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

Person-centered maternity care during childbirth and associated factors at public hospitals in central Ethiopia

Objectives

Person-centered maternity care during childbirth is crucial for improving maternal and newborn health outcomes. Therefore, this study was aimed at assessing the determinants of person-centered maternity care in Central Ethiopia.

Methods

An institutional-based cross-sectional study was conducted in public hospitals in Central Ethiopia from 30 January to 1 March 2023. A systematic random sampling technique was employed to enroll the study participants. Data were collected through face-to-face interviews using a structured questionnaire. After data collection, it was checked for completeness and consistency, then coded and entered into Epi Data version 4.4.2 and exported to SPSS version 26 for analysis. Both bivariate and multivariable logistic regressions were used to identify associated factors.

Results

In this study, a total of 565 participants were involved, resulting in a response rate of 98.77%. The respondents mean score for person-centered maternity care was 60.2, with a 95% CI of (59.1, 62.3). No formal education (β = -2.00, 95% CI: -4.36, -0.69), fewer than four antenatal contacts (β = -4.3, 95% CI: -5.46, -2.37), being delivered at night (β = 2.20, 95% CI: 1.56, 6.45), and complications during delivery (β = -6.00, 95% CI: -9.2, -0.79) were factors significantly associated with lower person-centered maternity care.

Conclusion

This study revealed that person-centered maternity care is low compared with other studies. Consequently, it is imperative to prioritize initiatives aimed at enhancing awareness among healthcare providers regarding the benchmarks and classifications of person-centered maternity care. Moreover, efforts should be directed toward fostering improved communication between care providers and clients, along with the implementation of robust monitoring and accountability mechanisms for healthcare workers to prevent instances of mistreatment during labor and childbirth.

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

Background

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

Methods

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

Results

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

Conclusions

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

Magnitude, disparity, and predictors of poor-quality antenatal care service: A systematic review and meta-analysis

Background

Antenatal care is directed toward ensuring healthy pregnancy outcomes. Quality antenatal care increases the likelihood of receiving an effective intervention to maintain maternal, fetal, and neonatal well-being, while poor quality is linked to poor pregnancy outcomes. However, owing to the complex nature of quality, researchers have followed several approaches to systematically measure it. The evidence from these variable approaches appears inconsistence and poses challenges to programmers and policymakers. Hence, it is imperative to obtain a pooled estimate of the quality of antenatal care. Therefore, considering the scarcity of evidence on the quality of antenatal care, this study aimed to review, synthesize, and bring pooled estimates of accessible evidence.

Objective

This study aimed to estimate the pooled magnitude and predictors of quality of antenatal care services and compare regional disparity.

Method

We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022. The methodological quality of eligible studies was checked using Joanna Briggs Institute critical appraisal tool for cross-sectional studies. Meta-analysis was carried out using STATA version 16. Statistical heterogeneity was assessed using Cochran's Q test. In the presence of moderate heterogeneity (I2 more than 50%), sensitivity and subgroup analyses were conducted and presented in a forest plot. Effect size was reported using standardized mean difference and its 95% confidence interval. Funnel plots and Egger's regression test were used to measure publication bias at the 5% significance level. A trim-and-fill analysis was conducted to adjust for publication bias. Pooled estimates were computed using random-effects models and weighted using the inverse variance method in the presence of high heterogeneity among studies. A 95% CI and 5% significance level were considered to declare significance variables.

Results

The global pooled poor-quality antenatal care was 64.28% (95% CI: 59.58%-68.98%) (I2 = 99.97%, p = 0.001). The identified pooled predictors of good-quality antenatal care service were: number of antenatal care visits (fourth and above antenatal care visit) (Adjusted odds ratio (AOR) = 2.6, 95% CI: 1.37-3.84), family wealth index (AOR = 2.72, 95% CI: 1.89-3.55), maternal education attainment (AOR = 3.03, 95% CI: 2.24-3.82), residence (urban dwellers) (AOR = 4.06, 95% CI: 0.95-7.17), and confidentiality antenatal care (AOR = 2.23, 95% CI: -0.36 to -4.82).

Conclusions

The study found regional and country-level disparities in the quality of antenatal care services for pregnant women, where poor-quality antenatal care services were provided for more than two-thirds to three-fourths of antenatal care attendants. Therefore, policymakers and health planners should put a great deal of emphasis on addressing the quality of antenatal care services.

Adoption of policies to improve respectful maternity care in Timor-Leste

INTRODUCTION

There are now well-established global standards for supporting improvement in women's experience of maternity services, including frameworks for the prevention of mistreatment during childbirth. To support initiatives to improve the quality of care in maternal health services in Timor-Leste, we examine the adoption of global respectful maternity care standards in the national intrapartum care policy and in three urban birth facilities in Dili.

METHODS

From May to July 2022, we conducted a desk review of the Timor-Leste National Intrapartum Care Standards and Clinical Protocols for Referral Facilities and Community Health Centres. This was followed by a health-facility audit of policies, guidelines and procedures in three main maternity facilities in the capital, Dili to examine the extent to which the WHO (2016) standards for women's experiences of care have been adopted.

RESULTS

Despite the availability of global guidelines, key standards to improve women's experience of care have not been included in the National Intrapartum Care guidelines in Timor-Leste. There was no mention of avoiding mistreatment of women, needing informed consent for procedures, or strengthening women's own capability and confidence. In the policy wording, women tended to be distanced from the care 'procedures' and the protocols could be improved by taking a more woman-centred approach. The results of the health facility assessment showed extremely low use of standards that improve women's experiences of care. Health Facility 1 and 2 met two of the 21 quality measures, while Health Facility 3 met none of them.

CONCLUSION

The discourse communicated through policy fundamentally affects how health care issues are framed and how policies are enacted. Given the findings of this study, combined with previously documented issues around quality of care and low satisfaction with maternal health services, there is a need for a fundamental shift in the culture of care for women. This will require an immediate focus on leadership, training and policy-frameworks to increase respectful care for women in health facilities. It will also require longer-term effort to address the power imbalances that drive mistreatment of women within and across social systems, and to support models of care that inherently foster understanding and compassion.

Utilizing Midwifery-Led Care Units (MLCU) for Enhanced Maternal and Newborn Health in India: An Evidence-Based Review

The allocation of the midwife-led care unit (MLCU), a midwifery-led care model in which midwives carry out eminent roles to enrich maternal and newborn outcomes with minimal standard interventions, has appeared to be productive in furthering the quality of care and positive childbirth experiences. In the present article, we review the investments needed in MLCUs for their inclusion into the public health system by describing their advantages, the latest trends in maternal mortality, the roles of midwives, the relevant background, and the current advances in midwifery practices in India. Midwifery-led care is directed by a philosophy that considers pregnancy and childbirth as normal physiological events for women. Making use of a midwife, especially in low-risk pregnancies, extends satisfactory and cost-effective care. The Government of India has begun to introduce midwifery services to the country to improve the quality, righteousness, and worthiness in the provision of care and to offload higher-level hospitals. The year 2020 was designated as the "Year of the Nurse and the Midwife" by the WHO, highlighting the importance of nurses' and midwives' roles in sustaining quality health care. Further, the acceptability among clinicians and the public is crucial for the future advancement and implementation of MLCUs in India.

Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

Exploring areas of improvement in postnatal care services in a tertiary care hospital in Lahore

Background and Objective

Poor postnatal care can increase morbidity and mortality. This study assessed the current deficiencies in quality of postnatal care provided to mothers in Lady Aitchison hospital, Lahore when compared to WHO standards and identifies the areas for quality improvement.

Methods

It is a descriptive cross-sectional study which employs quantitative method to collect and analyze the data. It was conducted to include ninety-six maternities attending the wards of Lady Aitchison Hospital, Lahore during January 2022 to February 2022. Consenting post-partum mothers were selected by random sampling and interviewed by using a structured proforma.

Results

Among 96 mothers, 56% were below 25 years of age, 39% had secondary education, with more than one child (71%) and 57% visited for the first time. Majority of mothers, were given medicine timely (82%) and found the attitude (85%) and information (83%) provided by the healthcare workers helpful. Their subjective satisfaction rate with staff was 90%. The main areas of concern were lack of proper examination guidelines and facilities, limited information to mothers regarding neonatal care and substandard interior of hospitals. The statistics on the detailed maternal and neonatal examination showed that it was left out in 30% to 50% patients. Information regarding the danger signs of mothers and neonates was not given in 69% and information on family planning was provided to only 28%. Contentment with the infrastructure of the hospital was subpar and it was suggested that the sanitary conditions of washrooms and the paraphernalia of the wards i.e., ACs and beds needed improvement.

