Introduction: Ethiopia has high maternal and neonatal mortality and low use of skilled maternity care. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), a 3.5-year learning project, used a community collaborative quality improvement approach to improve maternal and newborn health care during the birth-to-48-hour period. This study examines how the promotion of community maternal and newborn health (CMNH) family meetings and labor and birth notification contributed to increased postnatal care within 48 hours by skilled providers or health extension workers.Methods: Baseline and endline surveys, monthly quality improvement data, and MaNHEP's CMNH change package, a compendium of the most effective changes developed and tested by communities, were reviewed. Logistic regression assessed factors associated with postnatal care receipt. Monthly postnatal care receipt was plotted with control charts. Results:The baseline (n = 1027) and endline (n = 1019) surveys showed significant increases in postnatal care, from 5% to 51% and from 15% to 47% in the Amhara and Oromiya regions, respectively (both P Ͻ .001). Notification of health extension workers for labor and birth within 48 hours was closely linked with receipt of postnatal care. Women with any antenatal care were 1.7 times more likely to have had a postnatal care visit (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.10-2.54; P Ͻ .001). Women who had additionally attended 2 or more CMNH meetings with family members and had access to a health extension worker's mobile phone number were 4.9 times more likely to have received postnatal care (OR, 4.86; 95% CI,; P Ͻ .001). Discussion:The increase in postnatal care far exceeds the 7% postnatal care coverage rate reported in the 2011 Ethiopian Demographic and Health Survey (EDHS). This result was linked to ideas generated by community quality improvement teams for labor and birth notification and cooperation with community-level health workers to promote antenatal care and CMNH family meetings.
IntroductionClose-to-community (CTC) providers, including community health workers or volunteers or health extension workers, can be effective in promoting access to and utilization of health services. Tasks are often shifted to these providers with limited resources and support from CTC programmes or communities. The Community Health System Strengthening (CHSS) model is part of an improvement approach which draws on existing formal and informal networks within a community, such as agricultural or women’s groups, to support CTC providers and address gaps in community-based health services. The model offers a framework for bringing representatives from existing community networks, CTC providers, and health facility staff together to form a community team charged with identifying challenges in service delivery, testing solutions, and monitoring changes. CTC providers draw upon fellow community team members to disseminate health messages and refer community members in need of services.CasesTwo cases are presented. In Ethiopia, the CHSS model was applied in 18 communities to increase HIV testing among pregnant women and antenatal care service utilization and improve sanitation. Prior to implementation, representatives from community groups were unaware of health extension workers or were uncomfortable making referrals. By participating on the community team, representatives became familiar with and comfortable referring people to health extension workers and spreading health messages. During implementation, more pregnant women registered for antenatal care and tested for HIV; health extension workers conducted more postnatal visits; and more households had functioning latrines and proper latrine use increased.In Tanzania, the CHSS model was applied in five communities to improve HIV testing and retention into care. Community team members talked to their families and social networks about HIV testing and, when they identified someone who had dropped out of treatment, they referred those individuals to the home-based care volunteer. Increases in HIV testing and a reduction in patients lost to follow-up were observed.Discussion and conclusionThe CHSS model brings together existing networks within communities to support and lend legitimacy to CTC providers. This approach may result in sustainable community-based programmes, especially in HIV where the continuum of care extends beyond the facility and into the community.
Introduction:The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) adapted a collaborative improvement strategy to develop woreda (district) leadership capacity to support and facilitate continuous improvement of community maternal and neonatal health (CMNH) and to provide a model for other woredas, dubbed "lead" woredas. Community-level quality improvement (QI) teams tested solutions to improve CMNH care supported by monthly coaching and regular meetings to share experiences. This study examines the extent of the capacity built to support continuous improvement in CMNH care.Methods: Surveys and in-depth interviews assessed the extent to which MaNHEP developed improvement capacity. A survey questionnaire evaluated woreda culture, leadership support, motivation, and capacity for improvement activities. Interviews focused on respondents' understanding and perceived value of the MaNHEP improvement approach. Bivariate analyses and multivariate linear regression models were used to analyze the survey data. Interview transcripts were organized by region, cadre, and key themes. Results:Respondents reported significant positive changes in many areas of woreda culture and leadership, including involving a cross-section of community stakeholders (increased from 3.0 to 4.6 on 5-point Likert scale), using improvement data for decision making (2.8-4.4), using locally developed and tested solutions to improve CMNH care (2.5-4.3), demonstrating a commitment to improve the health of women and newborns (2.6-4.2), and creating a supportive environment for coaches and QI teams to improve CMNH (2.6-4.0). The mean scores for capacity were 3.7 and higher, reflecting respondents' agreement that they had gained capacity in improvement skills. Interview respondents universally recognized the capacity built in the woredas. The themes of community empowerment and focused improvement emerged strongly from the interviews.Discussion: MaNHEP was able to build capacity for continuous improvement and develop lead woredas. The multifaceted approach to building capacity was critical for the success in creating lead woredas able to serve as models for other districts.
A Community Health System Strengthening model, which mobilizes communities by applying quality improvement, was used in 39 communities around 3 health centers in Gaza Province, Mozambique, to increase identification of pregnant women and support them to attend antenatal care (ANC). This article describes the process and results. Community group representatives formed a community improvement team to spread messages about the importance of ANC, identify pregnant women, link them to the facility, and follow up. Between March 2014 and February 2015, teams identified 2020 pregnant women. Antenatal care attendance increased at all 3 centers. One health center did an additional chart review and found that postintervention, women were enrolling in care earlier in pregnancy. There were no changes in HIV testing or treatment initiation for HIV-positive women. Community-led improvement initiatives play an important role in connecting pregnant women with services to receive testing and treatment to promote optimal health and prevent HIV transmission.
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