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He A, Kanduma EL, Pérez-Escamilla R, Buckshee D, Chaquisse E, Cuco RM, Desai MM, Munguambe D, Reames SE, Manuel IR, Spiegelman D, Xu D. Barriers and facilitators for implementing the WHO Safe Childbirth Checklist (SCC) in Mozambique: A qualitative study using the Consolidated Framework for Implementation Research (CFIR). PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003174. [PMID: 39236014 PMCID: PMC11376584 DOI: 10.1371/journal.pgph.0003174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 08/08/2024] [Indexed: 09/07/2024]
Abstract
High maternal and neonatal mortality rates persist in Mozambique, with stillbirths remaining understudied. Most maternal and neonatal deaths in the country are due to preventable and treatable childbirth-related complications that often occur in low-resource settings. The World Health Organization introduced the Safe Childbirth Checklist (SCC) in 2015 to reduce adverse birth outcomes. The SCC, a structured list of evidence-based practices, targets the main causes of maternal and neonatal deaths and stillbirths in healthcare facilities. The SCC has been tested in over 35 countries, demonstrating its ability to improve the quality of care. However, it has not been adopted in Mozambique. This study aimed to identify potential facilitators and barriers to SCC implementation from the perspective of birth attendants, clinical administrators, and decision-makers to inform future SCC implementation in Mozambique. We conducted a qualitative study involving focus group discussions with birth attendants (n = 24) and individual interviews with clinical administrators (n = 6) and decision-makers (n = 8). The Consolidated Framework for Implementation Research guided the questions used in the interviews and focus group discussions, as well as the subsequent data analysis. A deductive thematic analysis of Portuguese-to-English translated transcripts was performed. In Mozambique, most barriers to potential SCC implementation stem from the challenges within a weak health system, including underfunded maternal care, lack of infrastructure and human resources, and low provider motivation. The simplicity of the SCC and the commitment of healthcare providers to better childbirth practices, combined with their willingness to adopt the SCC, were identified as major facilitators. To improve the feasibility of SCC implementation and increase compatibility with current childbirth routines for birth attendants, the SCC should be tailored to context-specific needs. Future research should prioritize conducting pre-implementation assessments to align the SCC more effectively with local contexts and facilitate sustainable enhancements in childbirth practices.
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Affiliation(s)
- Anqi He
- Department of Health Policy, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Elsa Luís Kanduma
- Comité para Saúde de Moçambique, Maputo City, Mozambique
- Mozambique Ministry of Health, Maputo City, Mozambique
| | - Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Devina Buckshee
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | | | | | - Mayur Mahesh Desai
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, United States of America
| | | | - Sakina Erika Reames
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | | | - Donna Spiegelman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Dong Xu
- Department of Health Systems and Global Health, Southern Medical University, Guangzhou, Guangdong, China
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Mandu R, Miller L, Namazzi G, Twum-Danso N, Achola KJA, Cooney I, Butrick E, Santos N, Masavah L, Nyakech A, Kirumbi L, Waiswa P, Walker D. Quality improvement collaboratives as part of a quality improvement intervention package for preterm births at sub-national level in East Africa: a multi-method analysis. BMJ Open Qual 2023; 12:e002443. [PMID: 38135302 DOI: 10.1136/bmjoq-2023-002443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives (QIC) are an approach to accelerate the spread and impact of evidence-based interventions across health facilities, which are found to be particularly successful when combined with other interventions such as clinical skills training. We implemented a QIC as part of a quality improvement intervention package designed to improve newborn survival in Kenya and Uganda. We use a multi-method approach to describe how a QIC was used as part of an overall improvement effort and describe specific changes measured and participant perceptions of the QIC. METHODS We examined QIC-aggregated run charts on three shared indicators related to uptake of evidence-based practices over time and conducted key informant interviews to understand participants' perceptions of quality improvement practice. Run charts were evaluated for change from baseline medians. Interviews were analysed using framework analysis. RESULTS Run charts for all indicators reflected an increase in evidence-based practices across both countries. In Uganda, pre-QIC median gestational age (GA) recording of 44% improved to 86%, while Kangaroo Mother Care (KMC) initiation went from 51% to 96% and appropriate antenatal corticosteroid (ACS) use increased from 17% to 74%. In Kenya, these indicators went from 82% to 96%, 4% to 74% and 4% to 57%, respectively. Qualitative results indicate that participants appreciated the experience of working with data, and the friendly competition of the QIC was motivating. The participants reported integration of the QIC with other interventions of the package as a benefit. CONCLUSIONS In a QIC that demonstrated increased evidence-based practices, QIC participants point to data use, friendly competition and package integration as the drivers of success, despite challenges common to these settings such as health worker and resource shortages. TRIAL REGISTRATION NUMBER NCT03112018.