Conclusions

This study suggests that in developing countries like Pakistan, majority of the patients were satisfied by the services of healthcare workers. The prime improvement area is the infra-structure of the hospital which can be upgraded to provide better quality facilities in terms of air-conditioning, washrooms and well-designed areas for extensive examination of breast, pelvis, abdomen and neonates. There is also need for introduction of standard guidelines for postnatal care.

A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal

Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal's context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014-2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78-89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.

Person-centered care for diverse women: Narrative review of foundational research

Despite advocacy and recommendations to improve health care and health for persons who identify as women, women continue to face inequities in access to and quality of care. Person-centered care for women is one approach that could reduce gendered inequities. We conducted a series of studies to understand what constitutes person-centered care for women and how to achieve it. The overall aim of this article is to highlight the key findings of those studies that can inform policy, practice, and ongoing research. We conducted a narrative review of all studies related to person-centered care for women conducted in our group starting in 2018 over a 5-year period, which was general at the outset, and increasingly focused on racialized immigrant women who constitute a large proportion of the Canadian population. We organized study summaries by research phase: synthesis of person-centered care for women research, exploration of existing person-centered care for women guidance, consultation with key informants, consensus survey of key informants to prioritize strategies to achieve person-centered care for women, and consensus meeting with key informants to prioritize future research. We conducted the reported research in collaboration with an advisory group of diverse women and managers of community agencies. Our research revealed that little prior research had fully established what constitutes person-centered care for women, and in particular, how to achieve it. We also found little acknowledgment of person-centered care for women or strategies to support it in medical curriculum, clinical guidelines, or healthcare policies. We subsequently consulted women who differed by age, ethno-cultural group, health issue, education and geography, and clinicians of different specialties, who offered considerable insight on strategies to support person-centered care for women. Other diverse women, clinicians, healthcare managers, and researchers prioritized issues that warrant future research. We hope that by compiling a summary of our completed research, we draw attention to the need for person-centered care for women and motivate others to pursue it through policy, practice, and research.

Satisfaction with comprehensive emergency obstetric and newborn care services and associated factors among clients in University of Gondar Specialized Hospital, Northwest Ethiopia: A cross-sectional study

Objective

Emergency obstetric and newborn care services treat 70-80% of maternal deaths. This study aimed to assess satisfaction with comprehensive emergency obstetric and newborn care (CEmONC) services and associated factors among clients in the University of Gondar Specialized Hospital.

Methods

Institution-based cross-sectional study was conducted on 404 participants using a systematic random sampling method. The study was conducted from March 5 to May 5, 2020, using interviewer-administered structured questionnaires. Binary logistic regression was used to find the association between independent variables and client satisfaction. The level of statistical significance was declared at a p value less than 0.05.

Results

The overall clients' satisfaction with CEmONC services was 65.1% (95% confidence interval (CI): 60.9-69.8). Clients' satisfaction was affected by women who had antenatal care (ANC) of three visits (adjusted odds ratio (AOR): 6.5; 95%, CI: 2.04-20.8), women waited less than 15 min (AOR: 4.15, 95% CI: 1.9-9.06), mothers stayed ⩽1 day (AOR: 0.28, 95% CI: 0.09-0.9) and 2-3 days (AOR: 0.98, 95% CI: 0.1-0.69), obtaining a welcoming environment (AOR: 4.6, 95% CI: 2.15-9.88), and getting providers explanation of examinations (AOR: 3.3, 95% CI: 1.97-5.52).

Conclusion

The observed clients' satisfaction with CEmONC services was suboptimal. Having ANC of three visits, waiting less than 15 min, duration of stay, obtaining a welcoming environment, and an explanation of providers' examination were the identified factors of client's satisfaction. Therefore, hospital managers and health professionals should work on the identified factors to increase the client's satisfaction with these services.

Adequacy of antenatal care services utilisation and its effect on anaemia in pregnancy

Anaemia in pregnancy remains a critical public health concern in many countries including Ghana and it poses severe consequences in the short to long-term for women and their unborn babies. Although antenatal care (ANC) is largely provided for pregnant women, the extent its utilisation protects against anaemia in pregnancy remains largely understudied. The study assessed the adequacy of ANC services utilisation and its effect on anaemia among pregnant women in the Wa Municipality of Ghana. A facility-based cross-sectional survey was conducted. Probability proportionate to size sampling and systematic random sampling were used to select the facilities and 353 respondents. While 80⋅2 % of the pregnant women reported having received a sufficient number of ANC services provided, the prevalence of the overall ANC adequacy was only 44⋅2 %. After adjusting for potential confounders, pregnant women who could not achieve adequate ANC attendance were 2⋅3 times more likely to be anaemic in the third trimester of gestation AOR = 2⋅26 (95 % CI 1⋅05, 4⋅89), compared to their counterparts who maintained adequate ANC attendance. Adequate ANC attendance was a consistent and significant predictor of anaemia in pregnancy in the third trimester. Health and nutrition education on the need for early initiation of ANC attendance and support for the consumption of diversified diets are two possible interventions that can help contain anaemia in pregnancy.

Evaluations of effective coverage of maternal and child health services: A systematic review

Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.

Factors affecting the duration of gestation among women taking prenatal care at Gondar referral hospital, Ethiopia

Background

Pregnant women taking prenatal care is vital for the health of the mother and the fetus. The duration of pregnancies provides a useful measure of a woman's natural length of pregnancy and may help in predicting an individual woman's due date. The objective of this study was to understand the factors affecting the duration of gestation among women taking prenatal care in Gondar referral hospital, Ethiopia.

Methods

A quantitative research design using secondary data available in the form of antenatal care (ANC) cards in the Gondar teaching referral hospital data set. Kaplan–Meier estimate was used to explain the median survival time of duration of gestation. A multivariate AFT model was performed to identify the factors related to the duration of gestation among women.

Results

The mean time of the length of pregnancy was 39.5 weeks. The factors such as, the age of women, number of children, number of doctor consultations, and the stage of gestation were found to be statistically significant (p < 0.05) for the survival time of time to birth of pregnant women in Ethiopia. Weibull AFT model was found to be the best model for predicting the time to birth of pregnant women in Ethiopia.

Conclusion

We did not see associations between length of gestation and blood pressure and bleeding during early pregnancy. We also did not find an association with the presence of disease, which has been associated with the length of pregnancy. The frequency of visiting a doctor during the gestation period enhances the length of the gestation period. The shorter gestation period from the due date is dangerous to the health of both mother and her fetus.

Estimating maternity ward birth attendant time use in India: a microcosting study

OBJECTIVES

Despite global concern over the quality of maternal care, little is known about the time requirements to complete the essential birth practices. Using three microcosting data collection methods within the BetterBirth trial, we aimed to assess time use and the specific time requirements to incorporate the WHO Safe Childbirth Checklist into clinical practice.

SETTING

We collected detailed survey data on birth attendant time use within the BetterBirth trial in Uttar Pradesh, India. The BetterBirth trial tested whether the peer-coaching-based implementation of the WHO Checklist was effective in improving the quality of facility-based childbirth care.

PARTICIPANTS

We collected measurements of time to completion for 18 essential birth practices from July 2016 through October 2016 across 10 facilities in five districts (1559 total timed observations). An anonymous survey asked about the impact of the WHO Checklist on birth attendants at every intervention facility (15 facilities, 83 respondents) in the Lucknow hub. Additionally, data collectors visited facilities to conduct a census of patients and birth attendants across 20 facilities in seven districts between June 2016 and November 2016 (six hundred and ten 2-hour facility observations).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure of this study is the per cent of staff time required to complete the essential birth practices included in the WHO Checklist.

RESULTS

When birth attendants were timed, we found practices were completed rapidly (18 s to 2 min). As the patient load increased, time dedicated to clinical care increased but remained low relative to administrative and downtime. On average, WHO Checklist clinical care accounted for less than 7% of birth attendant time use per hour.

CONCLUSIONS

We did not find that a coaching-based implementation of the WHO Checklist was a burden on birth attendant's time use. However, questions remain regarding the performance quality of practices and how to accurately capture and interpret idle and break time.

TRIAL REGISTRATION NUMBER

NCT02148952.

Women's experiences with maternity care in public health facilities of Assam, India

India is committed to Sustainable Development Goal 3 of reducing the national maternal mortality ratio to <70/100,000 live births by 2030. This article describes women's experiences of maternity care in public health facilities in three districts of the north-eastern Indian state of Assam. Fourteen focus-group discussions were carried out among 149 married women aged 18-45 years belonging to different ethnic communities. Data were analyzed using a grounded theory approach and organized using a framework of dimensions of maternal satisfaction. The findings suggest that access and distance were important considerations determining maternal care quality, especially in the two remote districts. Women reported inadequate infrastructure, lack of cleanliness, and poor access to medicines. Lack of prompt care was identified as an important issue, and women complained about being left unattended during labor and facing obstetric violence in the labor room. Our findings point toward the need to strengthen referral transport systems and establish maternity waiting homes in remote areas. It is important to also sensitize health providers about obstetric violence and the right of women to receive prompt and respectful maternity care.

