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Anderson R, Zaman SB, Jimmy AN, Read JM, Limmer M. Strengthening quality in sexual, reproductive, maternal, and newborn health systems in low- and middle-income countries through midwives and facility mentoring: an integrative review. BMC Pregnancy Childbirth 2023; 23:712. [PMID: 37798690 PMCID: PMC10552246 DOI: 10.1186/s12884-023-06027-0] [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: 06/30/2023] [Accepted: 09/24/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND There is an urgent global call for health systems to strengthen access to quality sexual, reproductive, maternal, newborn and adolescent health, particularly for the most vulnerable. Professional midwives with enabling environments are identified as an important solution. However, a multitude of barriers prevent midwives from fully realizing their potential. Effective interventions to address known barriers and enable midwives and quality sexual, reproductive, maternal, newborn and adolescent health are less well known. This review intends to evaluate the literature on (1) introducing midwives in low- and middle-income countries, and (2) on mentoring as a facilitator to enable midwives and those in midwifery roles to improve sexual, reproductive, maternal, newborn and adolescent health service quality within health systems. METHODS An integrative systematic literature review was conducted, guided by the Population, Intervention, Comparison, Outcome framework. Articles were reviewed for quality and relevance using the Gough weight-of-evidence framework and themes were identified. A master table categorized articles by Gough score, methodology, country of focus, topic areas, themes, classification of midwives, and mentorship model. The World Health Organization health systems building block framework was applied for data extraction and analysis. RESULTS Fifty-three articles were included: 13 were rated as high, 36 as medium, and four as low according to the Gough criteria. Studies that focused on midwives primarily highlighted human resources, governance, and service delivery while those focused on mentoring were more likely to highlight quality services, lifesaving commodities, and health information systems. Midwives whose pre-service education met global standards were found to have more efficacy. The most effective mentoring packages were comprehensive, integrated into existing systems, and involved managers. CONCLUSIONS Effectively changing sexual, reproductive, maternal, newborn and adolescent health systems is complex. Globally standard midwives and a comprehensive mentoring package show effectiveness in improving service quality and utilization. TRIAL REGISTRATION The protocol is registered in PROSPERO (CRD42022367657).
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Affiliation(s)
- Rondi Anderson
- The Faculty of Health and Medicine, Lancaster University, Lancaster, UK.
| | - Sojib Bin Zaman
- Department of Health Sciences, James Madison University, Harrisonburg, Virginia, USA
| | - Abdun Naqib Jimmy
- Environmental Science Department, Jahangirnagar University, Dhaka, Bangladesh
| | - Jonathan M Read
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Mark Limmer
- The Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Ssegujja E, Andipatin M. Examining the variations in the implementation of interventions to address stillbirth from the national to subnational levels: experiences from Uganda. Health Res Policy Syst 2022; 20:123. [PMID: 36333716 PMCID: PMC9636672 DOI: 10.1186/s12961-022-00928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background The current global burden of stillbirth disproportionately affects regions such as sub-Saharan Africa, where Uganda is located. To respond to this burden, policies made at the national level were diffused from the centre and translated into service delivery at the district level, which is charged with implementation under the decentralization of health services arrangement. Variations emerge whenever policy recommendations are moved from national to subnational levels, with some aspects often lost along the way. Tools are available to facilitate knowledge of determinants of policy and innovation implementation within the healthcare system. However, the extent to which these have been applied to explain variations in implementation of interventions to address stillbirth reduction in Uganda remains scant. The aim of this article was to examine the variations in the implementation of interventions to address stillbirth from the national to the subnational levels in Uganda using the Consolidated Framework for Implementation Research (CFIR). Methods The study adopted a qualitative case study design. Data were collected from a purposively selected sample of key informants drawn from both the national and subnational levels. All interviews were conducted in English and transcribed verbatim. ATLAS.ti was used to guide the coding process, which used a codebook developed following the CFIR domains as codes and constructs as sub-codes. Analysis followed a content analysis technique. Results National-level factors that favoured implementation of interventions to address stillbirth included the desire to comply with global norms, incentives to improve performance for stillbirth reduction indicators for better comparison with global peers, and clear policy alternatives as process implementation advanced by champions. Variations at the subnational level revealed aspirations to address service delivery gaps which fell within maternal health routine standard of care and ongoing health systems strengthening initiatives. Coalescing existing networks around maternal and child health was a key mobilization factor for advocacy and programming, with a promise that the set targets would be operationalized at the subnational level. The key champions were defined by their official roles within the district health systems, which enhanced accountability. Feedback and reflection were distinguished from the national to subnational through joint assemblies and formal audit reviews, respectively. Conclusions A heavy influence of the global events directed national-level adaptation of interventions to address stillbirth. Implementation context at the subnational level led to local adaptation and translation of policy provisions from the national level to suit the context, which to a greater extent explains the variations in the final content of policy provisions delivered.