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Affiliation(s)
- Rogers Mandu
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
| | - Lara Miller
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Gertrude Namazzi
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
| | | | | | - Isabella Cooney
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | | | | | - Leah Kirumbi
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
- Karolinska Institutet, Stockholm, Stockholm, Sweden
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
- Department of Obstetrics and Gynecology and Global Health Sciences, University of California San Francisco Medical Center at Parnassus, San Francisco, California, USA
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Smith Hughes C, Butrick E, Namutundu J, Olwanda E, Otieno P, Waiswa P, Walker D, Kahn JG. Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda. PLoS One 2023; 18:e0287309. [PMID: 37352149 PMCID: PMC10289453 DOI: 10.1371/journal.pone.0287309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/02/2023] [Indexed: 06/25/2023] Open
Abstract
INTRODUCTION Preterm birth is a leading cause of under-5 mortality, with the greatest burden in lower-resource settings. Strategies to improve preterm survival have been tested, but strategy costs are less understood. We estimate costs of a highly effective Preterm Birth Initiative (PTBi) intrapartum intervention package (data strengthening, WHO Safe Childbirth Checklist, simulation and team training, quality improvement collaboratives) and active control (data strengthening, Safe Childbirth Checklist). METHODS In our analysis, we estimated costs incremental to current cost of intrapartum care (in 2020 $US) for the PTBi intervention package and active control in Kenya and Uganda. We costed the intervention package and control in two scenarios: 1) non-research implementation costs as observed in the PTBi study (Scenario 1, mix of public and private inputs), and 2) hypothetical costs for a model of implementation into Ministry of Health programming (Scenario 2, mostly public inputs). Using a healthcare system perspective, we employed micro-costing of personnel, supplies, physical space, and travel, including 3 sequential phases: program planning/adaptation (9 months); high-intensity implementation (15 months); lower-intensity maintenance (annual). One-way sensitivity analyses explored the effects of uncertainty in Scenario 2. RESULTS Scenario 1 PTBi package total costs were $1.11M in Kenya ($48.13/birth) and $0.74M in Uganda ($17.19/birtth). Scenario 2 total costs were $0.86M in Kenya ($23.91/birth) and $0.28M in Uganda ($5.47/birth); annual maintenance phase costs per birth were $16.36 in Kenya and $3.47 in Uganda. In each scenario and country, personnel made up at least 72% of total PTBi package costs. Total Scenario 2 costs in Uganda were consistently one-third those of Kenya, largely driven by differences in facility delivery volume and personnel salaries. CONCLUSIONS If taken up and implemented, the PTBi package has the potential to save preterm lives, with potential steady-state (maintenance) costs that would be roughly 5-15% of total per-birth healthcare costs in Uganda and Kenya.
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Affiliation(s)
- Carolyn Smith Hughes
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | | | | | | | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - James G. Kahn
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
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Kaplan L, Richert K, Hülsen V, Diba F, Marthoenis M, Muhsin M, Samadi S, Susanti S, Sofyan H, Ichsan I, Vollmer S. Impact of the WHO Safe Childbirth Checklist on safety culture among health workers: A randomized controlled trial in Aceh, Indonesia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001801. [PMID: 37327202 PMCID: PMC10275423 DOI: 10.1371/journal.pgph.0001801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 04/28/2023] [Indexed: 06/18/2023]
Abstract
The World Health Organization (WHO) developed the Safe Childbirth Checklist (SCC) to increase the application of essential birth practices to ultimately reduce perinatal and maternal deaths. We study the effects of the SCC on health workers safety culture, in the framework of a cluster-randomized controlled trial (16 treatment facilities/16 control facilities). We introduced the SCC in combination with a medium intensity coaching in health facilities which already offered at minimum basic emergency obstetric and newborn care (BEMonC). We assess the effects of using the SCC on 14 outcome variables measuring self-perceived information access, information transmission, frequency of errors, workload and access to resources at the facility level. We apply Ordinary Least Square regressions to identify an Intention to Treat Effect (ITT) and Instrumental Variable regressions to determine a Complier Average Causal Effect (CACE). The results suggest that the treatment significantly improved self-assessed attitudes regarding the probability of calling attention to problems with patient care (ITT 0.6945 standard deviations) and the frequency of errors in times of excessive workload (ITT -0.6318 standard deviations). Moreover, self-assessed resource access increased (ITT 0.6150 standard deviations). The other eleven outcomes were unaffected. The findings suggest that checklists can contribute to an improvement in some dimensions of safety culture among health workers. However, the complier analysis also highlights that achieving adherence remains a key challenge to make checklists effective.
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Affiliation(s)
- Lennart Kaplan
- University of Goettingen, Göttingen, Germany
- German Institute of Development and Sustainability, Bonn, Germany
| | | | | | - Farah Diba
- Universitas Syiah Kuala, Banda Aceh, Indonesia
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Li X, Zhou T, Mao J, Wang L, Yang X, Xie L. Application of the PDCA cycle for implementing the WHO Safe Childbirth Checklist in women with vaginal deliveries. Medicine (Baltimore) 2023; 102:e33640. [PMID: 37145001 PMCID: PMC10158924 DOI: 10.1097/md.0000000000033640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/06/2023] [Indexed: 05/06/2023] Open
Abstract
The World Health Organization Safe Childbirth Checklist (SCC) has been recommended globally. However, the results are inconsistent. The aim of this study was to investigate the effectiveness of implementing the SCC based on plan-do-check-act (PDCA) cycle management. From November 2019 to October 2020, women who were hospitalized and had vaginal deliveries were enrolled in this study. Before October 2020, the PDCA cycle was not applied for the SCC, and women who had vaginal deliveries were included in the pre-intervention group. From January 2021 to December 2021, the PDCA cycle was applied for the SCC, and women who had vaginal deliveries were included in the post-intervention group. The SCC utilization rate and the incidence of maternal and neonatal complications were compared between the 2 groups. The SCC utilization rate in the post-intervention group was higher than that in the pre-intervention group (P < .01). The postpartum infection rate in the post-intervention group was lower than that in the pre-intervention group, and the difference was statistically significant (P < .05). After the intervention, postpartum hemorrhage, neonatal mortality, and neonatal asphyxia rates were also reduced, although no significant differences were observed between the 2 groups. There was no significant difference in the third-degree perineal laceration or neonatal intensive care unit hospitalization rate between the 2 groups (P > .05). Application of the PDCA cycle can improve the SCC utilization rate, and the SCC combined with the PDCA cycle can effectively reduce the postpartum infection rate.
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Affiliation(s)
- Xiaoyan Li
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tingting Zhou
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiayi Mao
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Longqiong Wang
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochang Yang
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liling Xie
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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