Partnership-defined quality approach to companionship during labour and birth in East New Britain, Papua New Guinea: A mixed-methods study

Companionship during labour and birth is a critical component of quality maternal and newborn care, resulting in improved care experiences and better birth outcomes. Little is known about the preferences and experiences of companionship in Papua New Guinea (PNG), and how it can be implemented in a culturally appropriate way. The aim of this study was to describe perspectives and experiences of women, their partners and health providers regarding labour and birth companionship, identify enablers and barriers and develop a framework for implementing this intervention in PNG health facilities. A mixed methods study was conducted with five facilities in East New Britain, PNG. Data included 5 facility audits, 30 labour observations and 29 in-depth interviews with women who had recently given birth, partners and maternity care providers. A conceptual framework was developed drawing on existing quality care implementation frameworks. Women and partners wanted companions to be present, whilst health providers had mixed views. Participants described benefits of companionship including encouragement and physical support for women, better communication and advocacy, improved labour outcomes and assistance with workforce issues. Adequate privacy and space constraints were highlighted as key barriers to address. Of the women observed, only 30% of women had a companion present during labour, and 10% had a companion at birth. A conceptual framework was used to highlight the interconnected inputs required at community, facility and provincial health system levels to improve the quality of care. Key elements to address included attitudes towards companionship, the need for education and training and restrictive hospital policies. Supporting women to have their companion of choice present during labour and birth is critical to improving women's experiences of care and improving the quality of maternal and newborn care. In order to provide companionship during labour and birth in PNG, a complex, intersecting, multi-faceted approach is required.

Readiness to Provide Antenatal Corticosteroids for Threatened Preterm Birth in Public Health Facilities in Northern India

INTRODUCTION

In 2014, the Government of India (GOI) released operational guidelines on the use of antenatal corticosteroids (ACS) in preterm labor. However, without ensuring the quality of childbirth and newborn care at facilities, the use of ACS in low- and middle-income countries is potentially harmful. This study assessed the readiness to provide ACS at primary and secondary care public health facilities in northern India.

METHODS

A cross-sectional study was conducted in 37 public health facilities in 2 districts of Haryana, India. Facility processes and program implementation for ACS delivery were assessed using pretested study tools developed from the World Health Organization (WHO) quality of care standards and WHO guidelines for threatened preterm birth.

RESULTS

Key gaps in public health facilities' process of care to provide ACS for threatened preterm birth were identified, particularly concerning evidence-based practices, competent workforce, and actionable health information system. Emphasis on accurate gestational age estimation, quality of childbirth care, and quality of preterm care were inadequate. Shortage of trained staff was widespread, and a disconnect was found between knowledge and attitudes regarding ACS use. ACS administration was provided only at district or subdistrict hospitals, and these facilities did not uniformly record ACS-specific indicators. All levels lacked a comprehensive protocol and job aids for identifying and managing threatened preterm birth.

CONCLUSIONS

ACS operational guidelines were not widely disseminated or uniformly implemented. Facilities require strengthened supervision and standardization of threatened preterm birth care. Facilities need greater readiness to meet required conditions for ACS use. Increasing uptake of a single intervention without supporting it with adequate quality of maternal and newborn care will jeopardize improvement in preterm birth outcomes. We recommend updating and expanding the existing GOI ACS operational guidelines to include specific actions for the safe and effective use of ACS in line with recent scientific evidence.

Barriers to Quality Midwifery Care: A Systematic Review and Meta-Synthesis of Qualitative Data

BACKGROUND

Skilled attendance at birth by well-educated and regulated midwives has been identified to reduce maternal and neonatal deaths, however, it has been established that midwives experience barriers that can affect their ability to provide quality care to women and neonates.

AIM

This systematic review and meta-synthesis of qualitative data was conducted to investigate the barriers to midwives' ability to provide quality care focusing on African and developed countries.

METHODS

The Joanna Briggs Institute process for conducting systematic reviews was followed for this review. Qualitative studies that reported on barriers to midwives' ability to provide quality care were identified by searching the following databases: CINAHL, PubMed, Web of Science, and PsychINFO. Studies reported in English in the last 10 years, within which most participants were midwives and the data reported on barriers to quality care provision by midwives were included in this review.

RESULTS

813 published research studies were screened, and 11 research papers were included in this review. The meta-synthesis of the findings resulted in six categories: the lack of equipment; inadequate skills and training, lack of space and infrastructure, staff shortages and high workloads, emotional barriers, and workplace culture. Using the Donabedian model of quality care, the barriers were grouped into structure, process, and outcome factors.

CONCLUSION

Currently efforts to improve quality care in African countries focus on structural factors. Efforts to improve quality care in developed countries focus on process factors. In order to improve quality care for women and neonates, efforts need to be focused on all the factors that promotequality care.

Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system “hardware” and “software” factors influencing the promotion of RMC were identified, and their interaction was complex. The “hardware” factors included bed availability, infrastructure and supplies, financing, and health workforce. “Software” factors encompassed service providers’ mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee-exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC.

Health care workers' perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico

BACKGROUND

Episiotomy in Mexico is highly prevalent and often routine - performed in up to 95% of births to primiparous women. The WHO suggests that episiotomy be used in selective cases, with an expected prevalence of 15%. Training programs to date have been unsuccessful in changing this practice. This research aims to understand how and why this practice persists despite shifts in knowledge and attitudes facilitated by the implementation of an obstetric training program.

METHODS

This is a descriptive and interpretative qualitative study. We conducted 53 pre and post-intervention (PRONTO© Program) semi-structured interviews with general physician, gynecologists and nurses (N = 32, 56% women). Thematic analysis was carried out using Atlas-ti© software to iteratively organize codes. Through interpretive triangulation, the team found theoretical saturation and explanatory depth on key analytical categories.

RESULTS

Themes fell into five major themes surrounding their perceptions of episiotomy: as a preventive measure, as a procedure that resolves problems in the moment, as a practice that gives the clinician control, as a risky practice, and the role of social norms in practicing it. Results show contradictory discourses among professionals. Despite the growing support for the selective use of episiotomy, it remains positively perceived as an effective prophylaxis for the complications of childbirth while maintaining control in the hands of health care providers.

CONCLUSIONS

Perceptions of episiotomy shed light on how and why routine episiotomy persists, and provides insight into the multi-faceted approaches that will be required to affect this harmful obstetrical practice.

An assessment of the knowledge, practices and resources during the delivery of malaria health care services among private health care practitioners: a cross section study in the Mid-Western Region of Uganda

BACKGROUND

Approximately 50 % of the population in Uganda seeks health care from private facilities but there is limited data on the quality of care for malaria in these facilities. This study aimed to document the knowledge, practices and resources during the delivery of malaria care services, among private health practitioners in the Mid-Western region of Uganda, an area of moderate malaria transmission.

METHODS

This was a cross sectional study in which purposive sampling was used to select fifteen private-for-profit facilities from each district. An interviewer-administered questionnaire that contained both quantitative and open-ended questions was used. Information was collected on availability of treatment aides, knowledge on malaria, malaria case management, laboratory practices, malaria drugs stock and data management. We determined the proportion of health workers that adequately provided malaria case management according to national standards.

RESULTS

Of the 135 health facilities staff interviewed, 61.48 % (52.91-69.40) had access to malaria treatment protocols while 48.89 % (40.19-57.63) received malaria training. The majority of facilities, 98.52 % (94.75-99.82) had malaria diagnostic services and the most commonly available anti-malarial drug was artemether-lumefantrine, 85.19 % (78-91), followed by Quinine, 74.81 % (67-82) and intravenous artesunate, 72.59 % (64-80). Only 14.07 % (8.69-21.10) responded adequately to the acceptable cascade of malaria case management practice. Specifically, 33.33 % (25.46-41.96) responded correctly to management of a patient with a fever, 40.00 % (31.67-48.79) responded correctly to the first line treatment for uncomplicated malaria, whereas 85.19 % (78.05-90.71) responded correctly to severe malaria treatment. Only 28.83 % submitted monthly reports, where malaria data was recorded, to the national database.

CONCLUSIONS

This study revealed sub-optimal malaria case management knowledge and practices at private health facilities with approximately 14 % of health care workers demonstrating correct malaria case management cascade practices. To strengthen the quality of malaria case management, it is recommended that the NMCD distributes current guidelines and tools, coupled with training; continuous mentorship and supportive supervision; provision of adequate stock of essential anti-malarials and RDTs; reinforcing communication and behavior change; and increasing support for data management at private health facilities.

