.1136/bmjopen-2018-024783] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Uptake of maternal health services remains suboptimal in Ethiopia. Significant proportions of antenatal care attendees give birth at home. This study was conducted to identify the predictors of non-institutional delivery among women who received antenatal care in the Southern Nations Nationalities and Peoples Region, Ethiopia. DESIGN A community-based cross-sectional survey was conducted among women who delivered in the year preceding the survey and who had at least one antenatal visit. Multistage cluster sampling was deployed to select 2390 women from all administrative zones of the region. A mixed-effects multivariable logistic regression analysis was performed to assess the predictors of non-institutional delivery; adjusted ORs (AOR) with 95% CIs are reported. RESULTS The proportion of non-institutional deliveries among participants was 62.2% (95% CI 60.2% to 64.2%). Previous experience of short and simple labour (46.9%) and uncomplicated home birth (42.9%), night-time labour (29.7%), absence of pregnancy-related problem (18.8%) and perceived providers poor reception of women (17.8%) were the main reasons to have non-institutional delivery. Attending secondary school and above (AOR=0.51; 95% CI 0.30 to 0.85), being a government employee (AOR=0.27; 95% CI 0.10 to 0.78) and woman's autonomy in healthcare utilisation decision making (AOR=0.51; 95% CI 0.33 to 0.79) were among the independent predictors negatively associated with non-institutional delivery. On the other hand, unplanned pregnancy (AOR=1.67; 95% CI 1.16 to 2.42), not experiencing any health problem during pregnancy (AOR=8.1; 95% CI 3.12 to 24.62), not perceiving the risks associated with home delivery (AOR=6.64; 95% CI 4.35 to 10.14) were the independent predictors positively associated with non-institutional delivery. CONCLUSIONS There is a missed opportunity among women attending antenatal care in southern Ethiopia. Further health system innovations that help to bridge the gap between antenatal care attendance and institutional delivery are highly recommended.
Collapse
Affiliation(s)
- Anteneh Asefa
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Samson Gebremedhin
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Tamiru Messele
- Southern Nations Nationalities and Peoples Region Health Bureau, Hawassa, Ethiopia
| | - Yohannes Letamo
- Southern Nations Nationalities and Peoples Region Health Bureau, Hawassa, Ethiopia
| | - Endashaw Shibru
- Southern Nations Nationalities and Peoples Region Health Bureau, Hawassa, Ethiopia
| | - Abraham Alano
- Southern Nations Nationalities and Peoples Region Health Bureau, Hawassa, Ethiopia
| | - Alison Morgan
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Michelle Kermode
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
15
|
Yadeta TA. Antenatal care utilization increase the odds of women knowledge on neonatal danger sign: a community-based study, eastern Ethiopia. BMC Res Notes 2018; 11:845. [PMID: 30497525 PMCID: PMC6267923 DOI: 10.1186/s13104-018-3957-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/26/2018] [Indexed: 11/28/2022] Open
Abstract
Objective This study, aimed to determine women knowledge on key neonatal dander sign and associated factors among women recently gave birth in eastern Ethiopia. Results Of the 757 women interviewed, fever was reported as a neonatal danger sign by 255 (33.7%) followed by poor sucking (24.8%), difficulty breathing (23.5%), convulsion (16.0%), lethargy (12.9%), a very small baby (11.8%) and hypothermia (2.9%). Overall 9.38% listed four or more danger signs spontaneously. Attending at least one antenatal care visit [AOR = 2.83; 95% CI (1.62, 4.93)], and giving birth at health facilities [AOR = 3.31; 95% CI (1.67, 6.53)] were significantly associated with knowledge of neonatal danger signs.
Collapse
Affiliation(s)
- Tesfaye Assebe Yadeta
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, P.O.B. 235, Harar, Ethiopia.
| |
Collapse
|
16
|
Wereta T, Betemariam W, Karim AM, Fesseha Zemichael N, Dagnew S, Wanboru A, Bhattacharya A. Effects of a participatory community quality improvement strategy on improving household and provider health care behaviors and practices: a propensity score analysis. BMC Pregnancy Childbirth 2018; 18:364. [PMID: 30255783 PMCID: PMC6157250 DOI: 10.1186/s12884-018-1977-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Maternal and newborn health care intervention coverage has increased in many low-income countries over the last decade, yet poor quality of care remains a challenge, limiting health gains. The World Health Organization envisions community engagement as a critical component of health care delivery systems to ensure quality services, responsive to community needs. Aligned with this, a Participatory Community Quality Improvement (PCQI) strategy was introduced in Ethiopia, in 14 of 91 rural woredas (districts) where the Last Ten Kilometers Project (L10 K) Platform activities were supporting national Basic Emergency Obstetric and Newborn Care (BEmONC) strengthening strategies. This paper examines the effects of the PCQI strategy in improving maternal and newborn care behaviors, and providers' and households' practices. METHODS PCQI engages communities in identifying barriers to access and quality of services, and developing, implementing and monitoring solutions. Thirty-four intervention kebeles (communities), which included the L10 K Platform, BEmONC, and PCQI, and 82 comparison kebeles, which included the L10 K Platform and BEmONC, were visited in December 2010-January 2011 and again 48 months later. Twelve women with children aged 0 to 11 months were interviewed in each kebele. Propensity score matching was used to estimate the program's average treatment effects (ATEs) on women's care seeking behavior, providers' service provision behavior and households' newborn care practices. RESULTS The ATEs of PCQI were statistically significant (p < 0.05) for two care seeking behaviors - four or more antenatal care (ANC) visits and institutional deliveries at 14% (95% CI: 6, 21) and 11% (95% CI: 4, 17), respectively - and one service provision behavior - complete ANC at 17% (95% CI: 11, 24). We found no evidence of an effect on remaining outcomes relating to household newborn care practices, and postnatal care performed by the provider. CONCLUSIONS National BEmONC strengthening and government initiatives to improve access and quality of maternal and newborn health services, together with L10 K Platform activities, appeared to work better for some care practices where communities were engaged in the PCQI strategy. Additional research with more robust measure of impact and cost-effectiveness analysis would be useful to establish effectiveness for a wider set of outcomes.
