Saving Mothers, Giving Life: It Takes a System to Save a Mother (Republication)

Qualitative application of the diffusion of innovation theory to maternity waiting homes in rural Zambia

BACKGROUND

Understanding factors affecting adoption of an innovation is critical to its long-term success. Maternity waiting homes (MWHs) increase access to facility-based delivery in low-resourced settings; yet, quality issues deter utilization of this innovative approach. We sought to understand how attributes that are thought to promote diffusion of innovations (e.g., relative advantage, compatibility, observability, complexity, etc.) affected MWH use after implementation of an improved quality MWH model in rural Zambia compared to standard of care.

METHODS

We conducted 158 in-depth interviews (IDIs) with randomly selected rural-living women who had delivered a baby in the prior 12 months. Half lived in catchment areas where new quality MWHs were constructed, half in catchment areas with standard of care (ranging from low quality community structures to no MWH). We applied content analysis to identify themes.

RESULTS

Utilization of MWHs was higher among intervention (65.4%) than control women (42.5%). Respondents in both study arms perceived relative advantages to pregnant women staying at MWHs compared to going directly to health facilities when labor begins. MWH stays allowed for clinical staff to routinely check on and educate women, and address complications immediately. Compatibility of the homes with cultural values and needs depended on implementation. While some women from intervention sites complained about overcrowding, women in control sites more often perceived the lack of cleanliness, amenities, and safety as deterrents to utilization. Women at intervention sites received sensitization about MWHs from a wider range of sources, including traditional leaders. Required preparations needed to stay at MWHs (e.g. delivery supplies, food, and childcare) made adoption complex and may have deterred utilization.

CONCLUSIONS

The improved MWH model addressed most community concerns around quality. Having opinion leaders who communicate the relative advantage of MWHs to pregnant women and their social networks may facilitate MWH utilization. The complexity of decisions and resources needed to stay at MWHs remains a critical barrier to use. To facilitate equitable adoption of MWHs among the most vulnerable women, planners should explore how to support women during their delivery preparations and MWH stays, particularly regarding food security and lack of social support for childcare.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02620436, Registered 02 December 2015, https://clinicaltrials.gov/study/NCT02620436?term=NCT02620436&rank=1.

The Effectiveness of Regionalization of Perinatal Care and Specific Facility-Based Interventions: A Systematic Review

INTRODUCTION

Appropriate perinatal care provision and utilization is crucial to improve maternal and newborn survival and potentially meet Sustainable Development Goal 3. Ensuring availability of healthcare infrastructure as well as skilled personnel can potentially help improve maternal and neonatal outcomes globally as well as in resource-limited settings.

METHODS

A systematic review on effectiveness of perinatal care regionalization was updated, and a new review on facility-based interventions to improve postnatal care coverage and outcomes was conducted. The interventions were identified through literature reviews and included transport, mHealth, telemedicine, maternal education, capacity building, and incentive packages. Search was conducted in relevant databases and meta-analysis conducted on Review Manager 5.4. We conducted subgroup analysis for evidence from low- and middle-income countries (LMICs).