Modification of oxytocin use through a coaching-based intervention based on the WHO Safe Childbirth Checklist in Uttar Pradesh, India: a secondary analysis of a cluster randomised controlled trial

OBJECTIVE

To understand the prevalence of intrapartum oxytocin use, assess associated perinatal and maternal outcomes, and evaluate the impact of a WHO Safe Childbirth Checklist intervention on oxytocin use at primary-level facilities in Uttar Pradesh, India.

DESIGN

Secondary analysis of a cluster-randomised controlled trial.

SETTING

Thirty Primary and Community public health facilities in Uttar Pradesh, India from 2014 to 2017.

POPULATION

Women admitted to a study facility for childbirth at baseline, 2, 6 or 12 months after intervention initiation.

METHODS

The BetterBirth intervention aimed to increase adherence to the WHO Safe Childbirth Checklist. We used Rao-Scott Chi-square tests to compare (1) timing of oxytocin use between study arms and (2) perinatal mortality and resuscitation of infants whose mothers received intrapartum oxytocin versus who did not.

MAIN OUTCOME MEASURES

Intrapartum and postpartum oxytocin administration, perinatal mortality, use of neonatal bag and mask.

RESULTS

We observed 5484 deliveries. At baseline, intrapartum oxytocin was administered to 78.2% of women. Two months after intervention initiation, intrapartum oxytocin (I) was administered to 32.1% of women compared with 70.6% in the control (C) (P < 0.01); this difference diminished after the end of the intervention (I = 48.2%, C = 74.7%, P = 0.03). Partograph use remained at <1% at all facilities. Resuscitation was performed on 7.5% of infants whose mother received intrapartum oxytocin versus 2.0% who did not (P < 0.0001).

CONCLUSIONS

In this setting, intrapartum oxytocin use was high despite limited maternal/fetal monitoring or caesarean capability, and was associated with increased neonatal resuscitation. The BetterBirth intervention was successful at decreasing intrapartum oxytocin use. Ongoing support is needed to sustain these practices.

TWEETABLE ABSTRACT

Coaching + WHO Safe Childbirth Checklist reduces intrapartum oxytocin use and need for newborn resuscitation.

Availability of facility resources and services and infection-related maternal outcomes in the WHO Global Maternal Sepsis Study: a cross-sectional study

BACKGROUND

Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes.

METHODS

GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women's needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes.

FINDINGS

We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1·84 [95% CI 1·05-3·22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2·44 [1·02-5·85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities).

INTERPRETATION

While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes.

FUNDING

UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development.

Quality of maternal and newborn health care in Ethiopia: a cross-sectional study

Background

Despite reports of universal access to and modest utilization of maternal and newborn health services in Ethiopia, mothers and newborns continue to die from preventable causes. Studies indicate this could be due to poor quality of care provided in health systems. Evidences show that high quality health care prevents more than half of all maternal deaths. In Ethiopia, there is limited knowledge surrounding the status of the quality of maternal and newborn health care in health facilities. This study aims to assess the quality of maternal and neonatal health care provision at the health facility level in four regions in Ethiopia.

Methodology

This study employed a facility-based cross-sectional study design. It included 32 health facilities which were part of the facilities for prototyping maternal and neonatal health quality improvement interventions. Data was collected using a structured questionnaire, key informant interviews and record reviews. Data was entered in Microsoft Excel and exported to STATA for analysis. Descriptive analysis results are presented in texts, tables and graphs. Quality of maternal and neonatal health care was measured by input, process and outputs components. The components were developed by computing scores using standards used to measure the three components of the quality of maternal and neonatal health care.

Result

The study was done in a total of 32 health facilities: 5 hospitals and 27 health centers in four regions. The study revealed that the average value of the quality of the maternal and neonatal health care input component among health facilities was 62%, while the quality of the process component was 43%. The quality of the maternal and neonatal health output component was 48%. According to the standard cut-off point for MNH quality of care, only 5 (15.6%), 3 (9.3%) and 3 (10.7%) of health facilities met the expected input, process and output maternal and neonatal health care quality standards, respectively.

Conclusion

This study revealed that the majority of health facilities did not meet the national MNH quality of care standards. Focus should be directed towards improving the input, process and output standards of the maternal and neonatal health care quality, with the strongest focus on process improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06680-1.

Adequacy of prenatal care services and associated factors in Southern Ethiopia

BACKGROUND

Prenatal care is an important component for the continuum of care in maternal and child health services. Despite increased attention on prenatal care service coverage, the adequacy of service provision has not been well addressed in Ethiopia. Therefore, this study aimed to describe the status of the adequacy of prenatal care and its associated factors in Southern Ethiopia.

METHOD

A longitudinal study done by the Performance care Monitoring and Accountability (PMA2020) project was used. The study was conducted from August 2016 to January 2017 in Southern Ethiopia. A multistage stratified cluster design in which all enumeration areas were randomly selected using probability proportional to size and all households were screened to identify 324 pregnant women of six or more months. Questions regarding early attendance of prenatal care, enough visits, and sufficient services were asked to measure the adequacy of prenatal care. Finally, an ordered logistic regression analysis was employed to assess factors associated with the adequacy of prenatal care services.

RESULTS

Of the total pregnant women 44.21 % attended enough visits, 84.10 % had early visits, and 42.03 % received sufficient services. The women residing in urban areas had 2.35 odds of having adequate prenatal care in reference to rural areas (adjusted odds ratio (aOR) 2.35 [95 % CI 1.05-5.31]). Women who attended primary and secondary education had 2.42(aOR 2.42 [95 % C.I. 1.04, 5.65]), and 4.18 (aOR 4.18 [95 % CI 1.32, 13.29]) odds of adequate prenatal care in reference with those who never attended education respectively. The women participating in one to five networks have 2.18 odds of adequate prenatal care in reference to their counterparts (aOR 2.78 [95 % CI 1.01, 7.71]).

CONCLUSIONS

The adequacy of prenatal care services in Southern Ethiopia is very low. The Ethiopian health care system should strengthen one to five networks to discuss on family health issues. Further research, should validate the tools and measure the adequacy of the services in different contexts of Ethiopia using a mixed method study for an in-depth understanding of the problem.

Antenatal care policies for low-risk pregnant women in high-income countries with a universal health system: a scoping review protocol

OBJECTIVE

The aim of this scoping review is to map the available evidence on the nature, extent, and range of antenatal care policies for low-risk pregnant women in high-income countries with a health system founded on the Beveridge Model.

INTRODUCTION

Low-risk women in high-income countries have good evolutionary perinatal outcomes but high intervention rates in pregnancy and childbirth, which ultimately leads to high morbidity. This has implications at all levels including families, the health care system, and society. This review aims to inform future policy and identify the viability of the adoption of alternative models to the Portuguese context that can reduce unnecessary interventions.

INCLUSION CRITERIA

Studies, protocols, guidelines, and policies that provide guidance on antenatal care for low-risk pregnant women in high-income countries with a health system founded on the Beveridge Model (universal health care) will be considered. Documents from 2005 to present will be included, and no language restrictions will be imposed.

METHODS

An initial search will be conducted in databases including MEDLINE (via PubMed) and CINAHL (via EBSCOhost), followed by a manual search of the reference lists from the documents accepted for inclusion, and a hand search of gray literature. For the countries whose policies are not available through the earlier steps, key persons from health ministries and academia will be contacted. Search results will be exported and data extracted using charting forms. Data will be synthesized using narrative description.

Maternal healthcare utilsation and complete childhood vaccination in sub-Saharan Africa: a cross-sectional study of 29 nationally representative surveys

OBJECTIVE

The objective of the study was to examine the association between maternal healthcare utilisation and complete childhood vaccination in sub-Saharan Africa.

DESIGN

Our study was a cross-sectional study that used pooled data from 29 countries in sub-Saharan Africa.

PARTICIPANTS

A total of 60 964 mothers of children aged 11-23 months were included in the study.

OUTCOME VARIABLES

The main outcome variable was complete childhood vaccination. The explanatory variables were number of antenatal care (ANC) visits, assistance during delivery and postnatal care (PNC).

RESULTS

The average prevalence of complete childhood vaccination was 85.6%, ranging from 67.0% in Ethiopia to 98.5% in Namibia. Our adjusted model, children whose mothers had a maximum of three ANC visits were 56% less likely to have complete vaccination, compared with those who had at least four ANC visits (adjusted OR (aOR)=0.44, 95% CI 0.42 to 0.46). Children whose mothers were assisted by traditional birth attendant/other (aOR=0.43, 95% CI 0.41 to 0.56) had lower odds of complete vaccination. The odds of complete vaccination were lower among children whose mothers did not attend PNC clinics (aOR=0.26, 95% CI 0.24 to 0.29) as against those whose mothers attended.