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Affiliation(s)
- Eric Ssegujja
- grid.11194.3c0000 0004 0620 0548Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda ,grid.8974.20000 0001 2156 8226School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Michelle Andipatin
- grid.8974.20000 0001 2156 8226Department of Psychology, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
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Blair AH, Openshaw M, Mphande I, Jana O, Malirakwenda R, Muller A, Rankin S, Baltzell K. Assessing Combined Longitudinal Mentorship and Skills Training on Select Maternal and Neonatal Outcomes in Rural and Urban Health Facilities in Malawi. J Transcult Nurs 2022; 33:704-714. [PMID: 36062416 PMCID: PMC9561805 DOI: 10.1177/10436596221118113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction: Despite successful efforts to improve clinical access and skilled birth
attendance in Malawi, it still faces high rates of maternal and neonatal
mortality. In 2017, the UCSF-GAIN partnership began a nurse-midwifery
clinical education and longitudinal mentorship program. While it has
received positive reviews, it is unclear whether routinely collected
indicators can assess such a program’s impact. Method: A longitudinal review of the Malawian DHIS2 database explored variables
associated with maternal and newborn care and outcomes before and after the
intervention. Data were analyzed using generalized estimating equations
(GEE) to account for facility-level correlations over time. Results: Quality issues with DHIS2 data were identified. Significant changes
potentially associated with the GAIN intervention were noted. Discussion: The GAIN approach appears to be associated with positive trends in maternal
and neonatal care. National summary databases are problematic, however, for
evaluating targeted interventions and the provision of care to specific
outcomes.
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Affiliation(s)
| | | | | | | | | | - Anna Muller
- University of California, San Francisco, USA
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Deussom R, Mwarey D, Bayu M, Abdullah SS, Marcus R. Systematic review of performance-enhancing health worker supervision approaches in low- and middle-income countries. HUMAN RESOURCES FOR HEALTH 2022; 20:2. [PMID: 34991604 PMCID: PMC8733429 DOI: 10.1186/s12960-021-00692-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/12/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND The strength of a health system-and ultimately the health of a population-depends to a large degree on health worker performance. However, insufficient support to build, manage and optimize human resources for health (HRH) in low- and middle-income countries (LMICs) results in inadequate health workforce performance, perpetuating health inequities and low-quality health services. METHODS The USAID-funded Human Resources for Health in 2030 Program (HRH2030) conducted a systematic review of studies documenting supervision enhancements and approaches that improved health worker performance to highlight components associated with these interventions' effectiveness. Structured by a conceptual framework to classify the inputs, processes, and results, the review assessed 57 supervision studies since 2010 in approximately 29 LMICs. RESULTS Of the successful supervision approaches described in the 57 studies reviewed, 44 were externally funded pilots, which is a limitation. Thirty focused on community health worker (CHW) programs. Health worker supervision was informed by health system data for 38 approaches (67%) and 22 approaches used continuous quality improvement (QI) (39%). Many successful approaches integrated digital supervision technologies (e.g., SmartPhones, mHealth applications) to support existing data systems and complement other health system activities. Few studies were adapted, scaled, or sustained, limiting reports of cost-effectiveness or impact. CONCLUSION Building on results from the review, to increase health worker supervision effectiveness we recommend to: integrate evidence-based, QI tools and processes; integrate digital supervision data into supervision processes; increase use of health system information and performance data when planning supervision visits to prioritize lowest-performing areas; scale and replicate successful models across service delivery areas and geographies; expand and institutionalize supervision to reach, prepare, protect, and support frontline health workers, especially during health emergencies; transition and sustain supervision efforts with domestic human and financial resources, including communities, for holistic workforce support. In conclusion, effective health worker supervision is informed by health system data, uses continuous quality improvement (QI), and employs digital technologies integrated into other health system activities and existing data systems to enable a whole system approach. Effective supervision enhancements and innovations should be better integrated, scaled, and sustained within existing systems to improve access to quality health care.
