An Assessment of Clinical Mentorship for Quality Improvement: The African Health Professions Regional Collaborative for Nurses and Midwives

ABSTRACT

The African Regional Collaborative for nurses and midwives funded quality improvement projects in five countries to enhance clinical mentorship programs supporting HIV service delivery for women, infants, and children. Each country team implemented specific interventions focused on the application of nurse-initiated and managed antiretroviral therapy guidelines and competencies. A site-level tool, the nursing practice framework, measured structural maturation in clinical mentorship programs across five stages at eight facilities. Clinical competencies that aligned with the framework were evaluated through a provider-level knowledge assessment to identify on-going needs for mentees before and after the implementation period. Key trends observed in the assessment include positive program progression for all facilities; competencies were higher for pregnant and breastfeeding women and lower for HIV-exposed infants; there was an increase in posttest participation for all facilities. The nursing practice framework provides a rapid assessment of structural changes and exploration of context to identify quality improvement needs.

Nurse- and Midwife-Led HIV Services in Eastern and Southern Africa: Challenges and Opportunities for Health Facilities

In eastern and southern Africa, much is unknown about implementation of nurse-initiated and managed antiretroviral therapy (NIMART). The purpose of this study was to identify perceived barriers and facilitators of NIMART for the prevention of mother-to-child transmission and pediatric HIV services in high-volume, high HIV-burden health facilities across this region. A total of 211 nurses, midwives, and nurse midwives and 62 supervisors from 30 health facilities in 11 countries participated in this mixed-methods evaluation. The findings show that although nurses, midwives, and nurse midwives clearly had the authority to provide NIMART services, they did not necessarily feel that they were well prepared and supported to do so. Deficits in supportive supervision and clinical mentorship were viewed as substantial challenges to effective provision of NIMART for the prevention of mother-to-child transmission and pediatric HIV services-particularly with respect to pediatric HIV services. Health facilities have important opportunities to advance NIMART practice through strengthening these aspects of in-service support.

From 'half-dead' to being 'free': resistance to HIV stigma, self-disclosure and support for PMTCT/HIV care among couples living with HIV in Kenya

In sub-Saharan Africa, self-disclosure of HIV-positive status may be a pivotal action for improving access to prevention of mother-to-child transmission services. However, understanding of HIV stigma and disclosure, and their effects on demand for care remains incomplete - particularly in the current context of new antiretroviral therapy guidelines. The purpose of this study was to explore these issues among self-disclosed couples living in southwest Kenya. We conducted 38 in-depth interviews with HIV-positive pregnant or postpartum women and their male partners. Of the 19 couples, 10 were HIV seroconcordant and 9 were serodiscordant. The textual analysis showed that HIV stigma continues to restrict full participation in community life and limit access to care by promoting fear, isolation and self-censorship. Against this backdrop, however, participants' narratives revealed varying forms and degrees of resistance to HIV stigma, which appeared to both produce and emerge from acts of self-disclosure. Such disclosure enabled participants to overcome fears and gain critical support for engaging in HIV care while further resisting HIV stigma. These findings suggest that programme interventions designed explicitly to stimulate and support processes of HIV stigma resistance and safe self-disclosure may be key to improving demand for and retention in HIV services.

A Text Messaging Intervention to Support Option B+ in Kenya: A Qualitative Study

Key challenges in providing lifelong antiretroviral therapy (ART) to pregnant and breastfeeding women (Option B+) in sub-Saharan Africa include achieving long-term adherence and retention in care. One intervention that may help address these challenges is mobile text messaging. We evaluated the acceptability of a text messaging intervention to support women's ART adherence and retention in care in rural western Kenya. Forty in-depth interviews with 20 pregnant/postpartum women infected with HIV, their male partners, and four focus groups with 30 health care providers were conducted during September-November 2014. Data were coded and analyzed using thematic analysis. Findings revealed the following themes: (a) overall acceptability of the text messaging intervention; (b) proposed content of text messages; (c) format, timing, and language of text messages; and (d) potential challenges of the text messaging intervention. Findings were used to refine a text messaging intervention being evaluated at Kenyan study sites rolling out Option B+.