Collapse
Affiliation(s)
- Tewabech Wereta
- The Last Ten Kilometers Project (L10K) 2020, JSI Research and Training Institute, Inc, Bole Sub-City, Kebele 03/05, Hs # 2111, Addis Ababa, Ethiopia
| | - Wuleta Betemariam
- The Last Ten Kilometers Project (L10K) 2020, JSI Research and Training Institute, Inc, Bole Sub-City, Kebele 03/05, Hs # 2111, Addis Ababa, Ethiopia
| | - Ali Mehryar Karim
- The Last Ten Kilometers Project (L10K) 2020, JSI Research and Training Institute, Inc, Bole Sub-City, Kebele 03/05, Hs # 2111, Addis Ababa, Ethiopia
| | - Nebreed Fesseha Zemichael
- The Last Ten Kilometers Project (L10K) 2020, JSI Research and Training Institute, Inc, Bole Sub-City, Kebele 03/05, Hs # 2111, Addis Ababa, Ethiopia
| | - Selamawit Dagnew
- The Last Ten Kilometers Project (L10K) 2020, JSI Research and Training Institute, Inc, Bole Sub-City, Kebele 03/05, Hs # 2111, Addis Ababa, Ethiopia
| | - Abera Wanboru
- The Last Ten Kilometers Project (L10K) 2020, JSI Research and Training Institute, Inc, Bole Sub-City, Kebele 03/05, Hs # 2111, Addis Ababa, Ethiopia
| | - Antoinette Bhattacharya
- Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| |
Collapse
|
17
|
Østebø MT, Cogburn MD, Mandani AS. The silencing of political context in health research in Ethiopia: why it should be a concern. Health Policy Plan 2018; 33:258-270. [PMID: 29165682 DOI: 10.1093/heapol/czx150] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2017] [Indexed: 11/12/2022] Open
Abstract
In 2004, the Ethiopian government launched what has been called an innovative and groundbreaking solution to the country's public health challenges; the Health Extension Programme (HEP). The positive public health outcomes that have been reported following the implementation of the HEP have led researchers and global health actors to propose it as a model for other countries to emulate. In this systematic review, we point to a potential weakness and methodological bias in the existing research. Despite being implemented within a context of an increasingly authoritarian regime, research conducted following the implementation of HEP reflects a limited discussion of the political context. Following a discussion of why political context is marginalized we provide arguments for why a focus on political context is important: first, political context has an impact on health systems and actualizes questions related to good governance and ethics. While some of the studies we reviewed acknowledge the importance of political factors we contend that the one-sided focus on the positive relationship between political will, political commitment and political leadership on the one hand, and key public health outcomes on the other, reflects a narrow engagement with health system governance frameworks. This leads to a silencing of issues actualized by the authoritarian nature of the Ethiopian regime. Secondly, the political context has methodological implications. More specifically, we contend that the current political situation increases the probability of social desirability bias. In order to balance the overarching positive literature on Ethiopia's health system, research that takes the political context into account is much needed.
Collapse
Affiliation(s)
- Marit Tolo Østebø
- Department of Anthropology, University of Florida, 1112 Turlington Hall, PO Box 117305, Gainesville, FL, USA
| | - Megan D Cogburn
- Department of Anthropology, University of Florida, 1112 Turlington Hall, PO Box 117305, Gainesville, FL, USA
| | - Anjum Shams Mandani
- Department of Anthropology, University of Florida, 1112 Turlington Hall, PO Box 117305, Gainesville, FL, USA
| |
Collapse
|
18
|
Amare Y, Paul S, Sibley LM. Illness recognition and appropriate care seeking for newborn complications in rural Oromia and Amhara regional states of Ethiopia. BMC Pediatr 2018; 18:265. [PMID: 30081872 PMCID: PMC6090701 DOI: 10.1186/s12887-018-1196-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 06/27/2018] [Indexed: 11/25/2022] Open
Abstract
Background Ethiopia has made significant progress in reducing child mortality but newborn mortality has stagnated at around 29 deaths per 1000 births. The Maternal Health in Ethiopia Partnership (MaNHEP) was a 3.5-year implementation project aimed at developing a community-oriented model of maternal and newborn health in rural Ethiopia and to position it for scale up. In 2014, we conducted a case study of the project focusing on recognition of and timely biomedical care seeking for maternal and newborn complications. In this paper, we detail the main findings from one component of the case study – the narrative interviews on newborn complications. Methods The study area, comprised of six districts in which MaNHEP had been implemented, was located in the two most populous federal regions of Ethiopia, Oromia and Amhara. The final purposive sample consisted of 16 cases in which the newborn survived to 28 days of life, and 13 cases in which the newborn died within 28 days of life, for a total sample size of 29 cases. Narrative interview were conducted with the main caregiver and several witnesses to the event. Analysis of the data included thematic content analysis and the determination of care seeking pathways and levels and timeliness of biomedical care seeking. Results Mothers and other witnesses do recognize certain symptoms of newborn illness which they often mentioned in clusters. The majority considered the symptoms to be serious and in some case hopeless. Perceived causes were mostly natural. Forty-one percent of care seekers sought timely biomedical care in the neonatal period. Surprisingly, perceived severity did not necessarily trigger care seeking. Facilitators of biomedical care seeking included accessibility of health facilities and counseling by health workers, whereas barriers included perceived vulnerability of newborns, post-partum restrictions on movements, hopelessness, wait-and-see atttitudes, poor communication and physical inaccessibility of health facilities. Conclusions Symptom recognition and care seeking patterns indicate the need to strengthen focused locally relevant health messages which target mothers, fathers and other community members, to further enhance access to health care and to improve referral and quality of care.
Collapse
Affiliation(s)
- Y Amare
- Consultancy for Social Development, P.O. Box - 70196, Addis Ababa, Ethiopia.
| | - S Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE, 30322, Atlanta, Georgia
| | - L M Sibley
- Nell Hodgson Woodruff School of Nursing and Rollins School of Public Health, Emory University, 1520 Clifton Road NE, 30322, Atlanta, Georgia
| |
Collapse
|
19
|
Tancred T, Mandu R, Hanson C, Okuga M, Manzi F, Peterson S, Schellenberg J, Waiswa P, Marchant T. How people-centred health systems can reach the grassroots: experiences implementing community-level quality improvement in rural Tanzania and Uganda. Health Policy Plan 2018; 33:e1-e13. [PMID: 29304250 DOI: 10.1093/heapol/czu070] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2014] [Indexed: 01/01/2023] Open
Abstract
Background Quality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here we share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff. Aim To describe experiences implementing EQUIP's QI approach at the community level. Methods A mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. We outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also. Results Village volunteers had the capacity to learn and apply QI techniques to address local maternal and neonatal health problems. Data collection and presentation was a persistent challenge for village volunteers, overcome through intensive continuous mentoring and coaching. Village volunteers complemented health facility staff, particularly to reinforce behaviour change on health facility delivery and birth preparedness. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce. Conclusions Community-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.
Collapse
Affiliation(s)
- Tara Tancred
- Ifakara Health Institute, Dar es Salaam, Tanzania.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Rogers Mandu
- Makerere University School of Public Health, Kampala, Uganda
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Monica Okuga
- Makerere University School of Public Health, Kampala, Uganda
| | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Stefan Peterson
- Makerere University School of Public Health, Kampala, Uganda.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,The Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | | |
Collapse
|
20
|
Cordova E, Al-Rousan T, Castillo-Angeles M, Aftab S, Nelson BD. Effect of low-cost interventions on the retention of knowledge and skills following Helping Babies Breathe training. Int J Gynaecol Obstet 2018; 142:248-254. [PMID: 29687893 DOI: 10.1002/ijgo.12512] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/19/2018] [Accepted: 04/20/2018] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the impact of a post-Helping Babies Breathe bundle of interventions on the retention of provider-level knowledge and skills. METHOD The present prospective pre-post study following a 1-day Helping Babies Breathe training of professional midwives, physicians, and nurses was conducted in Cajamarca Province, Peru between January 1 and July 31, 2017. The interventions to improve retention included structured worksite practice before every shift, weekly in-service simulated scenarios, and monthly supervised peer-to-peer abbreviated refresher trainings. Knowledge and skills were assessed before, immediately after, and 6 months after training using two validated multiple-choice knowledge test and objective structured clinical examinations (OSCEs; OSCE A and OSCE B). Data were analyzed for changes in knowledge and skills over time and to identify predictors of performance. RESULTS There were 60 learners included. No significant differences were observed between assessments immediately after training and at 6-month follow-up for knowledge scores or time-to-effective-ventilation. Pass rates for OSCE B increased from 83% immediately after training to 95% at follow-up (P=0.007). The only factor associated with a reduced time to effective ventilation at 6-month follow-up was working in a hospital (P<0.001), accounting for years of training and experience. CONCLUSION Helping Babies Breathe knowledge and skills can be retained and even improved with simple, inexpensive interventions, including supervised on-the-job and peer-to-peer training.
