Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster‐randomised study in rural Tanzania

Larson, Elysia; Gage, Anna; Mbaruku, Godfrey; Mbatia, Redempta; Haneuse, Sebastien; Kruk, Margaret E

doi:10.1111/tmi.13220

Cited by 13 publications

(16 citation statements)

References 39 publications

(50 reference statements)

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“…One of the large-scale cluster randomized controlled trials on the effect of the implementation of WHO’s Safer Birth Checklist on quality of care and birth outcome, using external facilitators in a healthcare facility in India, showed improvement in the intrapartum care in the intervention area but did not show changes in maternal and perinatal mortality [37]. In a cluster-randomized trial in 12 rural primary care centers in Tanzania, a QI intervention (training, mentoring, infrastructure support, and peer outreach) improved quality antenatal care [38]. A multicountry observational study showed that rapid scale-up of training of neonatal resuscitation was associated with improvement in overall neonatal resuscitation practice [39] and improvement in perinatal mortality in a subset of the population [40].…”

Section: Discussionmentioning

confidence: 99%

Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial

Ewald

Basnet³

et al. 2019

PLoS Med

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BackgroundImproving quality of intrapartum care will reduce intrapartum stillbirth and neonatal mortality, especially in resource-poor settings. Basic neonatal resuscitation can reduce intrapartum stillbirth and early neonatal mortality, if delivered in a high-quality health system, but there is a dearth of evidence on how to scale up such evidence-based interventions. We evaluated the scaling up of a quality improvement (QI) package for neonatal resuscitation on intrapartum-related mortality (intrapartum stillbirth and first day mortality) at hospitals in Nepal.Methods and findingsWe conducted a stepped-wedge cluster randomized controlled trial in 12 hospitals over a period of 18 months from April 14, 2017, to October 17, 2018. The hospitals were assigned to one of four wedges through random allocation. The QI package was implemented in a stepped-wedge manner with a delay of three months for each step. The QI package included improving hospital leadership on intrapartum care, building health workers’ competency on neonatal resuscitation, and continuous facilitated QI processes in clinical units. An independent data collection system was set up at each hospital to gather data on mortality through patient case note review and demographic characteristics of women using semi-structured exit interviews. The generalized linear mixed model (GLMM) and multivariate logistic regression were used for analyses. During this study period, a total of 89,014 women–infant pairs were enrolled. The mean age of the mother in the study period was 24.0 ± 4.3 years, with 54.9% from disadvantaged ethnic groups and 4.0% of them illiterate. Of the total birth cohort, 54.4% were boys, 16.7% had gestational age less than 37 weeks, and 17.1% had birth weight less than 2,500 grams. The incidence of intrapartum-related mortality was 11.0 per 1,000 births during the control period and 8.0 per 1,000 births during the intervention period (adjusted odds ratio [aOR], 0.79; 95% CI, 0.69–0.92; p = 0.002; intra-cluster correlation coefficient [ICC], 0.0286). The incidence of early neonatal mortality was 12.7 per 1,000 live births during the control period and 10.1 per 1,000 live births during the intervention period (aOR, 0.89; 95% CI, 0.78–1.02; p = 0.09; ICC, 0.1538). The use of bag-and-mask ventilation for babies with low Apgar score (<7 at 1 minute) increased from 3.2% in the control period to 4.0% in the intervention period (aOR, 1.52; 95% CI, 1.32–1.77, p = 0.003). There were two major limitations to the study; although a large sample of women–infant pairs were enrolled in the study, the clustering reduced the power of the study. Secondly, the study was not sufficiently powered to detect reduction in early neonatal mortality with the number of clusters provided.ConclusionThese results suggest scaled-up implementation of a QI package for neonatal resuscitation can reduce intrapartum-related mortality and improve clinical care. The QI intervention package is likely to be effective in similar settings. More implementation research is required to as...

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Section: Discussionmentioning