Promoting Regulatory Reform: The African Health Profession Regulatory Collaborative (ARC) for Nursing and Midwifery Year 4 Evaluation

As countries across sub-Saharan Africa work towards universal health coverage and HIV epidemic control, investments seek to bolster the quality and relevance of the health workforce. The African Health Profession Regulatory Collaborative (ARC) partnered with 17 countries across East, Central, and Southern Africa to ensure nurses and midwives were authorized and equipped to provide essential HIV services to pregnant women and children with HIV. Through ARC, nursing leadership teams representing each country identify a priority regulatory function and develop a proposal to strengthen that regulation over a 1-year period. Each year culminates with a summative congress meeting, involving all ARC countries, where teams present their projects and share lessons learned with their colleagues. During a recent ARC Summative Congress, a group survey was administered to 11 country teams that received ARC Year 4 grants to measure advancements in regulatory function using the five-stage Regulatory Function Framework, and a group questionnaire was administered to 16 country teams to measure improvements in national nursing capacity (February 2011-2016). In ARC Year 4, eight countries implemented continuing professional development projects, Botswana revised their scope of practice, Mozambique piloted a licensing examination to assess HIV-related competencies, and South Africa developed accreditation standards for HIV/tuberculosis specialty nurses. Countries reported improvements in national nursing leaders' teamwork, collaborations with national organizations, regional networking with nursing leaders, and the ability to garner additional resources. ARC provides an effective, collaborative model to rapidly strengthen national regulatory frameworks, which other health professional cadres or regions may consider using to ensure a relevant health workforce, authorized and equipped to meet the emerging demand for health services.

Health facility challenges to the provision of Option B+ in western Kenya: a qualitative study

Current WHO guidelines recommend lifelong antiretroviral therapy (ART) for all HIV-positive individuals, including pregnant and breastfeeding women (Option B+) in settings with generalized HIV epidemics. While Option B+ is scaled-up in Kenya, insufficient adherence and retention to care could undermine the expected positive impact of Option B+. To explore challenges to the provision of Option B+ at the health facility level, we conducted forty individual gender-matched in-depth interviews with HIV-positive pregnant/postpartum women and their male partners, and four focus groups with thirty health care providers at four health facilities in western Kenya between September-November 2014. Transcripts were coded with the Dedoose software using a coding framework based on the literature, topics from interview guides, and emerging themes from transcripts. Excerpts from broad codes were then fine-coded using an inductive approach. Three major themes emerged: 1) Option B+ specific challenges (same-day initiation into treatment, health care providers unconvinced of the benefits of Option B+, insufficient training); 2) facility resource constraints (staff and drug shortages, long queues, space limitations); and 3) lack of client-friendly services (scolding of patients, inconvenient operating hours, lack of integration of services, administrative requirements). This study highlights important challenges at the health facility level related to Option B+ rollout in western Kenya. Addressing these specific challenges may increase linkage, retention and adherence to life-long ART treatment for pregnant HIV-positive women in Kenya, contribute towards elimination of mother-to-child HIV transmission, and improve maternal and child outcomes.

An evaluation of equitable access to a community-based maternal and newborn health program in rural Ethiopia

INTRODUCTION

The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) aimed to promote equitable access to safe childbirth and postnatal care through a community-based educational intervention. This study evaluates the extent to which MaNHEP reached women who are socially and materially disadvantaged and, thus, at high risk for inadequate access to care.

METHODS

The data used in this analysis are from MaNHEP's cross-sectional 2010 baseline and 2012 endline surveys of women who gave birth in the prior year. A logistic regression model was fit to examine the effects of sociodemographic characteristics on participation in the MaNHEP program. Descriptive statistics of select characteristics by birth and postnatal care provider were also calculated to explore trends in services use.

RESULTS

Using data from the endline survey (N = 1019), the regression model showed that age, parity, education, and geographic residence were not significantly associated with MaNHEP exposure. However, women who were materially disadvantaged were still less likely to have participated in the program than their better-off counterparts. From the baseline survey (N = 1027) to the endline survey, women's use of skilled and semiskilled providers for birth care and postnatal care increased substantially, while use of untrained providers or no provider decreased. These shifts were greater for women with less personal wealth than for women with more personal wealth.

DISCUSSION

MaNHEP appears to have succeeded in meeting its equity goals to a degree. However, this study also supports the intractable relationship between wealth inequality and access to maternal and newborn health services. Strategies targeting the poor in diverse contexts may eventually prove consistently effective in equitable services delivery. Until that time, a critical step that all maternal and newborn health programs can take is to monitor and evaluate to what extent they are reaching disadvantaged groups within the populations they serve.