Collapse
Affiliation(s)
- Erika Cordova
- Harvard Neonatal Perinatal Medicine Fellowship, Boston Children's Hospital, Boston, MA, USA
| | - Tala Al-Rousan
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | | | - Saima Aftab
- Division of Neonatal Perinatal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brett D Nelson
- Harvard Medical School, Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
21
|
Sibley LM, Amare Y, Abebe ST, Belew ML, Shiffra K, Barry D. Appropriateness and timeliness of care-seeking for complications of pregnancy and childbirth in rural Ethiopia: a case study of the Maternal and Newborn Health in Ethiopia Partnership. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2017; 36:50. [PMID: 29297394 PMCID: PMC5764048 DOI: 10.1186/s41043-017-0120-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND In 2014, USAID and University Research Co., LLC, initiated a new project under the broader Translating Research into Action portfolio of projects. This new project was entitled Systematic Documentation of Illness Recognition and Appropriate Care Seeking for Maternal and Newborn Complications. This project used a common protocol involving descriptive mixed-methods case studies of community projects in six low- and middle-income countries, including Ethiopia. In this paper, we present the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) case study. METHODS Methods included secondary analysis of data from MaNHEP's 2010 baseline and 2012 end line surveys, health program inventory and facility mapping to contextualize care-seeking, and illness narratives to identify factors influencing illness recognition and care-seeking. Analyses used descriptive statistics, bivariate tests, multivariate logistic regression, and thematic content analysis. RESULTS Maternal illness awareness increased between 2010 and 2012 for major obstetric complications. In 2012, 45% of women who experienced a major complication sought biomedical care. Factors associated with care-seeking were MaNHEP CMNH Family Meetings, health facility birth, birth with a skilled provider, or health extension worker. Between 2012 and 2014, the Ministry of Health introduced nationwide initiatives including performance review, ambulance service, increased posting of midwives, pregnant women's conferences, user-friendly services, and maternal death surveillance. By 2014, most facilities were able to provide emergency obstetric and newborn care. Yet in 2014, biomedical care-seeking for perceived maternal illness occurred more often compared with care-seeking for newborn illness-a difference notable in cases in which the mother or newborn died. Most families sought care within 1 day of illness recognition. Facilitating factors were health extension worker advice and ability to refer upward, and health facility proximity; impeding factors were time of day, weather, road conditions, distance, poor cell phone connectivity (to call for an ambulance), lack of transportation or money for transport, perceived spiritual or physical vulnerability of the mother and newborn and associated culturally determined postnatal restrictions on the mother or newborn's movement outside of the home, and preference for traditional care. Some families sought care despite disrespectful, poor quality care. CONCLUSIONS Improvements in illness recognition and care-seeking observed during MaNHEP have been reinforced since that time and appear to be successful. There is still need for a concerted effort focusing on reducing identified barriers, improve quality of care and provider counseling, and contextualize messaging behavior change communications and provider counseling.
Collapse
Affiliation(s)
- Lynn M. Sibley
- Nell Hodgson Woodruff School of Nursing and Rollins School of Public Health, Emory University, Atlanta, GA 30322 USA
| | - Yared Amare
- Consultancy for Social Development, Addis Ababa, Ethiopia
| | | | | | | | | |
Collapse
|
22
|
Sibley L, Amare Y. Illness recognition and care seeking for maternal complications of pregnancy and birth in rural Amhara and Oromia Regional States of Ethiopia. BMC Pregnancy Childbirth 2017; 17:384. [PMID: 29145815 PMCID: PMC5691869 DOI: 10.1186/s12884-017-1572-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/06/2017] [Indexed: 11/10/2022] Open
Abstract
Background Ethiopia has made steady progress in improving maternal health over the decade, yet mortality remains high. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) was a 3.5-year project aimed at developing a community-oriented model to improve maternal and newborn survival in rural Ethiopia. Two years after the project ended, we carried out a case study to explore illness recognition and care seeking for complications of pregnancy and childbirth in the project area. This paper describes the results of one component: illness narratives. Methods Sampling involved random selection of 12 health facilities from 6 MaNHEP project districts in Amhara and >Oromia regions, and purposive selection of cases from the facility catchment areas. The purposive sample included 17 cases of perceived excessive bleeding, 5 cases of maternal death from any cause, and witnesses to the illness events. Two-person teams facilitated the narrative interviews. Analysis included thematic content analysis of symptoms, causes, decision makers and decision-making, factors facilitating and impeding care seeking, and delineation of care-seeking steps. Results Most surviving mothers (and witnesses) perceived the symptoms and seriousness of excessive bleeding; a majority (53%) sought timely biomedical care. Three of five families of mothers who died from causes unrelated to bleeding failed to initially perceive symptoms as serious, yet all sought timely appropriate care once they did so. Many of these families took multiple steps to obtain care, leading to delays.. Health worker counseling and proximity to health services facilitated, while certain cultural norms, economic, geographic, and environmental constraints impeded care seeking. Surprisingly, poor quality of care at health facilities was not a barrier. Conclusion Mothers and family caregivers are able to recognize and seek timely biomedical care for abnormal bleeding, and for less obvious symptoms of illness. These achievements can be reinforced through continued and focused health education and counseling, reduction of known barriers to care seeking, and improvements in the capacity of the health system to respond to maternal complications with high quality basic and comprehensive emergency obstetric care.
Collapse
Affiliation(s)
- Lynn Sibley
- Nell Hodgson Woodruff School of Nursing and Rollins School of Public Health, Emory University, 1520 Clifton Road NE, Room 268, 30322, Atlanta, Georgia.
| | - Yared Amare
- Consultancy for Social Development, P.O. Box - 70196, Addis Ababa, Ethiopia
| |
Collapse
|
23
|
Hynes M, Meehan K, Meyers J, Mashukano Maneno L, Hulland E. Using a quality improvement approach to improve maternal and neonatal care in North Kivu, Democratic Republic of Congo. REPRODUCTIVE HEALTH MATTERS 2017; 25:140-150. [PMID: 29231787 PMCID: PMC5757313 DOI: 10.1080/09688080.2017.1403276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Providing quality health care services in humanitarian settings is challenging due to population displacement, lack of qualified staff and supervisory oversight, and disruption of supply chains. This study explored whether a participatory quality improvement (QI) intervention could be used in a protracted conflict setting to improve facility-based maternal and newborn care. A longitudinal quasi-experimental design was used to examine delivery of maternal and newborn care components at 12 health facilities in eastern Democratic Republic of Congo. Study facilities were split into two groups, with both groups receiving an initial "standard" intervention of clinical training. The "enhanced" intervention group then applied a QI methodology, which involved QI teams in each facility, supported by coaches, testing small changes to improve care. This paper presents findings on two of the study outcomes: delivery of active management of the third stage of labour (AMTSL) and essential newborn care (ENC). We measured AMTSL and ENC through exit interviews with post-partum women and matched partographs at baseline and endline over a 9-month period. Using generalised equation estimation models, the enhanced intervention group showed a greater rate of change than the control group for AMTSL (aOR 3.47, 95% CI: 1.17-10.23) and ENC (OR: 49.62, 95% CI: 2.79-888.28), and achieved 100% ENC completion at endline. This is one of the first studies where this QI methodology has been used in a protracted conflict setting. A method where health staff take ownership of improving care is of even greater value in a humanitarian context where external resources and support are scarce.