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Affiliation(s)
- Rachel Deussom
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Doris Mwarey
- Human Resources for Health Consultant, Formerly With Chemonics International, PO Box 26432–00100, Nairobi, Kenya
| | - Mekdelawit Bayu
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Sarah S. Abdullah
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Rachel Marcus
- Office of Health Systems, Bureau for Global Health, United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20004 United States of America
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Sudhinaraset M, Giessler K, Nakphong MK, Roy KP, Sahu AB, Sharma K, Montagu D, Green C. Can changes to improve person-centred maternity care be spread across public health facilities in Uttar Pradesh, India? Sex Reprod Health Matters 2021; 29:1-15. [PMID: 33704027 PMCID: PMC8011686 DOI: 10.1080/26410397.2021.1892570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Poor quality person-centred maternity care (PCMC) leads to delays in care and adverse maternal and newborn outcomes. This study describes the impact of spreading a Change Package, or interventions that other health facilities had previously piloted and identified as successful, to improve PCMC in public health facilities in Uttar Pradesh, India. A quasi-experimental design was used including matched control-intervention facilities and pre-post data collection. This study took place in Uttar Pradesh, India in 2018-2019. Six large public health facilities participated in the evaluation of the spread study, including three intervention and three control facilities. Intervention facilities were introduced to a quality improvement (QI) Change Package to improve PCMC. In total, 1200 women participated in the study, including 600 women at baseline and 600 women at endline. Difference-in-difference estimators are used to examine the impact of spreading a QI Change Package across spread sites vs. control sites and at baseline and endline using a validated PCMC scale. Out of a 100-point scale, a 24.93 point improvement was observed in overall PCMC scores among spread facilities compared to control facilities from baseline to endline (95% CI: 22.29, 27.56). For the eight PCMC indicators that the Change Package targeted, spread facilities increased 33.86 points (95% CI: 30.91, 36.81) relative to control facilities across survey rounds. Findings suggest that spread of a PCMC Change Package results in improved experiences of care for women as well as secondary outcomes, including clinical quality, nurse and doctor visits, and decreases in delivery problems.Trial registration: ClinicalTrials.gov identifier: NCT04208841..
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Affiliation(s)
- May Sudhinaraset
- Associate Professor, Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA. Correspondence:
| | - Katie Giessler
- Associate Director, Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Michelle Kao Nakphong
- Doctoral Student, Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Kali Prosad Roy
- Associate Director-Research & Metrics, Population Services International, New Delhi, India
| | | | - Kovid Sharma
- Senior Specialist, Population Services International, New Delhi, India
| | - Dominic Montagu
- Professor, Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Cathy Green
- Independent Improvement Consultant, Western Cape, South Africa
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Montagu D, Giessler K, Nakphong MK, Green C, Roy KP, Sahu AB, Sharma K, Sudhinarset M. A comparison of intensive vs. light-touch quality improvement interventions for maternal health in Uttar Pradesh, India. BMC Health Serv Res 2020; 20:1121. [PMID: 33276773 PMCID: PMC7716449 DOI: 10.1186/s12913-020-05960-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/23/2020] [Indexed: 11/25/2022] Open
Abstract
Background Poor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and necessitate significant external input, making replication and scale difficult. This study compares the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch. Methods We use a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12 months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome Results Both Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a ‘halo’ effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed. Conclusions This study demonstrates that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a ‘halo’ effect, changing many other aspects of patient-provider interaction at the same time. Trial registration QI Phase 1 - NCT04208867. Retrospectively registered. December 19th, 2019. QI Phase 2 –NCT04208841. Retrospectively registered. December 23, 2019.
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Affiliation(s)
- Dominic Montagu
- University of California San Francisco, 550 16th St., San Francisco, CA, USA.
| | - Katie Giessler
- University of California San Francisco, 550 16th St., San Francisco, CA, USA
| | - Michelle Kao Nakphong
- University of California Los Angeles, 650 Charles E. Young Drive South, Los Angeles, CA, 90095-1772, USA
| | - Cathy Green
- Indepedent Improvement Consultant, 24 One Chapmans Peak Drive, Western Cape, Hout Bay, South Africa
| | - Kali Prosad Roy
- Population Services International, C-445 Chittranjan Park, New Delhi, 110019, India
| | - Ananta Basudev Sahu
- Population Services International. Nidhi Kamal Tower, 202, 2nd Floor, Plot - 37 & 38B, Barwara House, Ajmer Road, Jaipur, Rajasthan, India
| | - Kovid Sharma
- Population Services International, Lucknow, Uttar Pradesh, India
| | - May Sudhinarset
- University of California Los Angeles, 650 Charles E. Young Drive South, Los Angeles, CA, 90095-1772, USA
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