A regional comparison of distribution strategies and women's awareness, receipt, and use of misoprostol to prevent postpartum hemorrhage in rural Amhara and Oromiya regions of Ethiopia

INTRODUCTION

In Ethiopia, postpartum hemorrhage is a leading cause of maternal death. The Maternal Health in Ethiopia Partnership (MaNHEP) project developed a community-based model of maternal and newborn health focusing on birth and early postpartum care. Implemented in the Amhara and Oromiya regions, the model included misoprostol to prevent postpartum hemorrhage. This article describes regional trends in women's use of misoprostol; their awareness, receipt, and use of misoprostol at project's endline; and factors associated with its use.

METHODS

The authors assessed trends in use of misoprostol using monthly data from MaNHEP's quality improvement database; and awareness, receipt, use, and correct use of misoprostol using data from MaNHEP's endline survey of 1019 randomly sampled women who gave birth during the year prior to the survey.

RESULTS

Misoprostol use increased rapidly and was relatively stable over 20 months, but regional differences were stark. At endline, significantly more women in Oromiya were aware of misoprostol compared with women who resided in Amhara (94% vs 59%); significantly more had received misoprostol (80% vs 35%); significantly more had received it during pregnancy (93% vs 48%); and significantly more had received it through varied sources. Most women who received misoprostol used it (> 95%) irrespective of age, parity, or education. Factors associated with use were Oromiya residence (odds ratio [OR] 9.48; 95% confidence interval [CI], 6.78-13.24), attending 2 or more Community Maternal and Newborn Health (CMNH) family meetings (OR 2.62; 95% CI, 1.89-3.63), receiving antenatal care (OR 1.67; 95% CI, 1.08-2.58) and being attended at birth by a skilled provider or trained health extension worker, community health development agent, or traditional birth attendant versus an untrained caregiver or no one. Correct use was associated with having attended 2 or more CMNH family meetings (OR 2.02; 95% CI, 1.35-3.03).

DISCUSSION

Multiple distribution channels increase women's access to misoprostol. Most women who have access to misoprostol use it. Early distribution to pregnant women who are educated to use misoprostol appears to be safe and unrelated to choice of birthplace.

Assessing skilled birth attendants and emergency obstetric care in rural Tanzania: the inadequacy of using global standards and indicators to measure local realities

Current efforts to reduce maternal mortality and morbidity in low-resource settings often depend on global standards and indicators to assess obstetric care, particularly skilled birth attendants and emergency obstetric care. This paper describes challenges in using these standards to assess obstetric services in the Kilombero Valley of Tanzania. A health facility survey and extensive participant observation showed existing services to be complicated and fluid, involving a wide array of skills, resources, and improvisations. Attempts to measure these services against established standards and indicators were not successful. Some aspects of care were over-valued while others were under-valued, with significant neglect of context and quality. This paper discusses the implications of these findings for ongoing maternal health care efforts in unique and complex settings, questioning the current reliance on generic (and often obscure) archetypes of obstetric care in policy and programming. It suggests that current indicators may be insufficient to assess services in low-resource settings, but not that these settings should settle for lower standards of care. In addition to global benchmarks, assessment approaches that emphasize quality of care and recognize available resources might better account for local realities, leading to more effective, more sustainable service delivery.

Use of biomedical obstetric care in rural Tanzania: the role of social and material inequalities

Despite over 20 years of efforts to improve maternal health, complications of pregnancy and childbirth continue to threaten women's lives in many countries of sub-Saharan Africa. To reduce maternal mortality levels and achieve Millennium Development Goal Five, institutions working for safe motherhood are committed to making biomedical obstetric care more available to women during childbirth. However, implementation of this strategy is not reaching women at the lower end of the socioeconomic spectrum for reasons that are not well understood. Using data from fieldwork conducted between September 2007 and June 2008, this study examines women's use of biomedical obstetric care in two rural districts of south-central Tanzania where this care was being supplied. Specifically, it seeks to explain how social and material inequalities affect decisions and behaviors related to childbirth. In addressing this aim we employed a mixed-methods study design. Effects of sociodemographic characteristics on obstetric care use were examined with logistic regression analysis (n = 1150), while perspectives and experiences of childbearing women were explored with participant observation and in-depth interviews (n = 48). The results from quantitative and qualitative study components were interpreted in light of each other. Statistically significant social and material factors related to use of care included ethnicity, education, parity, and household assets. Qualitative themes involved physical, economic, and social access to health facilities as well as issues of risk perception and self-identity. The overall findings suggest that use of obstetric care is influenced by a complex interplay of factors closely tied to relative status in family and community. As individual agents differentially positioned by multiple markers of power, women pragmatically negotiate amidst a wide array of deterrents and motivators to secure the best care they can. In order to improve use of biomedical obstetric care, interventions aimed at increasing availability of these services should focus on improving access for women who are disadvantaged.