Collapse
Affiliation(s)
- Michelle Hynes
- a Epidemiologist , U.S. Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Kate Meehan
- b Health Scientist , U.S. Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Janet Meyers
- c Deputy Director Health Policy and Practice (Former) , International Medical Corps , Washington , DC , USA
| | - Leon Mashukano Maneno
- d Reproductive Health Manager , International Medical Corps , Goma , Democratic Republic of Congo
| | - Erin Hulland
- e Statistician , U.S. Centers for Disease Control and Prevention , Atlanta , GA , USA
| |
Collapse
|
24
|
Waiswa P, Manzi F, Mbaruku G, Rowe AK, Marx M, Tomson G, Marchant T, Willey BA, Schellenberg J, Peterson S, Hanson C. Effects of the EQUIP quasi-experimental study testing a collaborative quality improvement approach for maternal and newborn health care in Tanzania and Uganda. Implement Sci 2017; 12:89. [PMID: 28720114 PMCID: PMC5516352 DOI: 10.1186/s13012-017-0604-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/30/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Quality improvement is a recommended strategy to improve implementation levels for evidence-based essential interventions, but experience of and evidence for its effects in low-resource settings are limited. We hypothesised that a systemic and collaborative quality improvement approach covering district, facility and community levels, supported by report cards generated through continuous household and health facility surveys, could improve the implementation levels and have a measurable population-level impact on coverage and quality of essential services. METHODS Collaborative quality improvement teams tested self-identified strategies (change ideas) to support the implementation of essential maternal and newborn interventions recommended by the World Health Organization. In Tanzania and Uganda, we used a plausibility design to compare the changes over time in one intervention district with those in a comparison district in each country. Evaluation included indicators of process, coverage and implementation practice analysed with a difference-of-differences and a time-series approach, using data from independent continuous household and health facility surveys from 2011 to 2014. Primary outcomes for both countries were birth in health facilities, breastfeeding within 1 h after birth, oxytocin administration after birth and knowledge of danger signs for mothers and babies. Interpretation of the results considered contextual factors. RESULTS The intervention was associated with improvements on one of four primary outcomes. We observed a 26-percentage-point increase (95% CI 25-28%) in the proportion of live births where mothers received uterotonics within 1 min after birth in the intervention compared to the comparison district in Tanzania and an 8-percentage-point increase (95% CI 6-9%) in Uganda. The other primary indicators showed no evidence of improvement. In Tanzania, we saw positive changes for two other outcomes reflecting locally identified improvement topics. The intervention was associated with an increase in preparation of clean birth kits for home deliveries (31 percentage points, 95% CI 2-60%) and an increase in health facility supervision by district staff (14 percentage points, 95% CI 0-28%). CONCLUSIONS The systemic quality improvement approach was associated with improvements of only one of four primary outcomes, as well as two Tanzania-specific secondary outcomes. Reasons for the lack of effects included limited implementation strength as well a relatively short follow-up period in combination with a 1-year recall period for population-based estimates and a limited power of the study to detect changes smaller than 10 percentage points. TRIAL REGISTRATION Pan African Clinical Trials Registry: PACTR201311000681314.
Collapse
Affiliation(s)
- P Waiswa
- College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - F Manzi
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
| | - G Mbaruku
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
| | - A. K. Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - M Marx
- Evaplan GmbH the University of Heidelberg, Heidelberg, Germany
| | - G Tomson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Learning, Informatics, Management, Ethics, Karolinska Institutet, Stockholm, Sweden
| | - T Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - B. A. Willey
- Department Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - J Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - S Peterson
- College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- International Maternal and Child Health Unit, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - C Hanson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
25
|
Yirgu R, Molla M, Sibley L. Determinants of neonatal mortality in rural Northern Ethiopia: A population based nested case control study. PLoS One 2017; 12:e0172875. [PMID: 28419096 PMCID: PMC5395163 DOI: 10.1371/journal.pone.0172875] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/11/2017] [Indexed: 11/21/2022] Open
Abstract
Introduction In low income and middle income countries, neonatal mortality remains high despite the gradual reduction in under five mortality. Newborn death contributes for about 38% of all under five deaths. This study has identified the magnitude and independent predictors of neonatal mortality in rural Ethiopia. Methods This population based nested case control study was conducted in rural West Gojam zone, Northern Ethiopia, among a cohort of pregnant women who gave birth between March 2011 and Feb 2012. The cohort was established by Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project in 2010 by recruiting mothers in their third trimester, as identified by trained community volunteers. Once identified, women stayed in the cohort throughout their pregnancy period receiving Community Maternal and Newborn Health (CMNH) training by health extension workers and community volunteers till the end of the first 48 hours postpartum. Cases were 75 mothers who lost their newborns to neonatal death and controls were 150 randomly selected mothers with neonates who survived the neonatal period. Data to identify cause of death were collected using the WHO standard verbal autopsy questionnaire after the culturally appropriate 40 days of bereavement period. Binomial logistic regression model was used to identify independent contributors to neonatal mortality. Result The neonatal mortality rate was AOR(95%CI) = 18.6 (14.8, 23.2) per 1000 live births. Neonatal mortality declined with an increase in family size, neonates who were born among a family of more than two had lesser odds of death in the neonatal period than those who were born in a family of two AOR (95% CI) = 0.13 (0.02, 0.71). Mothers who gave birth to 2–4 AOR(95%CI) = 0.15 (0.05, 0.48) and 5+ children AOR(95%CI) = 0.08 (0.02, 0.26) had lesser odds of losing their newborns to neonatal mortality. Previous history of losing a newborn to neonatal death also increased the odds of neonatal mortality during the last birth AOR (95%CI) = 0.25 (0.11, 0.53). Conclusion The neonatal mortality rate in our study was three times lower than the regional neonatal mortality rate estimate, indicating community based interventions could significantly decrease neonatal mortality. The identified determinants, which are amenable for change, emphasize the need to improve quality of care during pregnancy, labour and delivery to improve pregnancy outcome.
Collapse
Affiliation(s)
- Robel Yirgu
- Department of Reproductive Health and Health Service Management, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Mitike Molla
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lynn Sibley
- Nell Hodgson Woodruff School of Nursing and Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| |
Collapse
|
26
|
Tancred T, Manzi F, Schellenberg J, Marchant T. Facilitators and Barriers of Community-Level Quality Improvement for Maternal and Newborn Health in Tanzania. QUALITATIVE HEALTH RESEARCH 2017; 27:738-749. [PMID: 27022034 DOI: 10.1177/1049732316638831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
A quality improvement intervention for maternal and newborn health was carried out in southern Tanzania at the community level. It sought to improve health-seeking behaviors and uptake of community-level maternal and newborn health practices. A process evaluation populated using data primarily from in-depth interviews and focus group discussions with the intervention's implementers was undertaken in four villages receiving the intervention to evaluate the intervention's implementation, uncover facilitators and barriers of quality improvement, and highlight contextual factors that might have influenced implementation. Performance implementation scores were used to rank the villages. Identifying higher- and lower-performing villages highlighted key facilitators and barriers of community-level quality improvement related to support from local leaders, motivation through use of local quality improvement data, and regular education around quality improvement and maternal and newborn health. These findings can be taken formatively in the design of similar interventions in the future.