CONCLUSION

The study found significant variations in complete childhood vaccination across countries in sub-Saharan Africa. Maternal healthcare utilisation (ANC visits, skilled birth delivery, PNC attendance) had significant association with complete childhood vaccination. These findings suggest that programmes, interventions and strategies aimed at improving vaccination should incorporate interventions that can enhance maternal healthcare utilisation. Such interventions can include education and sensitisation, reducing cost of maternal healthcare and encouraging male involvement in maternal healthcare service utilisation.

Youth-centered maternity care: a binational qualitative comparison of the experiences and perspectives of Latina adolescents and healthcare providers

Background

Although there is growing recognition of the importance of person-centered maternity care, the needs and perspectives of pregnant adolescents are rarely considered. The purpose of this study was to compare the maternity care experiences of Mexican-origin adolescents in Guanajuato, Mexico and Fresno, California from both youth and healthcare provider perspectives.

Methods

Qualitative interviews and focus groups were conducted with a total of 89 respondents, including 74 pregnant and parenting adolescents as well as 15 providers between December 2016 and July 2017. Adolescents also completed a short demographic survey prior to participation. Transcripts in English and Spanish were coded and thematically analyzed using Dedoose software. Results were compared by location and between youth and providers.

Results

Four themes emerged regarding patient-provider interactions: the need for communication and clear explanations, respectful versus judgmental providers, engaging youth in decision-making, and a focus on the age of the youth and their partners. While youth had similar perspectives and priorities in both locations, youth in Mexico reported more negative healthcare experiences than youth in California. Perspectives varied between the youth and providers, with providers in both California and Mexico identifying several structural challenges in providing quality care to adolescents. In California, challenges to supporting immigrant Latina adolescents and their families included language and translation issues as well as barriers to care due to immigration status and documentation. In both locations, providers also mentioned high patient caseloads and their own concerns about the youth’s life choices.

Conclusion

Youth-centered care requires more effective and respectful patient-provider communication, where adolescents are engaged in their healthcare decision-making and delivery options. Changes in patient-provider interactions can help improve the maternity care experiences and outcomes of Latina adolescents. Healthcare systems and providers need to reconfigure their approaches to focus on the needs and priorities of adolescents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03831-4.

What determines client satisfaction on labor and delivery service in Ethiopia? systematic review and meta-analysis

Introduction

The uptake of Health services, maternal and newborn health care outcomes are dictated by the satisfaction of clients on the service provided. Client satisfaction is one of the vital indicators to measure the quality of service. However, it is not well addressed and little evidence is existed in Ethiopia. Therefore, the purpose of this systematic review aimed to assess the prevalence and determinant of client satisfaction on labor and delivery service in Ethiopia.

Methods

This study has included published and unpublished articles. The main databases PubMed, Embase, EBSCO, Medline, CINHAL, Poplin, and the search engine like Google and Google scholar were used from June1-30/2020. Studies with observational study design which are conducted in English language and met the eligibility criteria were included in the review. Meta-analyses with random effects were performed. Data synthesis and statistical analysis were conducted using OpenMeta and CMA version 2 software.

Results

The pooled prevalence of client satisfaction on labor and delivery service in Ethiopia was 73.5% [95% CI [64.9%, 82.1%]. The pooled odds ratio showed a negative association between client satisfaction on labour and delivery service with Promptness of care [OR = 0.25; 95% CI: (0.18, 0.34), P = 0.0001], Free service charge [OR = 0.70; 95% CI: (0.57, 0.86), P < 0.0007], Privacy during examination [OR = 0.25; 95% CI: (0.10, 0.64), P < 0.004], Respectful maternal care [OR = 0.40;95% CI: (0.19, 0.83), P = 0.01], Plan to delivered at health facility [OR = 0.49; 95% CI: (0.37, 0.66), P < 0.00001] and ANC follow-up [OR = 0.39; 95% CI: 0.24, 0.63, P < 0.0001].

Conclusions

This review revealed that client satisfaction on labor and delivery service in Ethiopia was 73.5%. Besides poor care of providers on the antepartum, intrapartum and lack compassionate and respectful care affects client satisfaction on labor and delivery service in Ethiopia.

Why are women still dying from obstetric hemorrhage? A narrative review of perspectives from high and low resource settings

The possibility of hemorrhage will always co-exist with pregnancy, whether anticipated or not. It remains the unwelcome guest in the corner of every delivery room, stealing the lives of young women every day across the globe. In 2014, the World Health Organization reported that hemorrhage was the leading contributor to maternal mortality worldwide, with nearly 75% of maternal deaths due to postpartum hemorrhage. In low resource settings, while maternal mortality is decreasing, hemorrhage remains the single most important contributor to maternal death. Hospital-based deliveries with skilled birth attendants have been encouraged to improve outcomes and, as a result, hospital births have dramatically increased. However, access to higher levels of emergency obstetric care as well as blood products and therapeutic resources remain limiting factors. Meanwhile, in high resource settings, maternal mortality from hemorrhage is increasing, particularly among women of color. While very rare, mortality from hemorrhage generally follows medical interventions such as surgical management of placenta accreta or emergency cesarean section. Primary prevention therefore requires careful selection and conduct of medical interventions, as well as the provision of high quality, supportive, and safe maternity care. It is clear that there is not one single solution in preventing obstetric hemorrhage on a global scale. The international community must employ creative solutions to reduce this ever-present problem.

Patient feedback surveys among pregnant women in Eswatini to improve antenatal care retention

Background

Uptake and retention in antenatal care (ANC) is critical for preventing adverse pregnancy outcomes for both mothers and infants.

Methods

We implemented a rapid quality improvement project to improve ANC retention at seven health facilities in Eswatini (October-December 2017). All pregnant women attending ANC visits were eligible to participate in anonymous tablet-based audio assisted computer self-interview (ACASI) surveys. The 24-question survey asked about women’s interactions with health facility staff (HFS) (nurses, mentor mothers, receptionists and lab workers) with a three-level symbolic response options (agree/happy, neutral, disagree/sad). Women were asked to self-report HIV status. Survey results were shared with HFS at monthly quality improvement sessions. Chi-square tests were used to assess differences in responses between months one and three, and between HIV-positive and negative women. Routine medical record data were used to compare retention among pregnant women newly enrolled in ANC two periods, January-February 2017 (‘pre-period’) and January-February 2018 (‘post-period’) at two of the participating health facilities. Proportions of women retained at 3 and 6 months were compared using Cochran-Mantel-Haenszel and Wilcoxon tests.

Results

A total of 1,483 surveys were completed by pregnant women attending ANC, of whom 508 (34.3%) self-reported to be HIV-positive. The only significant change in responses from month one to three was whether nurses listened with agreement increasing from 88.3% to 94.8% (p<0.01). Overall, WLHIV had significantly higher proportions of reported satisfaction with HFS interactions compared to HIV-negative women. A total of 680 pregnant women were included in the retention analysis; 454 (66.8%) HIV-negative and 226 (33.2%) WLHIV. In the pre- and post-periods, 59.4% and 64.6%, respectively, attended at least four ANC visits (p = 0.16). The proportion of women retained at six months increased from 60.9% in the pre-period to 72.7% in the post-period (p = 0.03). For HIV-negative women, pre- and post-period six-month retention significantly increased from 56.6% to 71.6% (p = 0.02); however, the increase in WLHIV retained at six months from 70.7% (pre-period) to 75.0% (post-period) was not statistically significant (p = 0.64).

Conclusion

The type of rapid quality improvement intervention we implemented may be useful in improving patient-provider relationships although whether it can improve retention remains unclear.

Translating international guidelines for use in routine maternal and neonatal healthcare quality measurement

BACKGROUND

Improving facility-based quality for maternal and neonatal care is the key to reducing morbidity and mortality rates in low- and middle-income countries. Recent guidance from WHO and others has produced a large number of indicators to choose from to track quality.

OBJECTIVE

To explore how to translate complex global maternal and neonatal health standards into actionable application at the facility level.

METHODS

We applied a two-step process as an example of how the 352 indicators in WHO's 2016 Standards for Improving Quality of Maternal and Newborn Care in Health Facilities might be reduced to only those with the strongest evidence base, associated with outcomes, and actionable by facility managers. We applied Hill criteria and assessed whether indicators were within the control of facility managers. We next conducted a rapid review of supporting literature and applied GRADE analysis, retaining those with scores of 'moderate' or 'high'. To understand the utility and barriers to measuring this limited set of indicators in practice, we undertook a case study of hypothetical measurement application in two districts in Bangladesh, interviewing 25 clinicians, managers, and other stakeholders.

