Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia

Association between antenatal care facility readiness and provision of care at the client level and facility level in five low- and middle-income countries

BACKGROUND

Despite growing interest in monitoring improvements in quality of care, data on service quality in low-income and middle-income countries (LMICs) is limited. While health systems researchers have hypothesized the relationship between facility readiness and provision of care, there have been few attempts to quantify this relationship in LMICs. This study assesses the association between facility readiness and provision of care for antenatal care at the client level and facility level.

METHODS

To assess the association between provision of care and various facility readiness indices for antenatal care, we used multilevel, multivariable random-effects linear regression models. We tested an inflection point on readiness scores by fitting linear spline models. To compare the coefficients between models, we used a bootstrapping approach and calculated the mean difference between all pairwise comparisons. Analyses were conducted at client and facility levels.

RESULTS

Our results showed a small, but significant association between facility readiness and provision of care across countries and most index constructions. The association was most evident in the client-level analyses that had a larger sample size and were adjusted for factors at the facility, health worker, and individual levels. In addition, spline models at a facility readiness score of 50 better fit the data, indicating a plausible threshold effect.

CONCLUSIONS

The results of this study suggest that facility readiness is not a proxy for provision of care, but that there is an important association between facility readiness and provision of care. Data on facility readiness is necessary for understanding the foundations of health systems particularly in countries with the lowest levels of service quality. However, a comprehensive view of quality of care should include both facility readiness and provision of care measures.

Understanding variation in person-centered maternity care: Results from a household survey of postpartum women in 6 regions of Ethiopia

BACKGROUND

Effective communication, respect and dignity, and emotional support are critical for a positive childbirth experience that is responsive to the needs and preferences of women.

OBJECTIVE

This study evaluated the performance of a person-centered maternity care scale in a large, representative household sample of postpartum women, and it describes differences in person-centered maternity care across individuals and communities in Ethiopia.

STUDY DESIGN

The study used data from 2019 and 2020 from a representative sample of postpartum women in 6 regions of Ethiopia. It measured person-centered maternity care using a scale previously validated in other settings. To assess the scale validity in Ethiopia, we conducted cognitive interviews, measured internal consistency, and evaluated construct validity. Then, we fit univariable and multivariable linear regression models to test for differences in mean person-centered maternity care scores by individual and community characteristics. Lastly, multilevel modeling separated variance in person-centered maternity care scores within and between communities.

RESULTS

Effective communication and support of women's autonomy scored lowest among person-centered maternity care domains. Of 1575 respondents, 704 (44.7%) were never asked their permission before examinations and most said that providers rarely (n=369; 23.4%) or never (n=633; 40.2%) explained why procedures were done. Person-centered maternity care was significantly higher for women with greater wealth, more formal education, and those aged >20 years. Variation in person-centered maternity care scores between individuals within the same community (τ²=58.3) was nearly 3 times greater than variation between communities (σ²=21.2).

CONCLUSION

Ethiopian women reported widely varying maternity care experiences, with individuals residing within the same community reporting large differences in how they were treated by providers. Poor patient-provider communication and inadequate support of women's autonomy contributed most to poor person-centered maternity care.

Assessment of health system readiness for routine maternal and newborn health services in Nepal: Analysis of a nationally representative health facility survey, 2015

Access to and utilisation of routine maternal and newborn health (MNH) services, such as antenatal care (ANC), and perinatal services, has increased over the last two decades in Nepal. The availability, delivery, and utilisation of quality health services during routine MNH visits can significantly impact the survival of mothers and newborns. Capacity of health facility is critical for the delivery of quality health services. However, little is known about health system readiness (structural quality) of health facilities for routine MNH services and associated determinants in Nepal. Data were derived from the Nepal Health Facility Survey (NHFS) 2015. Total of 901 health facilities were assessed for structural quality of ANC services, and 454 health facilities were assessed for perinatal services. Adapting the World Health Organization's Service Availability and Readiness Assessment manual, we estimated structural quality scores of health facilities for MNH services based on the availability and readiness of related subdomain-specific items. Several health facility-level characteristics were considered as independent variables. Logistic regression analyses were conducted, and the odds ratio (OR) was reported with 95% confidence intervals (CIs). The significance level was set at p-value of <0.05. The mean score of the structural quality of health facilities for ANC, and perinatal services was 0.62, and 0.67, respectively. The average score for the availability of staff (e.g., training) and guidelines-related items in health facilities was the lowest (0.37) compared to other four subdomains. The odds of optimal structural quality of health facilities for ANC services were higher in private health facilities (adjusted odds ratio (aOR) = 2.65, 95% CI: 1.48, 4.74), and health facilities supervised by higher authority (aOR = 1.96; CI: 1.22, 3.13) while peripheral health facilities had lower odds (aOR = 0.13; CI: 0.09, 0.18) compared to their reference groups. Private facilities were more likely (aOR = 1.69; CI:1.25, 3.40) to have optimal structural quality for perinatal services. Health facilities of Karnali (aOR = 0.29; CI: 0.09, 0.99) and peripheral areas had less likelihood (aOR = 0.16; CI: 0.10, 0.27) to have optimal structural quality for perinatal services. Provincial and local governments should focus on improving the health system readiness in peripheral and public facilities to deliver quality MNH services. Provision of trained staff and guidelines, and supply of laboratory equipment in health facilities could potentially equip facilities for optimal quality health services delivery. In addition, supervision of health staff and facilities and onsite coaching at peripheral areas from higher-level authorities could improve the health management functions and technical capacity for delivering quality MNH services. Local governments can prioritise inputs, including providing a trained workforce, supplying equipment for laboratory services, and essential medicine to improve the quality of MNH services in their catchment.

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

BACKGROUND

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

METHODS

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

INTERVENTION

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

RESULTS

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

CONCLUSIONS

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

Factors influencing place of delivery in Ethiopia: Linking individual, household, and health facility-level data

INTRODUCTION

Maternal mortality remains high, especially in sub-Saharan Africa. Institutional delivery is one of the key intervention to reduce it. Despite service utilization reflects an interplay of demand- and supply-side factors, previous studies mainly focused on either sides due to methodological challenges and data availability. But, a more comprehensive understanding can be obtained by assessing both sides. The aim of this study is to assess individual, household, community, and health facility factors associated with deliveryplace in Ethiopia.

METHODS

We have used the 2019 Performance Monitoring for Action survey data set, which is a nationally representative sample of women linked with national sample of health facilities in Ethiopia. A total of 2547 women who recently delivered were linked with 170 health centers and 41 hospitals. Facility readiness index was calculated based on previous study conducted by Stierman EK on similar data set. We applied survey weights for descriptive statistics. Multilevel mixed-effects logistic regression was used to identify factors influencing delivery place.

RESULTS

Coverage of institutional delivery was 54.49%. Women aged 20-34 [AOR; 0.55 (0.32-0.85)] compared with those younger than 20 years; those with no formal education [AOR: 0.19 (10.05-0.76)] or attended only primary school [AOR: 0.20 (0.05-0.75)] compared with those attended above secondary; and women whose partners didn't encourage antinatal visit [AOR; 0.57 (0.33-0.98)] all have decreased odd of institutional delivery. Attending at least one antenatal visit [AOR: 3.09 (1.87-5.10)] and increased availability of medicines in the closest facility [AOR: 17.33 (1.32-26.4)] increase odds of institutional deliver.

CONCLUSION

In Ethiopia, nearly half of the total deliveries take place outside health facilities. In addition to improving women's education, utilization of antenatal care, and encouragement by partners, it is important to consider the availability of medicine and commodities in the nearby health facilities while designing and implementing programs to reduce home delivery.