Collapse
Affiliation(s)
- Tara Tancred
- 1 London School of Hygiene & Tropical Medicine, London, UK
| | - Fatuma Manzi
- 2 Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Tanya Marchant
- 1 London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
27
|
Phuma-Ngaiyaye EE, Adejumo O, Dartey AF. Challenges in Neonatal Nursing Clinical Teaching to Nurse-Midwife Technicians in Malawi. J Nurs Educ 2017; 56:215-221. [PMID: 28383745 DOI: 10.3928/01484834-20170323-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/01/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Practice-based learning is important in clinical teaching of nursing and midwifery as students develop the necessary competencies and confidence aligned by the outcomes of their learning programs. However, in Malawi, research shows that clinical teaching in neonatal nursing has not been given adequate consideration. This article reports on challenges faced by educators and students in clinical teaching and learning in neonatal nursing for nurse-midwife technicians. METHOD An explorative qualitative study was conducted. Data were collected through 23 focus group discussions with 140 students and 31 clinical teachers from eight nursing colleges. Audiorecorded data were transcribed verbatim and analyzed using Hennink's content analysis stages. RESULTS Challenges faced by clinical teachers and students were short duration and variation in clinical placements, lack of emphasis in clinical teaching, and lack of skills among clinical staff. CONCLUSION Nursing training institutions should maximize student learning opportunities in neonatal nursing practice by creating more practice-based learning opportunities that meet the students' needs. [J Nurs Educ. 2017;56(4):215-221.].
Collapse
|
28
|
Callaghan‐Koru JA, Estifanos AS, Sheferaw ED, Graft‐Johnson J, Rosado C, Patton‐Molitors R, Worku B, Rawlins B, Baqui A. Practice of skin-to-skin contact, exclusive breastfeeding and other newborn care interventions in Ethiopia following promotion by facility and community health workers: results from a prospective outcome evaluation. Acta Paediatr 2016; 105:e568-e576. [PMID: 27644765 DOI: 10.1111/apa.13597] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/23/2016] [Accepted: 09/15/2016] [Indexed: 11/30/2022]
Abstract
AIM To assess the effects of a facility and community newborn intervention package on coverage of early skin-to-skin contact (SSC) and exclusive breastfeeding - the therapeutic components of kangaroo mother care. METHODS A multilevel community and facility intervention in Ethiopia trained health workers in 10 health centres and the surrounding communities to promote early SSC and exclusive breastfeeding for all babies born at home or in the facility. Changes in SSC and exclusive breastfeeding were assessed by comparing baseline and endline household surveys. RESULTS Overall practice of SSC at any time following delivery increased significantly from 13.1 to 44.1% of mothers. Coverage of immediate SSC also increased significantly from 8.4 to 24.1%. Breastfeeding within the first hour increased from 51.4 to 67.9% and exclusive breastfeeding within the first three days increased from 86 to 95.8%. At endline, SSC was significantly higher among facility births than home births and community health workers had limited contact with mothers. CONCLUSION While targeted behaviours improved overall, the programme did not achieve adequate increases in SSC and exclusive breastfeeding among home deliveries to expect a reduction in mortality for low birthweight babies. Newborn care programs in Ethiopia should continue to encourage facility delivery while strengthening coverage of community programmes.
Collapse
Affiliation(s)
- Jennifer A. Callaghan‐Koru
- Department of Sociology, Anthropology, and Health Administration and Policy University of Maryland Baltimore County Baltimore MD USA
- International Center for Maternal and Newborn Health Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
- Maternal and Child Health Integrated Program Washington DC USA
| | - Abiy Seifu Estifanos
- Department of Reproductive Health and Health Service Management School of Public Health College of Health Sciences Addis Ababa University Addis Ababa Ethiopia
| | | | | | - Carina Rosado
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| | - Rachel Patton‐Molitors
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| | - Bogale Worku
- Department of Pediatrics Addis Ababa University Addis Ababa Ethiopia
| | - Barbara Rawlins
- Maternal and Child Health Integrated Program Washington DC USA
| | - Abdullah Baqui
- International Center for Maternal and Newborn Health Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
- Maternal and Child Health Integrated Program Washington DC USA
| |
Collapse
|
29
|
Yang L, Pan S, Zhou Y, Wang X, Qin A, Huang Y, Sun S. The Correlation Between Serum Vitamin D Deficiency and Preterm Birth. Med Sci Monit 2016; 22:4401-4405. [PMID: 27851719 PMCID: PMC5117241 DOI: 10.12659/msm.898117] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Preterm birth is an important cause of death and developmental disorder in neonates. Vitamin D deficiency has been shown to regulate body inflammatory factor levels that stimulate elevation of uterine contraction hormones, such as prostaglandin, thus causing preterm birth. However, current observations regarding the relationship between vitamin D and preterm birth are inconsistent. We performed a nested case-control study to investigate the effect of vitamin D on preterm birth. MATERIAL AND METHODS A prospective cohort study included 200 cases of pregnant women in our hospital from May 2013 to May 2015. Blood samples were collected from early, middle, and late stages of pregnancy. Forty-six patients with preterm delivery were compared with age-matched full-term delivery cases (N=92). High performance liquid chromatography-mass spectrometry (HPLC-MS) was used to detect serum levels of 25(OH)D, 25(OH)D2, and 25(OH)D3. Logistic regression was performed to analyze the correlation between 25(OH)D and risk of preterm birth. RESULTS No significant difference in age, smoking/drinking, education level, BMI and vitamin D levels was found between the preterm birth group and full-term delivery group. No significant difference was found for vitamin D levels across different stages of pregnancy; no difference in concentration of 25(OH)D related to preterm birth risk was found. After adjusting for potentially confounding factors, serum vitamin D level did not increase the risk of preterm birth. CONCLUSIONS This study did not found evidence of an increase in preterm birth risk related to vitamin D level during pregnancy.