RESULTS

From the initial 352 indicators, 56 were retained. The 56 indicators were used as a base for interviews. Respondents emphasized the practical challenges to the use of complex guides and the need for parsimonious and actionable sets of quality indicators.

CONCLUSIONS

This work offers one way to move towards a reduced quality indicator set, beginning from current WHO guidance. Despite study limitations, this work provides evidence of the need for reduced and evidence-based sets of quality indicators if guides are to be used to improve quality in practice. We hope that future research will build on and refine our efforts. Measuring quality effectively so that evidence guides and improves practice is the first step to assuring safe maternal and neonatal care.

Defining, conceptualizing, and measuring perceived maternal care quality in low- to high-income countries: a scoping review protocol

BACKGROUND

Health practitioners and researchers must be able to measure and assess maternal care quality in facilities to monitor, intervene, and reduce global maternal mortality rates. On the global scale, there is a general lack of consensus on how maternal care quality is defined, conceptualized, and measured. Much of the literature addressing this problem has focused primarily on defining, conceptualizing, and measuring clinical indicators of maternal care quality. Less attention has been given in this regard to perceived maternal care quality among women which is known to influence care utilization and adherence. Therefore, there is a need to map the literature focused on defining, conceptualizing, and measuring perceived maternal care quality across low-, middle-, and high-income country contexts.

METHODS

This scoping review protocol will follow the Arksey and O'Malley methodological framework. A comprehensive search strategy will be used to search for articles published from inception to 2020 in Ovid MEDLINE, Embase, AMED, and WHO Global Index Medicus. Gray literature will be included. Two independent reviewers will screen articles by title and abstract, then by full-text based on pre-determined inclusion/exclusion criteria. A third reviewer will arbitrate any discrepancies. This protocol outlines a four-step analytic approach that includes numerical, graphical, tabular, and narrative summaries to provide a comprehensive description of the body of literature.

DISCUSSION

The findings from this scoping review will provide a comprehensive overview of the existing evidence on perceived maternal care quality. The findings are expected to inform future work on building consensus around the definition and conceptualization of perceived maternal care quality, and lay the groundwork for future research aimed at developing measures of perceived maternal care quality that can be applied across country contexts. Consequently, this review may aid in facilitating coordinated efforts to measure and improve maternal care quality across diverse country contexts (i.e., low-, middle-, and high-income country contexts).

REVIEW REGISTRATION

This scoping review has been registered in the Open Science Framework (osf.io/k8nqh).

Protocol for a randomised trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada)

INTRODUCTION

The 'Developmental Origins of Health and Disease' hypothesis suggests that a healthy trajectory of growth and development in pregnancy and early childhood is necessary for optimal health, development and lifetime well-being. The purpose of this paper is to present the protocol for a randomised controlled trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada). The primary objective of HeLTI Canada is to determine whether a 4-phase 'preconception to early childhood' lifecourse intervention can reduce the rate of child overweight and obesity. Secondary objectives include improved child: (1) growth trajectories; (2) cardiometabolic risk factors; (3) health behaviours, including nutrition, physical activity, sedentary behaviour and sleep; and (4) development and school readiness at age 5 years.

METHOD AND ANALYSIS

A randomised controlled multicentre trial will be conducted in two of Canada's highly populous provinces-Alberta and Ontario-with 786 nulliparous (15%) and 4444 primiparous (85%) women, their partners and, when possible, the first 'sibling child.' The intervention is telephone-based collaborative care delivered by experienced public health nurses trained in healthy conversation skills that includes detailed risk assessments, individualised structured management plans, scheduled follow-up calls, and access to a web-based app with individualised, evidence-based resources. An 'index child' conceived after randomisation will be followed until age 5 years and assessed for the primary and secondary outcomes. Pregnancy, infancy (age 2 years) and parental outcomes across time will also be assessed.

ETHICS AND DISSEMINATION

The study has received approval from Clinical Trials Ontario (CTO 1776). The findings will be published in peer-reviewed journals and disseminated to policymakers at local, national and international agencies. Findings will also be shared with study participants and their communities.

TRIAL REGISTRATION NUMBER

ISRCTN13308752; Pre-results.

The use of data in resource limited settings to improve quality of care

Quality improvement is driven by benchmarking between and within institutions over time and the collaborative improvement efforts that stem from these comparisons. Benchmarking requires systematic collection and use of standardized data. Low- and middle-income countries (LMIC) have great potential for improvements in newborn outcomes but serious obstacles to data collection, analysis, and implementation of robust improvement methodologies exist. We review the importance of data collection, internationally recommended neonatal metrics, selected methods of data collection, and reporting. The transformation from data collection to data use is illustrated by several select data system examples from LMIC. Key features include aims and measures important to neonatal team members, co-development with local providers, immediate access to data for review, and multidisciplinary team involvement. The future of neonatal care, use of data, and the trajectory to reach global neonatal improvement targets in resource-limited settings will be dependent on initiatives led by LMIC clinicians and experts.

The role of evaluation in iterative learning and implementation of quality of care interventions

Background: The Lancet Global Health Commission (LGHC) has argued that quality of care (QoC) is an emergent property that requires an iterative process to learn and implement. Such iterations are required given that health systems are complex adaptive systems.Objective: This paper explores the multiple roles that evaluations need to play in order to help with iterative learning and implementation. We argue evaluation needs to shift from a summative focus toward an approach that promotes learning in complex systems. A framework is presented to help guide the iterative learning, and includes the dimensions of clinical care, person-centered care, continuum of care, and 'more than medicine. Multiple roles of evaluation corresponding to each of the dimensions are discussed.Methods: This paper is informed by reviews of the literature on QoC and the roles of evaluation in complex systems. The proposed framework synthesizes the multiple views of QoC. The recommendations of the roles of evaluation are informed both by review and experience in evaluating multiple QoC initiatives.Results: The specific roles of different evaluation approaches, including summative, realist, developmental, and participatory, are identified in relationship to the dimensions in our proposed framework. In order to achieve the potential of LGHC, there is a need to discuss how different evaluation approaches can be combined in a coherent way to promote iterative learning and implementation of QoC initiatives.Conclusion: One of the implications of the QoC framework discussed in the paper is that time needs to be spent upfront in recognizing areas in which knowledge of a specific intervention is not complete at the outset. This, of course, implies taking stock of areas of incompleteness in knowledge of context, theory of change, support structures needed in order for the program to succeed in specific settings. The role of evaluation should not be limited to only providing an external assessment, but an important goal in building evaluation capacity should be to promote adaptive management among planners and practitioners. Such iterative learning and adaptive management are needed to achieve the goals of sustainable development goals.

Leaving no one behind: using action research to promote male involvement in maternal and child health in Iringa region, Tanzania

INTRODUCTION

Male involvement has been reported to improve maternal and child health (MCH) outcomes. However, most studies in low-income and middle-income countries have reported low participation of men in MCH-related programmes. While there is a growing interest in the involvement of men in MCH, little is known on how male involvement can be effectively promoted in settings where entrenched unequal gender roles, norms and relations constrain women from effectively inviting men to participate in MCH.

METHODS AND ANALYSIS

This paper reports participatory action research (PAR) aimed to promote male participation in pregnancy and childbirth in Iringa Region, Tanzania. As part of the Innovating for Maternal and Child Health in Africa project, PAR was conducted in 20 villages in two rural districts in Tanzania. Men and women were engaged separately to identify barriers to male involvement in antenatal care and during delivery; and then they were facilitated to design strategies to promote male participation in their communities. Along with the PAR intervention, researchers undertook a series of research activities. A thematic analysis was used to analyse the data. The common strategies designed were: engaging health facility committees; using male champions and male gatekeepers; and using female champions to sensitise and provide health education to women. These strategies were validated during stakeholders' meetings, which were convened in each community.

DISCUSSION

The use of participatory approach not only empowers communities to diagnose barriers to male involvement and develop culturally acceptable strategies but also increases sustainability of the interventions beyond the life span of the project. More lessons will be identified during the implementation of these strategies.

Antenatal care booking within the first trimester of pregnancy and its associated factors among pregnant women residing in an urban area: a cross-sectional study in Debre Berhan town, Ethiopia

OBJECTIVE

This study aimed to assess antenatal care (ANC) booking within the first trimester of pregnancy and its associated factors among urban dwellers of pregnant women in Debre Berhan town, Ethiopia.

DESIGN

Cross-sectional.

SETTING

Public and private health facilities that provide ANC services in Debre Berhan town.

OUTCOME MEASURE

First ANC booking within the first trimester of pregnancy.