RESULTS

Implementation of regionalization programs significantly decreased maternal mortality in LMICs (OR: 0.43; 95% CI: 0.34-0.55, 2 studies), stillbirth overall (OR: 0.70; 95% CI: 0.54-0.89, 5 studies), perinatal mortality overall (OR: 0.54; 95% CI: 0.5-0.58, 2 studies), and LMICs (OR: 0.54; 95% CI: 0.50-0.58, 1 study). Transport-related interventions significantly decreased maternal mortality overall (OR: 0.55; 95% CI: 0.40-0.74, 1 study), neonatal mortality (RR: 0.76; 95% CI: 0.66-0.88, 1 study), perinatal mortality (RR: 0.86; 95% CI: 0.77-0.95, 1 study), and improved postnatal care coverage (OR: 6.89; 95% CI: 5.15-9.21, 1 study) in LMICs. Adding maternity homes/units significantly decreased stillbirth (OR: 0.75; 95% CI: 0.61-0.93, 1 study) in LMICs. Incentives for postnatal care significantly improved infant mortality (RR: 0.79; 95% CI: 0.65-0.96, 1 study), stillbirth (OR: 0.60; 95% CI: 0.44-0.83, 1 study), and postnatal care coverage (RR: 1.13; 95% CI: 1.03-1.25, 1 study) in LMICs. Telemedicine improved postnatal care coverage significantly in LMICs (RR: 2.54; 95% CI: 1.22-5.28, 3 studies) and decreased maternal mortality (OR: 0.46; 95% CI: 0.21-0.98, 1 study) and infant mortality (OR: 0.65; 95% CI: 0.45-0.95) in LMICs. Maternal education significantly decreased neonatal mortality (RR: 0.75; 95% CI: 0.66-0.84, 2 studies), perinatal mortality (RR: 0.86; 95% CI: 0.77-0.95, 1 study), infant mortality (RR: 0.79; 95% CI: 0.65-0.96, 1 study), and stillbirth (RR: 0.61; 95% CI: 0.45-0.82, 1 study). Capacity-building interventions significantly decreased maternal mortality in LMICs (OR: 0.37; 95% CI: 0.29-0.46, 5 studies), neonatal mortality overall (OR: 0.72; 95% CI: 0.53-0.98, 4 studies) and in LMICs (OR: 0.63; 95% CI: 0.54-0.74, 3 studies, and RR: 0.61; 95% CI: 0.48-0.79, 3 studies), perinatal mortality (OR: 0.53; 95% CI: 0.45-0.62, 2 studies, and RR: 0.86; 95% CI: 0.77-0.95, 1 study), infant mortality (OR: 0.50; 95% CI: 0.43-0.59, 1 study, and RR: 0.79; 95% CI: 0.65-0.96, 1 study), under-5 mortality (RR: 0.79; 95% CI: 0.66-0.94, 1 study), and stillbirth in LMICs (OR: 0.71; 95% CI: 0.62-0.82, 4 studies), and preterm birth overall (OR: 0.39; 95% CI: 0.19-0.81, 1 study).

CONCLUSION

Perinatal regionalization and facility-based interventions have a positive impact on maternal and neonatal outcomes and calls for implementation in high burden settings but a better understanding of optimal interventions is needed through comprehensive trials in diverse settings.

Types, reporting and acceptability of community-based interventions for stillbirth prevention in sub-Saharan Africa (SSA): a systematic review

Background

Community-based interventions are increasingly being implemented in Sub-Saharan Africa (SSA) for stillbirth prevention, but the nature of these interventions, their reporting and acceptability are poorly assessed. In addition to understanding their effectiveness, complete reporting of the methods, results and intervention acceptability is essential as it could potentially reduce research waste from replication of inadequately implemented and unacceptable interventions. We conducted a systematic review to investigate these aspects of community-based interventions for preventing stillbirths in SSA.

Methods

In this systematic review, eight databases (MEDLINE(OvidSP), Embase (OvidSP), Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index (Web of Science Core Collection), CINAHL (EBSCOhost) and Global Index Medicus) and four grey literature sources were searched from January 1, 2000 to July 7, 2023 for relevant quantitative and qualitative studies from SSA (PROSPERO-CRD42021296623). Following deduplication, abstract screening and full-text review, studies were included if the interventions were community-based with or without a health facility component. The main outcomes were types of community-based interventions, completeness of intervention reporting using the TIDier (Template for Intervention Description and replication) checklist, and themes related to intervention acceptability identified using a theoretical framework. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools.

Findings

Thirty-nine reports from thirty-four studies conducted in 18 SSA countries were eligible for inclusion. Four types of interventions were identified: nutritional, infection prevention, access to skilled childbirth attendants and health knowledge/behaviour of women. These interventions were implemented using nine strategies: mHealth (defined as the use of mobile and wireless technologies to support the achievement of health objectives), women's groups, community midwifery, home visits, mass media sensitisation, traditional birth attendant and community volunteer training, community mobilisation and transport vouchers. The completeness of reporting using the TIDier checklist varied across studies with a very low proportion of the included studies reporting the intervention intensity, dosing, tailoring and modification. The quality of the included studies were graded as poor (n = 6), fair (n = 14) and good (n = 18). Though interventions were acceptable, only 4 (out of 7) studies explored women's perceptions, mostly focusing on perceived intervention effects and how they felt, omitting key constructs like ethicality, opportunity cost and burden of participation.