Collapse
Affiliation(s)
- Lixia Yang
- Department of Nutrition and Food Hygiene, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Shilei Pan
- Department of Obstetrics and Gynecology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yufeng Zhou
- Department of Obstetrics and Gynecology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Xiaoyang Wang
- Department of Obstetrics and Gynecology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Aikai Qin
- Department of Obstetrics and Gynecology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yuxin Huang
- Department of Obstetrics and Gynecology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Suxia Sun
- Department of Nutrition and Food Hygiene, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China (mainland)
| |
Collapse
|
30
|
Wekesah FM, Mbada CE, Muula AS, Kabiru CW, Muthuri SK, Izugbara CO. Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review. Syst Rev 2016; 5:137. [PMID: 27526773 PMCID: PMC4986260 DOI: 10.1186/s13643-016-0305-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/20/2016] [Indexed: 12/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Frederick M. Wekesah
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Julius Global Health, Julius Center for Health Sciences and Primary Care, Utrecht Medical Center, Utrecht Huispost Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, Netherlands
| | - Chidozie E. Mbada
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Department of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Health, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre, Malawi
- African Center for Public Health and Herbal Medicine, University of Malawi, Blantyre, Malawi
| | - Caroline W. Kabiru
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Stella K. Muthuri
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Chimaraoke O. Izugbara
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| |
Collapse
|
31
|
Reisman J, Arlington L, Jensen L, Louis H, Suarez-Rebling D, Nelson BD. Newborn Resuscitation Training in Resource-Limited Settings: A Systematic Literature Review. Pediatrics 2016; 138:peds.2015-4490. [PMID: 27388500 DOI: 10.1542/peds.2015-4490] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Birth asphyxia contributes substantially to neonatal mortality in low- and middle-income countries (LMICs). The effects of training birth attendants in neonatal resuscitation (NR) on mortality are limited by falloff of skills and knowledge over time and transference of learned skills into clinical practice. OBJECTIVE This review examined acquisition and retention of NR knowledge and skills by birth attendants in LMICs and the effectiveness of interventions to improve them. DATA SOURCES Medline, Cochrane, Embase, CINAHL, Bireme, and African Index Medicus databases were searched. We reviewed Web pages and reports from non-peer-reviewed (or "gray") literature sources addressing NR training in LMICs. STUDY SELECTION Articles on acquisition and retention of NR knowledge and skills, and interventions to improve them, were limited to LMICs. RESULTS The initial search identified 767 articles, of which 45 met all inclusion criteria. Of these, 31 articles analyzed acquisition of knowledge and skills, and 19 analyzed retention. Most studies found high acquisition rates, although birth attendants struggled to learn bag-mask ventilation. Although significant falloff of knowledge and skills occurred after training, refresher training seemed to improve retention. Results of the gray literature analysis suggest that formal, structured practice sessions improve retention. LIMITATIONS This review did not analyze training's direct impact on mortality. CONCLUSIONS Knowledge and skills falloff is a significant barrier to the success of NR training programs and possibly to reducing newborn mortality in LMICs. Refresher training and structured practice show significant promise. Additional research is needed to implement and assess retention improvement strategies in classroom and clinical settings.
Collapse
Affiliation(s)
- Jonathan Reisman
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; and
| | - Lauren Arlington
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Lloyd Jensen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Henry Louis
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Brett D Nelson
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; and
| |
Collapse
|
32
|
Dynes MM, Hadley C, Stephenson R, Sibley LM. A network study exploring factors that promote or erode interaction among diverse community health workers in rural Ethiopia. Health Policy Plan 2015; 30:1093-104. [PMID: 25311147 PMCID: PMC4597038 DOI: 10.1093/heapol/czu113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2014] [Indexed: 01/25/2023] Open
Abstract
Task shifting in response to the health workforce shortage has resulted in community-based health workers taking on increasing responsibility. Community health workers are expected to work collaboratively, though they are often a heterogeneous group with a wide range of training and experience. Interpersonal relationships are at the very core of effective teamwork, yet relational variables have seldom been the focus of health systems research in low resource, rural settings. This article helps fill this knowledge gap by exploring the dyadic level, or relational, characteristics of community maternal and newborn health workers and the individual and collective influence of these characteristics on interaction patterns. Network data were collected from community health workers (N = 194) in seven rural kebeles of Amhara region, Ethiopia from November 2011 to January 2012. Multiple Regression Quadratic Assignment Procedure was used to fit regression models for frequency of work interactions, a proxy for teamwork. Strong and consistent evidence was found in support of Trust and Past training together as important relational factors for work interactions; less consistent evidence was found across sites in support of Homophily, Distance and Shared motivations. Our findings also point to a typology of network structure across sites, where one set of networks was characterized by denser and stronger health worker ties relative to their counterparts. Our results suggest that the development of interventions that promote trust and incorporate cross-cadre training is an important step in encouraging collective action. Moreover, assessing the structure of health worker networks may be an effective means of evaluating health systems strengthening efforts in rural, low-resource settings.
Collapse
Affiliation(s)
- Michelle M Dynes
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA 30322, USA,
| | - Craig Hadley
- Department of Anthropology, Emory University, 1557 Dickey Dr., Atlanta, GA 30322, USA and
| | - Rob Stephenson
- Hubert Department of Global Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA
| | - Lynn M Sibley
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA 30322, USA
| |
Collapse
|
33
|
Kok MC, Kea AZ, Datiko DG, Broerse JEW, Dieleman M, Taegtmeyer M, Tulloch O. A qualitative assessment of health extension workers' relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance. HUMAN RESOURCES FOR HEALTH 2015; 13:80. [PMID: 26423049 PMCID: PMC4589131 DOI: 10.1186/s12960-015-0077-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 09/17/2015] [Indexed: 05/28/2023]
Abstract
BACKGROUND Health extension workers (HEWs) in Ethiopia have a unique position, connecting communities to the health sector. This intermediary position requires strong interpersonal relationships with actors in both the community and health sector, in order to enhance HEW performance. This study aimed to understand how relationships between HEWs, the community and health sector were shaped, in order to inform policy on optimizing HEW performance in providing maternal health services. METHODS We conducted a qualitative study in six districts in the Sidama zone, which included focus group discussions (FGDs) with HEWs, women and men from the community and semi-structured interviews with HEWs; key informants working in programme management, health service delivery and supervision of HEWs; mothers; and traditional birth attendants. Respondents were asked about facilitators and barriers regarding HEWs' relationships with the community and health sector. Interviews and FGDs were recorded, transcribed, translated, coded and thematically analysed. RESULTS HEWs were selected by their communities, which enhanced trust and engagement between them. Relationships were facilitated by programme design elements related to support, referral, supervision, training, monitoring and accountability. Trust, communication and dialogue and expectations influenced the strength of relationships. From the community side, the health development army supported HEWs in liaising with community members. From the health sector side, top-down supervision and inadequate training possibilities hampered relationships and demotivated HEWs. Health professionals, administrators, HEWs and communities occasionally met to monitor HEW and programme performance. Expectations from the community and health sector regarding HEWs' tasks sometimes differed, negatively affecting motivation and satisfaction of HEWs. CONCLUSION HEWs' relationships with the community and health sector can be constrained as a result of inadequate support systems, lack of trust, communication and dialogue and differing expectations. Clearly defined roles at all levels and standardized support, monitoring and accountability, referral, supervision and training, which are executed regularly with clear communication lines, could improve dialogue and trust between HEWs and actors from the community and health sector. This is important to increase HEW performance and maximize the value of HEWs' unique position.
Collapse
Affiliation(s)
- Maryse C Kok
- Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
- VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan 1081, 1081 HV, Amsterdam, The Netherlands.
| | | | - Daniel G Datiko
- REACH Ethiopia, P.O. Box 303, Hawassa, Ethiopia.
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Jacqueline E W Broerse
- VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan 1081, 1081 HV, Amsterdam, The Netherlands.
| | - Marjolein Dieleman
- Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Olivia Tulloch
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| |
Collapse
|
34
|
Event-based surveillance in north-western Ethiopia: experience and lessons learnt in the field. Western Pac Surveill Response J 2015; 6:22-7. [PMID: 26668763 DOI: 10.5365/wpsar.2015.6.2.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study piloted an event-based surveillance system at the health centre (HC) level in Ethiopia. The system collects rumours in the community and registers them in rumour logbooks to record events of disease outbreaks and public health emergencies. Descriptive analysis was conducted on the events captured at the 59 study HCs in the Amhara Region in north-western Ethiopia between October 2013 and November 2014. A total of 126 rumours were registered at two thirds of the HCs during the study period. The average event reporting time was 3.8 days; response time of the HCs was 0.6 days, resulting in a total response time of 4.4 days. The most commonly reported rumours were measles-related (n = 90, 71%). These rumours followed a similar pattern of measles cases reported in the routine surveillance system. The largest proportion of rumours were reported by community members (n = 38, 36%) followed by health post workers (n = 36, 29%) who were normally informed by the community members about the rumours. This surveillance system was established along with an existing indicator-based surveillance system and was simple to implement. The implementation cost was minimal, requiring only printing and distribution of rumour logbooks to the HCs and brief orientations to focal persons. In countries where routine surveillance is still weak, an event-based surveillance system similar to this should be considered as a supplementary tool for disease monitoring.