PARTICIPANTS

Urban dwellers of pregnant women in Debre Berhan town (n=384).

RESULTS

A total of 387 pregnant women in Debre Berhan town were selected for this study, of which 384 responded giving a response rate of 99.2%. The proportion of pregnant women who had ANC booking within the first trimester of pregnancy was 156 (40.6%; 95% CI: 35.8% to 45.6%). In the multivariable analysis, the odds of first ANC booking within the first trimester was higher among pregnant women who had secondary school (adjusted OR (AOR): 1.84; 95% CI: 1.10 to 3.19) and more than secondary level of education (AOR: 2.26; 95% CI: 1.27 to 4.03) compared with those who had less than a secondary school level of education. Pregnant women who have any ill health with their current pregnancy (AOR: 1.99; 95% CI: 1.21 to 3.27) were more likely to start booking within the first trimester than their counterparts. The odds of ANC booking within the first trimester was threefold higher among women with knowledge of ANC (AOR: 3.05; 95% CI: 1.52 to 6.11) compared with their counterparts.

CONCLUSION

First ANC booking within the first trimester was found to be low among urban dwellers of Debre Berhan town. Secondary school and more educational level, having ill health during early pregnancy and women's knowledge about ANC services were statistically associated with ANC booking within the first trimester of pregnancy. Therefore, improving ANC booking according to the WHO recommendation requires due attention. Further qualitative research exploring why early ANC booking remains low among urban dwellers is important to design intervention modalities.

A qualitative study on acceptability of the mistreatment of women during childbirth in Myanmar

BACKGROUND

Improving the quality of maternal health care is critical to reduce mortality and improve women's experiences. Mistreatment during childbirth in health facilities can be an important barrier for women when considering facility-based childbirth. Therefore, this study attempted to explore the acceptability of mistreatment during childbirth in Myanmar according to women and healthcare providers, and to understand how gender power relations influence mistreatment during childbirth.

METHODS

A qualitative study was conducted in two townships in Bago Region in September 2015, among women of reproductive age (18-49 years), healthcare providers and facility administrators. Semi-structured discussion guides were used to explore community norms, and experiences and perceptions regarding mistreatment. Coding was conducted using athematic analysis approach and Atlas.ti. Results were interpreted using a gender analysis approach to explore how power dynamics, hierarchies, and gender inequalities influence how women are treated during childbirth.

RESULTS

Women and providers were mostly unaccepting of different types of mistreatment. However, some provided justification for slapping and shouting at women as encouragement during labour. Different access to resources, such as financial resources, information about pregnancy and childbirth, and support from family members during labor might impact how women are treated. Furthermore, social norms around pregnancy and childbirth and relationships between healthcare providers and women shape women's experiences. Both informal and formal rules govern different aspects of a woman's childbirth care, such as when she is allowed to see her family, whether she is considered "obedient", and what type of behaviors she is expected to have when interacting with providers.

CONCLUSIONS

This is the first use of gender analysis to explore how gender dynamics and power relations contribute to women's experiences of mistreatment during childbirth. Both providers and women expected women to understand and "obey" the rules of the health facility and instructions from providers in order to have better experiences. In this way, deviation from following the rules and instructions puts the providers in a place where perpetrating acts of mistreatment were justifiable under certain conditions. Understanding how gender norms and power structures how women are treated during childbirth is critical to improve women's experiences.

Adherence to clinical practice guidelines for South Australian pregnant women with cardiac conditions between 2003 and 2013

Background

For pregnant women with a known cardiac condition or those who develop cardiac disease during pregnancy, there is an increased risk of complications during pregnancy, to both mother and foetus. To reduce this risk, best practice guidelines have been developed and available in South Australia for several years. Measuring clinical practice against the guideline recommendations verifies real-life practice and an essential part of any clinical practice quality improvement project by identifying gaps. This study is the first report on adherence to statewide perinatal guidelines for these women in South Australia.

Objectives

Design

A retrospective cross-sectional observational design that analysed data from medical records.

Setting

Three SA Health public metropolitan, university-affiliated teaching hospitals with an obstetric service within a ten-year timeframe (2003–2013).

Participants

271 admissions of women who were categorised as ‘pre-existent’ or ‘newly acquired’ cardiac condition during their pregnancy.

Outcome measures

Adherence to guidelines was measured using a purposefully designed scoring system across the three sites. The researcher chose a minimum acceptable score of 17 applicable to the ‘newly acquired’ group and 35 for the ‘pre-existent’ group.

Results

Overall adherence to the perinatal guidelines for the combined groups (n = 271) reported a mean score of 16.3, SD ± 6.7, with a median score of 17. Women in the ‘newly acquired’ group scored less compared to women in the ‘pre-existent’ group (Estimate -2.3, CI -3.9,-0.7). Variance in adherence was observed across the three hospitals (P value <0.0001). The most significant predictor of adherence to guidelines was pre-pregnancy cardiac consultation which increased the likelihood of preconception care by Odds ratio 18.5 (95%, CI 2, 168). Similarly, compliance with mental health screening was associated with improved adherence to antenatal assessments (OR: 11.3(95% CI 4.7, 27.3).

Conclusion

There was overall suboptimal adherence to the statewide guidelines for women with cardiac conditions in pregnancy. The variance in the level of adherence across the three hospitals correlated with the exposure to higher acuity cases, and that appropriate up- referral to a higher acuity hospital was intrinsically linked to better adherence. Recommendations include preconception counselling, and to ensure that all health practitioners have the skills, sufficient training and time to complete a comprehensive initial antenatal assessment

Trial registration

ACTRN12617000417381

Implementation Lessons from a Multifaceted National Newborn Program in Solomon Islands: A Mixed-Methods Study

Multifaceted interventions are important in improving neonatal quality of care and health outcomes. This study describes the implementation of an intervention to improve the quality of newborn care in Solomon Islands, a small island developing state and lower middle-income country in the Western Pacific. Inputs included training, equipment provision, and healthcare system organizational changes. For evaluation, we used a mixed-methods design, using quantitative (audits of health facility equipment, structure, and organization) and qualitative (semi-structured interviews and focused group discussions with healthcare workers) methods. Participants highlighted the practical, interactive, coaching style of training and its short duration as positive features in establishing skills. Training had indirect impacts through improving culture of the workplace, and the evaluation provided a valuable opportunity for reflection of the implementation process for healthcare workers. Facility limitations from equipment deficits and poor condition of clinical areas had implications by limiting the provision of quality care, as well as contributing to healthcare workers feeling undervalued. Resuscitation of a nonbreathing baby was a stressful experience for many health workers, compounded by geographic isolation and feeling unsupported. Our findings highlight the importance of training methodology, impact from structural limitations, and experience of resuscitation for the healthcare worker. Attention to these factors may help the design and implementation of newborn care programs in similar contexts.

Assessment of facility and health worker readiness to provide quality antenatal, intrapartum and postpartum care in rural Southern Nepal

Background

Increased coverage of antenatal care and facility births might not improve maternal and newborn health outcomes if quality of care is sub-optimal. Our study aimed to assess the facility readiness and health worker knowledge required to provide quality maternal and newborn care.

Methods

Using an audit tool and interviews, respectively, facility readiness and health providers’ knowledge of maternal and immediate newborn care were assessed at all 23 birthing centers (BCs) and the District hospital in the rural southern Nepal district of Sarlahi. Facility readiness to perform specific functions was assessed through descriptive analysis and comparisons by facility type (health post (HP), primary health care center (PHCC), private and District hospital). Knowledge was compared by facility type and by additional skilled birth attendant (SBA) training.

Results

Infection prevention items were lacking in more than one quarter of facilities, and widespread shortages of iron/folic acid tablets, injectable ampicillin/gentamicin, and magnesium sulfate were a major barrier to facility readiness. While parenteral oxytocin was commonly provided, only the District hospital was prepared to perform all seven basic emergency obstetric and newborn care signal functions. The required number of medical doctors, nurses and midwives were present in only 1 of 5 PHCCs. Private sector SBAs had significantly lower knowledge of active management of third stage of labor and correct diagnosis of severe pre-eclampsia. While half of the health workers had received the mandated additional two-month SBA training, comparison with the non-trained group showed no significant difference in knowledge indicators.

Conclusions

Facility readiness to provide quality maternal and newborn care is low in this rural area of Nepal. Addressing the gaps by facility type through regular monitoring, improving staffing and supply chains, supervision and refresher trainings is important to improve quality.

Evaluating the impact of a hospital scale-up phase of a quality improvement intervention in Ghana on mortality for children under five

OBJECTIVE

To evaluate the scale-up phase of a national quality improvement initiative across hospitals in Southern Ghana.