Interpretation

Different community-based interventions have been tried and evaluated for stillbirth prevention in SSA. The reproducibility and implementation scale-up of these interventions may be limited by incomplete intervention descriptions in the published literature. To strengthen impact, it is crucial to holistically explore the acceptability of these interventions among women and their families.

Funding

Clarendon/Balliol/NDPH DPhil scholarship for UGA. MN is funded by a Medical Research Council Transition Support Award (MR/W029294/1).

Evaluation of a comprehensive maternal newborn health intervention in rural Tanzania: single-arm pre-post coverage survey results

Background

In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed.

Objective

Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania.

Methods

A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used ‘wedge sampling’ protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the ‘Real Accountability: Data Analysis for Results Coverage Survey to women 15–49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD.

Results

Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [−0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019.

Conclusions

Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved.

Designed to Fail? Revisiting Uganda's Maternal Health Policies to Understand Policy Design Issues Underpinning Missed Targets for Reduction of Maternal Mortality Ratio (MMR): 2000-2015

BACKGROUND

Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to '3Cs' (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming.

METHODS

We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the 'three delay model' combined with a broader literature on 'policy mixing.'

RESULTS

Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues.

CONCLUSION

The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the 'three delays' but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.

Investments for effective functionality of health systems towards Universal Health Coverage in Africa: A scoping review

The health challenges in Africa underscore the importance of effectively investing in health systems. Unfortunately, there is no information on systems investments adequate for an effective functional health system. We aimed to address this by conducting a scoping review of existing evidence following the Joanna Briggs Institute Manual for Evidence Synthesis and preregistered with the Open Science Framework (https://osf.io/bvg4z). We included any empirical research describing interventions that contributed to the functionality of health systems in Africa or any low-income or lower-middle-income regions. We searched Web of Science, MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL, and ERIC from their inception, and hand-searched other relevant sources. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. We identified 554 unique reports describing 575 interventions, of which 495 reported evidence of effectiveness. Most interventions were undertaken in Africa (80.9%), covered multiple elements of health systems (median: 3), and focused on service delivery (77.4%) and health workforce (65.6%). Effective interventions contributed to improving single (35.6%) or multiple (64.4%) capacities of health systems: access to essential services (75.6%), quality of care (70.5%), demand for essential services (38.6%), or health systems resilience (13.5%). For example, telemedicine models which covered software (technologies) and hardware (health workers) elements were used as a strategy to address issues of access to essential services. We inventoried these effective interventions for improving health systems functionality in Africa. Further analyses could deepen understanding of how such interventions differ in their incorporation of evidence for potential scale across African countries.

Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study

Introduction

Facility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes.

Methods

We conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO’s Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for ‘comparison’. We interviewed 43 facility managers and 818 providers, observed 1516 client–provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality.

Results

EMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems.

Conclusion

Institutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

Dinámicas sociales en salud materna con énfasis en la Morbilidad Materna Extrema y aportes de la bioética en su comprensión

El propósito del presente artículo es analizar las dinámicas sociales en salud materna y los aportes de la bioética en su comprensión, haciendo énfasis en la Morbilidad Materna Extrema. Para ello, se llevó a cabo una revisión narrativa realizada en las bases de datos Scopus, Pubmed, Web of Science, Lilacs, Scielo y Google Scholar con la estrategia “Maternal Health” AND “Bioethics” OR “Social Justice”; incluyendo artículos en español, inglés y portugués, publicados en los últimos 25 años. En los resultados se incluyeron 79 manuscritos originales y 21 manuscritos de reflexión y revisión, que surtieron el análisis descriptivo al generar las siguientes categorías temáticas: 1. Necesidades de atención en salud y de cuidado; 2. Determinantes sociales, factores de riesgo y protectores; 3. Calidad de la atención, experiencias en el tratamiento y barreras de acceso; y 4. Perspectivas éticas y bioéticas de la salud materna. Como conclusión, se pudo afirmar que el abordaje bioético de la salud materna propone categorías de análisis como la justicia, la equidad, la autonomía y el acceso. Además de las condiciones de vida desde la pluralidad cultural y las consideraciones en cuanto a la comunicación y el lenguaje. Lo anterior, implica que desde los sistemas de salud se deben rediseñar los enfoques de atención en salud materna para abordar las vulnerabilidades y potenciar las capacidades de las mujeres.

Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review

Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.

Impact evaluation of a maternal and neonatal health training intervention in private Ugandan facilities

Global and country-specific targets for reductions in maternal and neonatal mortality in low-resource settings will not be achieved without improvements in the quality of care for optimal facility-based obstetric and newborn care. This global call includes the private sector, which is increasingly serving low-resource pregnant women. The primary aim of this study was to estimate the impact of a clinical and management-training programme delivered by a non-governmental organization [LifeNet International] that partners with clinics on adherence to global standards of clinical quality during labour and delivery in rural Uganda. The secondary aim included describing the effect of the LifeNet training on pre-discharge neonatal and maternal mortality. The LifeNet programme delivered maternal and neonatal clinical trainings over a 10-month period in 2017-18. Direct clinical observations of obstetric deliveries were conducted at baseline (n = 263 pre-intervention) and endline (n = 321 post-intervention) for six faith-based, not-for-profit primary healthcare facilities in the greater Masaka area of Uganda. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum haemorrhage and neonatal resuscitation). Data were supplemented by daily facility-based assessments of infrastructure during the study periods. Results showed positive and clinically meaningful increases in observed handwashing, observed delayed cord clamping, partograph use documentation and observed 1- and/or 5-minute APGAR assessments (rapid scoring system for assessing clinical status of newborn), in particular, between baseline and endline. High-quality intrapartum facility-based care is critical for reducing maternal and early neonatal mortality, and this evaluation of the LifeNet intervention indicates that their clinical training programme improved the practice of quality maternal and neonatal healthcare at all six primary care clinics in Uganda, at least over a relatively short-term period. However, for several of these quality indicators, the adherence rates, although improved, were still far from 100% and could benefit from further improvement via refresher trainings and/or a closer examination of the barriers to adherence.

The health response to the Rohingya refugee crisis post August 2017: Reflections from two years of health sector coordination in Cox's Bazar, Bangladesh

On August 25 2017, an unprecedented influx of Rohingya refugees began from Rakhine State in Myanmar into Bangladesh's district of Cox's Bazar. The scale and acuteness of this humanitarian crisis was unprecedented and unique globally, requiring strong coordination of a multitude of actors. This paper reflects on the health sector coordination from August 2017 to October 2019, focusing on selected achievements and persisting challenges of the health sector strategic advisory group (HSSAG), and the health sector working groups including epidemiology and case management, sexual and reproductive health, community health, mental health and psychosocial support, and emergency preparedness. In the early days of the response, minimum service standards for primary health care were established, a fundamental initial step which enabled the standardization of services based on critical needs. Similarly, establishing standards for community health outreach was the backbone for capitalizing on this important health workforce. Novel approaches were adopted for infectious disease responses for acute watery diarrhoea and varicella, drawing on inter-sectoral collaborations. Sexual and reproductive health services were prioritized from the initial onset of the crisis and improvements in skilled delivery attendance, gender-based violence services, abortion care and family planning were recorded. Mental health service provision was strengthened through community-based approaches although integration of mental health programmes into primary health care has been limited by availability of specialist psychiatrists. Strong, collaborative and legitimate leadership by the health sector strategic advisory group, drawing on inter-sectoral collaborations and the technical expertise of the different technical working groups, were critical in the response and proved effective, despite the remaining challenges to be addressed. Anticipated reductions in funding as the crisis moves into protracted status threatens the achievements of the health sector in provision of health services to the Rohingya refugees.

Implementing an intrapartum package of interventions to improve quality of care to reduce the burden of preterm birth in Kenya and Uganda

Background

Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication.

Methods

Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative.

Results

In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake.

Conclusion

Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up. The trial is registered at ClinicalTrials.govNCT03112018, registered December 2016, posted April 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00109-w.