Implementing an intrapartum package of interventions to improve quality of care to reduce the burden of preterm birth in Kenya and Uganda

Abstract

Background Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication. Methods Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative. Results In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake. Conclusion Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up. The trial is registered at ClinicalTrials.govNCT03112018, registered December 2016, posted April 2017.

Implementing the WHO Safe Childbirth Checklist modified for preterm birth: lessons learned and experiences from Kenya and Uganda

“…There are a few key limitations to this study. Although the cRCT showed positive impact on health outcomes [ 15 ], it is not possible to determine the individual impact of the interventions that comprised the package, including the mSCC. It would have been ideal to obtain qualitative interviews mid-study and post-study across the two countries in order to better capture how perceptions evolved over time.…”

“…The trial’s results are reported elsewhere; briefly, 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group (odds ratio 0·66, 95% CI 0·54–0·81) [ 14 ]. A description of the overall intervention package has been previously published [ 15 ], and further information about the package elements and Logic Model is provided in Additional File 1 .…”

Effect of a quality improvement intervention for management of preterm births on outcomes of all births in Kenya and Uganda: A secondary analysis from a facility-based cluster randomized trial

“…The intervention package for the trial was designed using an integrated approach to optimize care for the mother-baby dyad, to impact provider behavior at critical moments during triage, labor, birth, and the early neonatal period. The four components of the interventions package are described in detail elsewhere [ 7 ]. Additionally, a summary is provided in Figure S2.…”

“…in the Online Supplementary Document . The intervention package included: (a) PRONTO simulation and team training; (b) quality improvement collaboratives; (c) modified Safe Childbirth Checklist (mSCC); and (d) data strengthening [ 5 , 7 ]. The package aimed to strengthen provider skills, teamwork and emphasized use of evidence-based practices for PTB, including but not limited to the appropriate administration of antenatal corticosteroids, immediate skin to skin contact, breastfeeding, newborn resuscitation, and feeding preterm neonates.…”

“…Each of the PTBi package components was chosen because it met stakeholder requirements of: (a) having the potential to improve quality of care for preterm infants as well as for the mother-baby dyad more generally, and (b) demonstrable effectiveness as standalone interventions based on prior evidence. Our intervention package reinforced evidence-based practices, many of which should be observed for all births including those of intrapartum monitoring and neonatal resuscitation [ 7 ].…”