Collapse
|
35
|
Molla M, Mitiku I, Worku A, Yamin A. Impacts of maternal mortality on living children and families: A qualitative study from Butajira, Ethiopia. Reprod Health 2015; 12 Suppl 1:S6. [PMID: 26001276 PMCID: PMC4423766 DOI: 10.1186/1742-4755-12-s1-s6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The consequences of maternal mortality on orphaned children and the family members who support them are dramatic, especially in countries that have high maternal mortality like Ethiopia. As part of a four country, mixed-methods study (Ethiopia, Malawi, South Africa, and Tanzania) qualitative data were collected in Butajira, Ethiopia with the aim of exploring the far reaching consequences of maternal deaths on families and children. Methods We conducted interviews with 28 adult family members of women who died from maternal causes, as well as 13 stakeholders (government officials, civil society, and a UN agency); and held 10 focus group discussions with 87 community members. Data were analyzed using NVivo10 software for qualitative analysis. Results We found that newborns and children whose mothers died from maternal causes face nutrition deficits, and are less likely to access needed health care than children with living mothers. Older children drop out of school to care for younger siblings and contribute to household and farm labor which may be beyond their capacity and age, and often choose migration in search of better opportunities. Family fragmentation is common following maternal death, leading to tenuous relationships within a household with the births and prioritization of additional children further stretching limited financial resources. Currently, there is no formal standardized support system for families caring for vulnerable children in Ethiopia. Conclusions Impacts of maternal mortality on children are far-reaching and have the potential to last into adulthood. Coordinated, multi-sectorial efforts towards mitigating the impacts on children and families following a maternal death are lacking. In order to prevent impacts on children and families, efforts targeting maternal mortality must address inequalities in access to care at the community, facility, and policy levels.
Collapse
|
36
|
Tesfaye S, Barry D, Gobezayehu AG, Frew AH, Stover KE, Tessema H, Alamineh L, Sibley LM. Improving coverage of postnatal care in rural Ethiopia using a community-based, collaborative quality improvement approach. J Midwifery Womens Health 2015; 59 Suppl 1:S55-64. [PMID: 24588916 DOI: 10.1111/jmwh.12168] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Ethiopia has high maternal and neonatal mortality and low use of skilled maternity care. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), a 3.5-year learning project, used a community collaborative quality improvement approach to improve maternal and newborn health care during the birth-to-48-hour period. This study examines how the promotion of community maternal and newborn health (CMNH) family meetings and labor and birth notification contributed to increased postnatal care within 48 hours by skilled providers or health extension workers. METHODS Baseline and endline surveys, monthly quality improvement data, and MaNHEP's CMNH change package, a compendium of the most effective changes developed and tested by communities, were reviewed. Logistic regression assessed factors associated with postnatal care receipt. Monthly postnatal care receipt was plotted with control charts. RESULTS The baseline (n = 1027) and endline (n = 1019) surveys showed significant increases in postnatal care, from 5% to 51% and from 15% to 47% in the Amhara and Oromiya regions, respectively (both P < .001). Notification of health extension workers for labor and birth within 48 hours was closely linked with receipt of postnatal care. Women with any antenatal care were 1.7 times more likely to have had a postnatal care visit (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.10-2.54; P < .001). Women who had additionally attended 2 or more CMNH meetings with family members and had access to a health extension worker's mobile phone number were 4.9 times more likely to have received postnatal care (OR, 4.86; 95% CI, 2.67-8.86; P < .001). DISCUSSION The increase in postnatal care far exceeds the 7% postnatal care coverage rate reported in the 2011 Ethiopian Demographic and Health Survey (EDHS). This result was linked to ideas generated by community quality improvement teams for labor and birth notification and cooperation with community-level health workers to promote antenatal care and CMNH family meetings.
Collapse
|
37
|
Spangler SA, Barry D, Sibley L. An evaluation of equitable access to a community-based maternal and newborn health program in rural Ethiopia. J Midwifery Womens Health 2015; 59 Suppl 1:S101-9. [PMID: 24588911 DOI: 10.1111/jmwh.12133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) aimed to promote equitable access to safe childbirth and postnatal care through a community-based educational intervention. This study evaluates the extent to which MaNHEP reached women who are socially and materially disadvantaged and, thus, at high risk for inadequate access to care. METHODS The data used in this analysis are from MaNHEP's cross-sectional 2010 baseline and 2012 endline surveys of women who gave birth in the prior year. A logistic regression model was fit to examine the effects of sociodemographic characteristics on participation in the MaNHEP program. Descriptive statistics of select characteristics by birth and postnatal care provider were also calculated to explore trends in services use. RESULTS Using data from the endline survey (N = 1019), the regression model showed that age, parity, education, and geographic residence were not significantly associated with MaNHEP exposure. However, women who were materially disadvantaged were still less likely to have participated in the program than their better-off counterparts. From the baseline survey (N = 1027) to the endline survey, women's use of skilled and semiskilled providers for birth care and postnatal care increased substantially, while use of untrained providers or no provider decreased. These shifts were greater for women with less personal wealth than for women with more personal wealth. DISCUSSION MaNHEP appears to have succeeded in meeting its equity goals to a degree. However, this study also supports the intractable relationship between wealth inequality and access to maternal and newborn health services. Strategies targeting the poor in diverse contexts may eventually prove consistently effective in equitable services delivery. Until that time, a critical step that all maternal and newborn health programs can take is to monitor and evaluate to what extent they are reaching disadvantaged groups within the populations they serve.
Collapse
|
38
|
Gobezayehu AG, Mohammed H, Dynes MM, Desta BF, Barry D, Aklilu Y, Tessema H, Tadesse L, Mikulich M, Buffington ST, Sibley LM. Knowledge and skills retention among frontline health workers: community maternal and newborn health training in rural Ethiopia. J Midwifery Womens Health 2015; 59 Suppl 1:S21-31. [PMID: 24588913 DOI: 10.1111/jmwh.12146] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We examined the degree to which the skills and knowledge of health workers in Ethiopia were retained 18 months after initial maternal and newborn health training and sought to identify factors associated with 18-month skills assessment performance. METHODS A nonexperimental, descriptive design was employed to assess 18-month skills performance on the topics of Prevent Problems Before Baby Is Born and Prevent Problems After Baby Is Born. Assessment was conducted by project personnel who also received the maternal and newborn health training and additional training to reliably assess health worker performance. RESULTS Among the 732 health workers who participated in maternal and newborn health training in 6 rural districts of the Amhara and Oromia regions of Ethiopia (including pretesting before training and a posttraining posttest), 75 health extension workers (78%) and 234 guide team members (37%) participated in 18-month posttest. Among health extension workers in both regions, strong knowledge retention was noted in 10 of 14 care steps for Prevent Problems Before Baby Is Born and in 14 of 16 care steps of Prevent Problems After Baby Is Born. Lower knowledge retention was observed among guide team members in the Amhara region. Across regions, health workers scored lowest on steps that involved nonaction (eg, do not give oxytocin). Educational attainment and age were among the few variables found to significantly predict test performance, although participants varied substantially by other sociodemographic characteristics. DISCUSSION Results demonstrated an overall strong retention of knowledge and skills among health extension workers and highlighted the need for improvement among some guide team members. Refresher training and development of strategies to improve knowledge of retention of low-performing steps were recommended.
