Beyond coverage: improving the quality of antenatal care delivery through integrated mentorship and quality improvement at health centers in rural Rwanda

Abstract

BackgroundInadequate antenatal care (ANC) can lead to missed diagnosis of danger signs or delayed referral to emergency obstetrical care, contributing to maternal mortality. In developing countries, ANC quality is often limited by skill and knowledge gaps of the health workforce. In 2011, the Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) program was implemented to strengthen providers’ ANC performance at 21 rural health centers in Rwanda. We evaluated the effect of MESH-QI on the completeness of danger sign assessments.MethodsCompleteness of danger sign assessments was measured by expert nurse mentors using standardized observation checklists. Checklists completed from October 2010 to May 2011 (n = 330) were used as baseline measurement and checklists completed between February and November 2012 (12–15 months after the start of MESH-QI implementation) were used for follow-up. We used a mixed-effects linear regression model to assess the effect of the MESH-QI intervention on the danger sign assessment score, controlling for potential confounders and the clustering of effect at the health center level.ResultsComplete assessment of all danger signs improved from 2.1% at baseline to 84.2% after MESH-QI (p < 0.001). Similar improvements were found for 20 of 23 other essential ANC screening items. After controlling for potential confounders, the improvement in danger sign assessment score was significant. However, the effect of the MESH-QI was different by intervention district and type of observed ANC visit. In Southern Kayonza District, the increase in the danger sign assessment score was 6.28 (95% CI: 5.59, 6.98) for non-first ANC visits and 5.39 (95% CI: 4.62, 6.15) for first ANC visits. In Kirehe District, the increase in danger sign assessment score was 4.20 (95% CI: 3.59, 4.80) for non-first ANC visits and 3.30 (95% CI: 2.80, 3.81) for first ANC visits.ConclusionAssessment of critical danger signs improved under MESH-QI, even when controlling for nurse-mentees’ education level and previous training in focused ANC. MESH-QI offers an approach to enhance quality of care after traditional training and may be an approach to support newer providers who have not yet attended content-focused courses.

The burden of hypertensive disorders of pregnancy in Africa: A systematic review and meta‐analysis

“…However, since many forms of HDP (GH, CH, and PE without severe features), may be clinically unapparent at onset, a significant number of pregnant women with subclinical HDP could also have been missed by studies included in this report, in a context where utilization of ANC and institutional delivery services is relatively low . Yet, among pregnant women who attend ANC in Africa, the timing of visits, considered as a practical way of preventing adverse pregnancy outcomes, is not always adequate; even when adequate, the quality of ANC care is often suboptimal, as blood pressure and proteinuria measurement may not be routinely available . Second, the uneven distribution of risk factors for HDP between high‐income countries and Africa, where women are more frequently of low socioeconomic background, are more likely to have a maternal infection or anemia, could partly explain the higher rate of HDP in the region.…”

“…30,31 Yet, among pregnant women who attend ANC in Africa, the timing of visits, considered as a practical way of preventing F I G U R E 1 Meta-analysis of the prevalence of overall hypertensive disorders of pregnancy adverse pregnancy outcomes, is not always adequate 33 ; even when adequate, the quality of ANC care is often suboptimal, as blood pressure and proteinuria measurement may not be routinely available. 34 Second, the uneven distribution of risk factors for HDP between high-income countries and Africa, where women are more frequently of low socioeconomic background, are more likely to have a maternal infection or anemia, 16 could partly explain the higher rate of HDP in the region.…”

Coaching Intensity, Adherence to Essential Birth Practices, and Health Outcomes in the BetterBirth Trial in Uttar Pradesh, India

“…15 These strategies are effective at improving quality of care in low-and middle-income countries across a variety of clinical areas, 16,17 including Integrated Management of Childhood Illness, 18,19 drug management and prescription practices, 20,21 primary care, 22 malaria case management, 23 voluntary male circumcision, 24 and reproductive health. 25,26 Although some studies have reported associations between increased intensity of coachingrelated activities and improved quality of care, [21][22][23] the optimal coaching intensity needed to promote and sustain behavior change is unknown. Coaching intensity can be quantified across multiple domains, including frequency (e.g., 2 coaching visits per week); duration (e.g., 6 weeks of coaching); and cumulative dose, which reflects both the frequency and the duration of the intervention (e.g., 2 sessions per week for 6 weeks equals 12 cumulative visits).…”

The Three-Gap Model of Health Worker Performance

“…A primary symptom of this poor quality is low adherence to medical protocols [1,2,3,4,5,6,7,8,9,10,11]. Given the significant evidence that increases in protocol adherence are one of the most effective ways to improve outcomes and prevent childhood deaths [12,13,14,15], a continued focus on process quality seems appropriate.…”