confidence: 99%

Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial

Ewald

Basnet³

et al. 2019

PLoS Med

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“…No significant effect on women’s perceptions of technical care, quality of amenities, and interpersonal relations for any of the three sets of services observed (ANC, L&D, and PNC); increased the proportion of women reporting to have received medications/treatment during childbirth. Qualitative interviews: most women reported improved health service provision as a result of the intervention; drugs, equipment, and supplies were readily available due to the RBF4MNH; instances of neglect, disrespect, and verbal abuse during the process of care; increased workload resulting from an increased number of women seeking services at RBF4MNH facilities Moderate Larson et al (2019) [ 47 ] Rural Tanzania In-service training; mentoring; supportive supervision; peer outreach 04 years Mid-level cadres Primary care (community-based and primary care clinics) A cluster-randomized study: baseline (2012) and end line (2016) household surveys in control and intervention catchments; difference-in-differences analysis (DiD) Total study population-DiD: improved quality of ANC/contents of ANC [Adjusted (A) RR: 1.64; 95% CI: 1.00–2.71]; perceived quality of ANC (ARR: 1.14; 95% CI: 0.88–1.47); perceived obstetric care quality at intervention facility (ARR: 1.13; 95% CI: 0.79–1.62); reduced payment for obstetric care at intervention facility (ARR: − 3.76; 95% CI: − 7.02 to − 0.49). Previous home births-DiD: improved quality of ANC/contents of ANC (ARR: 2.31; 95% CI: 1.44–3.71); improved perceived quality of ANC (ARR: 1.57; 95% CI: 1.07–2.31); perceived obstetric care quality at intervention facility (ARR: 1.12; 95% CI: 0.78–1.59); reduced payment for obstetric care at intervention facility (ARR: − 2.24; 95% CI -4.76—0.28) Selection: LR Performance: SC Attrition: LR Detection: LR Reporting: LR (Magge et al (2017) [ 45 ] Rwanda Monthly onsite, regular clinical mentorship and training on evidence-based life-saving maternal and newborn care; learning collaborative to build healthcare workers’ leadership in data utilization for continuous quality improvement (QI); mobilizing financial resources; procurement and distribution of essential equipment and supplies 18 months Nurses, community health supervisors, data officers, and health facility and district leadership Primary care (Community-based and health centres), and secondary care hospitals A retrospective case study using the quantitative method: pre–post intervention evaluation Pre- vs post-intervention: ≥ 4 ANC (23% vs 38%); 1st trimester ANC (23% vs 34%); pregnant women with premature rupture of membrane (PROM) treated with antibiotics (24% vs. 38%); pregnant women with preterm labour treated with corticosteroids (26% vs 75%); SPAB (87% vs. 95%); time to C-section in minutes [median, (IQR): 99 (50–195) vs. 72 (59–77)]; immediate skin-to-skin care after delivery (19% vs. 87%); newborns checked for danger signs within 24 h of birth (47% vs. 98%) …”

Section: Resultsmentioning

confidence: 99%

“…The included studies described interventions that had been implemented in a range of settings: primary care ( n = 13) [ 39 , 40 , 44 , 47 – 49 , 54 – 57 , 59 – 61 , 63 ], secondary care hospitals ( n = 1) [ 52 ], primary care, and secondary care hospitals ( n = 8) [ 41 – 43 , 45 , 46 , 50 , 53 , 58 ], primary care, and secondary and tertiary care hospitals ( n = 1) [ 51 ], and referral hospitals ( n = 1) [ 62 ].…”

Section: Resultsmentioning

confidence: 99%

“…The interventions involved different cadres of health personnel [ 16 ]. Twelve studies included skilled personnel (doctors, nurses, nurse-midwives, midwives, auxiliary nurses, auxiliary midwives, auxiliary nurse midwives, and/or health officers) [ 39 – 41 , 44 , 46 , 47 , 52 , 53 , 56 , 60 – 62 ], three focused on lay personnel (CHWs and/or TBAs) [ 43 , 50 , 54 ]. Five studies included skilled and lay personnel [ 48 , 49 , 51 , 57 , 59 ], one involved skilled personnel, lay personnel, and lady health supervisors [ 55 ].…”

Section: Resultsmentioning

confidence: 99%

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How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review