Collapse
|
39
|
Dynes MM, Stephenson R, Hadley C, Sibley LM. Factors shaping interactions among community health workers in rural Ethiopia: rethinking workplace trust and teamwork. J Midwifery Womens Health 2015; 59 Suppl 1:S32-43. [PMID: 24588914 DOI: 10.1111/jmwh.12135] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Worldwide, a shortage of skilled health workers has prompted a shift toward community-based health workers taking on greater responsibility in the provision of select maternal and newborn health services. Research in mid- and high-income settings suggests that coworker collaboration increases productivity and performance. A major gap in this research, however, is the exploration of factors that influence teamwork among diverse community health worker cadres in rural, low-resource settings. The purpose of this study is to examine how sociodemographic and structural factors shape teamwork among community-based maternal and newborn health workers in Ethiopia. METHODS A cross-sectional survey was conducted with health extension workers, community health development agents, and traditional birth attendants in 3 districts of the West Gojam Zone in the Amhara region of Ethiopia. Communities were randomly selected from Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) sites; health worker participants were recruited using a snowball sampling strategy. Fractional logit modeling and average marginal effects analyses were carried out to identify the influential factors for frequency of work interactions with each cadre. RESULTS One hundred and ninety-four health workers participated in the study. A core set of factors-trust in coworkers, gender, and cadre-were influential for teamwork across groups. Greater geographic distance and perception of self-interested motivations were barriers to interactions with health extension workers, while greater food insecurity (a proxy for wealth) was associated with increased interactions with traditional birth attendants. DISCUSSION Interventions that promote trust and gender sensitivity and improve perceptions of health worker motivations may help bridge the gap in health services delivery between low- and high-resource settings. Inter-cadre training may be one mechanism to increase trust and respect among diverse health workers, thereby increasing collaboration. Large-scale, longitudinal research is needed to understand how changes in trust, gender norms, and perceptions of motivations influence teamwork over time.
Collapse
|
40
|
Barry D, Frew AH, Mohammed H, Desta BF, Tadesse L, Aklilu Y, Biadgo A, Buffington ST, Sibley LM. The effect of community maternal and newborn health family meetings on type of birth attendant and completeness of maternal and newborn care received during birth and the early postnatal period in rural Ethiopia. J Midwifery Womens Health 2015; 59 Suppl 1:S44-54. [PMID: 24588915 DOI: 10.1111/jmwh.12171] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Maternal and newborn deaths occur predominantly in low-resource settings. Community-based packages of evidence-based interventions and skilled birth attendance can reduce these deaths. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) used community-level health workers to conduct prenatal Community Maternal and Newborn Health family meetings to build skills and care-seeking behaviors among pregnant women and family caregivers. METHODS Baseline and endline surveys provided data on a random sample of women with a birth in the prior year. An intention-to-treat analysis, plausible net effect calculation, and dose-response analysis examined increases in completeness of care (mean percentage of 17 maternal and newborn health care elements performed) over time and by meeting participation. Regression models assessed the relationship between meeting participation, completeness of care, and use of skilled providers or health extension workers for birth care-controlling for sociodemographic and health service utilization factors. RESULTS A 151% increase in care completeness occurred from baseline to endline. At endline, women who participated in 2 or more meetings had more complete care than women who participated in fewer than 2 meetings (89% vs 76% of care elements; P < .001). A positive dose-response relationship existed between the number of meetings attended and greater care completeness (P < .001). Women with any antenatal care were nearly 3 times more likely to have used a skilled provider or health extension worker for birth care. Women who had additionally attended 2 or more meetings with family members were over 5 times as likely to have used these providers, compared to women without antenatal care and who attended fewer than 2 meetings (odds ratio, 5.19; 95% confidence interval, 2.88-9.36; P < .001). DISCUSSION MaNHEP's family meetings complemented routine antenatal care by engaging women and family caregivers in self-care and care-seeking, resulting in greater completeness of care and more highly skilled birth care.
Collapse
|
41
|
Koblinsky M. Reducing maternal and perinatal mortality through a community collaborative approach: introduction to a special issue on the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP). J Midwifery Womens Health 2015; 59 Suppl 1:S1-5. [PMID: 24588910 DOI: 10.1111/jmwh.12174] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
42
|
Stover KE, Tesfaye S, Frew AH, Mohammed H, Barry D, Alamineh L, Teshome A, Hepburn K, Sibley LM. Building district-level capacity for continuous improvement in maternal and newborn health. J Midwifery Womens Health 2015; 59 Suppl 1:S91-S100. [PMID: 24588921 DOI: 10.1111/jmwh.12164] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) adapted a collaborative improvement strategy to develop woreda (district) leadership capacity to support and facilitate continuous improvement of community maternal and neonatal health (CMNH) and to provide a model for other woredas, dubbed "lead" woredas. Community-level quality improvement (QI) teams tested solutions to improve CMNH care supported by monthly coaching and regular meetings to share experiences. This study examines the extent of the capacity built to support continuous improvement in CMNH care. METHODS Surveys and in-depth interviews assessed the extent to which MaNHEP developed improvement capacity. A survey questionnaire evaluated woreda culture, leadership support, motivation, and capacity for improvement activities. Interviews focused on respondents' understanding and perceived value of the MaNHEP improvement approach. Bivariate analyses and multivariate linear regression models were used to analyze the survey data. Interview transcripts were organized by region, cadre, and key themes. RESULTS Respondents reported significant positive changes in many areas of woreda culture and leadership, including involving a cross-section of community stakeholders (increased from 3.0 to 4.6 on 5-point Likert scale), using improvement data for decision making (2.8-4.4), using locally developed and tested solutions to improve CMNH care (2.5-4.3), demonstrating a commitment to improve the health of women and newborns (2.6-4.2), and creating a supportive environment for coaches and QI teams to improve CMNH (2.6-4.0). The mean scores for capacity were 3.7 and higher, reflecting respondents' agreement that they had gained capacity in improvement skills. Interview respondents universally recognized the capacity built in the woredas. The themes of community empowerment and focused improvement emerged strongly from the interviews. DISCUSSION MaNHEP was able to build capacity for continuous improvement and develop lead woredas. The multifaceted approach to building capacity was critical for the success in creating lead woredas able to serve as models for other districts.
Collapse
|
43
|
Sisay MM, Yirgu R, Gobezayehu AG, Sibley LM. A Qualitative Study of Attitudes and Values Surrounding Stillbirth and Neonatal Mortality Among Grandmothers, Mothers, and Unmarried Girls in Rural Amhara and Oromiya Regions, Ethiopia: Unheard Souls in the Backyard. J Midwifery Womens Health 2014; 59 Suppl 1:S110-7. [DOI: 10.1111/jmwh.12156] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
44
|
Spangler SA, Gobezayehu AG, Getachew T, Sibley LM. Interpretation of National Policy Regarding Community-Based Use of Misoprostol for Postpartum Hemorrhage Prevention in Ethiopia: A Tale of Two Regions. J Midwifery Womens Health 2014; 59 Suppl 1:S83-90. [DOI: 10.1111/jmwh.12154] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|