DESIGN

This evaluation used a comparison of pre- and post-intervention means to assess changes in outcomes over time. Multivariable interrupted time series analyses were performed to determine whether change categories (interventions) tested were associated with improvements in the outcomes.

SETTING

Hospitals in Southern Ghana.

PARTICIPANTS

The data sources were monthly outcome data from intervention hospitals along with program records.

INTERVENTION

The project used a quality improvement approach whereby process failures were identified by health staff and process changes were implemented in hospitals and their corresponding communities. The three change categories were: timely care-seeking, prompt provision of care and adherence to protocols.

MAIN OUTCOME MEASURES

Facility-level neonatal mortality, facility-level postneonatal infant mortality and facility-level postneonatal under-five mortality.

RESULTS

There were significant improvements for two outcomes from the pre-intervention to the post-intervention phase. Postneonatal infant mortality dropped from 44.3 to 21.1 postneonatal infant deaths per 1000 admissions, while postneonatal under-five mortality fell from 23.1 to 11.8 postneonatal under-five deaths per 1000 admissions. The multivariable interrupted time series analysis indicated that over the long-term the prompt provision of care change category was significantly associated with reduced postneonatal under five mortality (β = -0.0024, 95% CI -0.0051, 0.0003, P < 0.10).

CONCLUSIONS

The reduced postneonatal under-five mortality achieved in this project gives support to the promotion of quality improvement as a means to achieve health impacts at scale.

Communication between mothers and health workers is important for quality of newborn care: a qualitative study in neonatal units in district hospitals in South Africa

Background

There is a high global burden of neonatal mortality, with many newborn babies dying of preventable and treatable conditions, particularly in low and middle-income countries. Improving quality of newborn care could save the lives of many thousands of babies. Quality of care (QoC) is a complex and multifaceted construct that is difficult to measure, but patients’ experiences of care are an important component in any measurement of QoC. We report the findings of a qualitative study exploring observations and experiences of health workers (HWs) and mothers of babies in neonatal units in South Africa.

Methods

A qualitative case study approach was adopted to explore care of newborn babies admitted to neonatal units in district hospitals. Observation data were collected by a registered nurse during working hours over a continuous five-day period. Doctors and nurses working in the neonatal unit and mothers of babies admitted during the observation period were interviewed using a semi-structured interview guide. All interviews were audio recorded. Observation data were transcribed from hand written notes. Audiotapes of interviews were transcribed verbatim and, where necessary, translated into English. A thematic content analysis was used to analyse the data.

Results

Observations and interviews were conducted in seven participating hospitals between November 2015 and May 2016. Our findings highlight the importance of information sharing between HWs and mothers of babies, contrasting the positive communication reported by many mothers which led to them feeling empowered and participating actively in the care of their babies, with incidents of poor communication. Poor communication, rudeness and disrespectful behaviour of HWs was frequently described by mothers, and led to mothers feeling anxious, unwilling to ask questions and excluded from their baby’s care. In some cases poor communication and misunderstandings led to serious mismanagement of babies with HWs delaying or withholding care, or to mothers putting their babies at risk by not following instructions.

Conclusion

Good communication between mothers and HWs is critical for building mothers’ confidence, promoting bonding and participation of mothers in the care of their baby and may have long term benefits for the health and well-being of the mother and her baby.

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

Introduction

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

Aims and Objectives

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

Materials and Methods

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

Result

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

Conclusions

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

Quality of labor and birth care in Sindh Province, Pakistan: Findings from direct observations at health facilities

This study presents data from the first observation of labor, childbirth and immediate newborn care in a clinical setting in Sindh, the second most populous province of Pakistan. Trained midwives observed 310 births at 126 district level referral facilities and primary health care facilities in 10 districts of Sindh where the USAID-funded Maternal Child Health Integrated Program (MCHIP) was implemented. The facility participation rate was 78%. The findings show that monitoring vital signs during the initial examination was conducted for less than one-in-ten women. Infection prevention practices were only observed for one-in-four women. Modesty was preserved for less than half of women. In spite of an absence of monitoring during the first and second stages of labor, providers augmented labor with oxytocin in two-thirds of births. To prevent post-partum hemorrhage, oxytocin was administered within a minute of birth in 51% of cases. Immediate drying of the baby was nearly universal and eight out of ten babies were wrapped in a dry towel. Newborn vital signs and the baby’s weight were taken in one-in-ten cases. Breastfeeding was initiated during the first hour of birth in 18% of cases. A support-person was present during labor and birth for 90% of women. While quality of care is poor across all facilities, the provision of care at district-level referral facilities was even lower quality than at primary health care facilities. This is because dais or assistants without formal training provided labor, birth, and newborn care for 40% of deliveries during night shifts at referral facilities. This study found many examples of suboptimal practice by skilled birth attendants across all levels of health facilities. There remains an urgent need to improve quality of service provision among skilled birth attendants in Pakistan.

Implementation of an international standardized set of outcome indicators in pregnancy and childbirth in Kenya: Utilizing mobile technology to collect patient-reported outcomes

Background

Limited data exist on health outcomes during pregnancy and childbirth in low- and middle-income countries. This is a pilot of an innovative data collection tool using mobile technology to collect patient-reported outcome measures (PROMs) selected from the International Consortium of Health Outcomes Measurement (ICHOM) Pregnancy and Childbirth Standard Set in Nairobi, Kenya.

Methods

Pregnant women in the third trimester were recruited at three primary care facilities in Nairobi and followed prospectively throughout delivery and until six weeks postpartum. PROMs were collected via mobile surveys at three antenatal and two postnatal time points. Outcomes included incontinence, dyspareunia, mental health, breastfeeding and satisfaction with care. Hospitals reported morbidity and mortality. Descriptive statistics on maternal and child outcomes, survey completion and follow-up rates were calculated.

Results

In six months, 204 women were recruited: 50% of women returned for a second ante-natal care visit, 50% delivered at referral hospitals and 51% completed the postnatal visit. The completion rates for the five PROM surveys were highest at the first antenatal care visit (92%) and lowest in the postnatal care visit (38%). Data on depression, dyspareunia, fecal and urinary incontinence were successfully collected during the antenatal and postnatal period. At six weeks postpartum, 86% of women breastfeed exclusively. Most women that completed the survey were very satisfied with antenatal care (66%), delivery care (51%), and post-natal care (60%).

Conclusion

We have demonstrated that it is feasible to use mobile technology to follow women throughout pregnancy, track their attendance to pre-natal and post-natal care visits and obtain data on PROM. This study demonstrates the potential of mobile technology to collect PROM in a low-resource setting. The data provide insight into the quality of maternal care services provided and will be used to identify and address gaps in access and provision of high quality care to pregnant women.

Socio-cultural contextual factors that contribute to the uptake of a mobile health intervention to enhance maternal health care in rural Senegal

BACKGROUND

Although considerable progress has been made in reducing maternal mortality over the past 25 years in Senegal, the national maternal mortality ratio (MMR), at 315 deaths per 100,000 live births, is still unacceptably high. In recent years a mobile health (mHealth) intervention to enhance maternal health care has been introduced in rural and remote areas of the country. CommCare is an application that runs on cell phones distributed to community health workers known as matrones who enroll and track women throughout pregnancy, birth and the post-partum, offering health information, moral support, appointment reminders, and referrals to formal health care providers.

METHODS

An ethnographic study of the CommCare intervention and the larger maternal health program into which it fits was conducted in order to identify key social and cultural contextual factors that contribute to the uptake and functioning of this mHealth intervention in Senegal. Ethnographic methods and semi-structured interviews were used with participants drawn from four categories: NGO field staff (n = 16), trained health care providers (including physicians, nurses, and midwives) (n = 19), community level health care providers (n = 13); and women belonging to a community intervention known as the Care Group (n = 14). Data were analyzed using interpretive analysis informed by critical medical anthropology theory.

RESULTS

The study identified five socio-cultural factors that work in concert to encourage the uptake and use of CommCare: convening women in the community Care Group; a cultural mechanism for enabling pregnancy disclosure; constituting authoritative knowledge amongst women; harnessing the roles of older women; and adding value to community health worker roles. We argue that, while CommCare is a powerful tool of information, clinical support, surveillance, and data collection, it is also a social technology that connects and motivates people, transforming relationships in ways that can optimize its potential to improve maternal health care.

CONCLUSIONS

In Senegal, mHealth has the potential not only to bridge the gaps of distance and expertise, but to engage local people productively in the goal of enhancing maternal health care. Successful mHealth interventions do not work as 'magic bullets' but are part of 'assemblages' - people and things that are brought together to accomplish particular goals. Attention to the social and cultural elements of the global health assemblage within which CommCare functions is critically important to understand and develop this mHealth technology to its full potential.

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

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