2021

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Background Well-trained, competent, and motivated human resources for health (HRH) are crucial to delivering quality service provision across the sexual, reproductive, maternal, and newborn health (SRMNH) care continuum to achieve the 2030 Sustainable Development Goals (SDGs) maternal and neonatal health targets. This review aimed to identify HRH interventions to support lay and/or skilled personnel to improve SRMNH care quality along the continuum in low- and lower-middle-income countries (LLMICs). Methods A structured search of CINAHL, Cochrane Library/trials, EMBASE, PubMed, SCOPUS, Web of Science, and HRH Global Resource Centre databases was undertaken, guided by the PRISMA framework. The inclusion criteria sought to identify papers with a focus on 1. HRH management, leadership, partnership, finance, education, and/or policy interventions; 2. HRH interventions' impact on two or more quality SRMNH care packages across the continuum from preconception to pregnancy, intrapartum and postnatal care; 3. Skilled and/or lay personnel; and 4. Reported primary research in English from LLMICs. A deductive qualitative content analysis was employed using the World Health Organization-HRH action framework. Results Out of identified 2157 studies, 24 intervention studies were included in the review. Studies where ≥ 4 HRH interventions had been combined to target various healthcare system components, were more effective than those implementing ≤ 3 HRH interventions. In primary care, HRH interventions involving skilled and lay personnel were more productive than those involving either skilled or lay personnel alone. Results-based financing (RBF) and its policy improved the quality of targeted maternity services but had no impact on client satisfaction. Local budgeting, administration, and policy to deliver financial incentives to health workers and improve operational activities were more efficacious than donor-driven initiatives. Community-based recruitment, training, deployment, empowerment, supportive supervision, access to m-Health technology, and modest financial and non-financial incentives for community health workers (CHWs) improved the quality of care continuum. Skills-based, regular, short, focused, onsite, and clinical simulation, and/or mobile phone-assisted in-service training of skilled personnel were more productive than knowledge-based, irregular, and donor-funded training. Facility-based maternal and perinatal death reviews, coupled with training and certification of skilled personnel, positively affected SRMNH care quality across the continuum. Preconception care, an essential component of the SRMNH care continuum, lacks studies and services in LLMICs. Conclusions We recommend maternal and perinatal death audits in all health facilities; respectful, woman-centered care as a critical criterion of RBF initiatives; local administration of health worker allowances and incentives; and integration of CHWs into the healthcare system. There is an urgent need to include preconception care in the SRMNH care continuum and studies in LLMICs.

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“…Women's beliefs about local health services quality were also associated with ANC4 + attendance and facility-based delivery, which underscores long-standing evidence that quality of health services is a main determinant of its use. (29,30) Within the emotional dimension, self-e cacy was a signi cant ideational domain associated with use ANC4 + attendance and facility-based delivery. We found that women who felt con dent that they could get to a facility for ANC or delivery were 2.5-and 3.4-times more likely to attend ANC4 + times or give birth in a facility than women who lacked such con dence.…”

Section: Discussionmentioning

confidence: 99%

Psychosocial Influences on Pregnancy and Childbirth Behaviors in Northwestern Nigeria: A Cross-Sectional Analysis

Johansson¹,

Anaba²,

Abegunde³

et al. 2020

Preprint

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BackgroundAntenatal care (ANC) and facility delivery are essential maternal health services, but uptake remains low in northwestern Nigeria. To increase service use, social and behavior change (SBC) programs target psychosocial influences across cognitive, emotional and social domains including knowledge, beliefs, self-efficacy, and social norms. Yet there remains limited research that measures and quantitatively examines the role of psychosocial influences on pregnancy and childbirth behaviors in Nigeria or elsewhere. MethodsA cross-sectional population-based survey of randomly sampled women with a child under two years was conducted in Kebbi, Sokoto and Zamfara states of northwestern Nigeria in September 2019. Women were asked about maternal health behaviors during their last pregnancy. New psychosocial metrics were developed using the Ideation Model of Strategic Communication and Behavior Change. Predicted probabilities for visiting ANC four or more times (ANC4+) and giving birth in a facility were derived using mixed-effects logistic regression models adjusted for ideational and sociodemographic variables.ResultsAmong 3,039 women, 23.6% (95% CI: 18.0%-30.3%) attended ANC4+ times and 15.5% (95% CI: 11.8%-20.1%) gave birth in a facility. Among women who did not attend ANC4+ times or have a facility-based delivery during their last pregnancies, the most commonly cited reasons were lack of perceived need (42% and 67%, respectively) and spousal opposition (25% and 27%, respectively). Women who knew any ANC benefit or the recommended number of ANC visits were 3.2- and 2.1-times more likely to attend ANC4+ times. Women who held positive views about health facilities for childbirth had 1.2- and 2.6-times higher likelihood of attending ANC4+ times and facility delivery, while women who believed ANC was only for sickness or pregnancy complications had 17% lower likelihood of attending ANC4+ times. Self-efficacy and supportive spousal influence were also significantly associated with both outcomes.ConclusionsTo improve pregnancy and childbirth practices in northwestern Nigeria, programs should address a range of psychosocial factors – across cognitive, emotional and social domains – that were significantly associated with pregnancy and childbirth behaviors: raising knowledge and dispelling myths, building women’s confidence to access services, engaging spousal support in decision-making, and improving perceived (and actual) maternal health services quality.

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Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster‐randomised study in rural Tanzania

Cited by 13 publications

References 39 publications

Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial

Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial

How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review

Psychosocial Influences on Pregnancy and Childbirth Behaviors in Northwestern Nigeria: A Cross-Sectional Analysis

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