Obstetric care navigation: results of a quality improvement project to provide accompaniment to women for facility-based maternity care in rural Guatemala

Abstract

Background Many maternal and perinatal deaths in low-resource settings are preventable. Inadequate access to timely, quality care in maternity facilities drives poor outcomes, especially where women deliver at home with traditional birth attendants (TBA). Yet few solutions exist to support TBA-initiated referrals or address reasons patients frequently refuse facility care, such as disrespectful and abusive treatment. We hypothesised that deploying accompaniers-obstetric care navigators (OCN)-trained to provide integrated patient support would facilitate referrals from TBAs to public hospitals. Methods This project built on an existing collaboration with 41 TBAs who serve indigenous Maya villages in Guatemala's Western Highlands, which provided baseline data for comparison. When TBAs detected pregnancy complications, families were offered OCN referral support. Implementation was guided by bimonthly meetings of the interdisciplinary quality improvement team where the OCN role was iteratively tailored. The primary process outcomes were referral volume, proportion of births receiving facility referral, and referral success rate, which were analysed using statistical process control methods. Results Over the 12-month pilot, TBAs attended 847 births. The median referral volume rose from 14 to 27.5, meeting criteria for special cause variation, without a decline in success rate. The proportion of births receiving facility-level care increased from 24±6% to 62±20% after OCN implementation. Hypertensive disorders of pregnancy and prolonged labour were the most common referral indications. The OCN role evolved to include a number of tasks, such as expediting emergency transportation and providing doula-like labour support. Conclusions OCN accompaniment increased the proportion of births under TBA care that received facility-level obstetric care. Results from this of obstetric care navigation suggest it is a feasible, patient-centred intervention to improve maternity care.

Perceptions of beneficiaries and health professionals regarding a conditional cash transfer program to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomized controlled study

“…They indicated that dedicated units, taking into account the woman's global situation and with enough staff to call women who did not attend their appointments would be preferable. However, patient navigation during pregnancy has mostly been found effective in low and medium income countries (32). Additionally, our experience suggests that phone calls would not be enough because many women, particularly those whose prenatal follow-up care was inadequate, were really hard to reach for this study.…”

Out-of-Pocket Costs for Facility-Based Obstetrical Care in Rural Guatemala

“…The study was a retrospective chart review of electronic data on obstetrical referrals collected as part of an obstetrical care navigation intervention, where primary clinical outcomes have already been reported [ 11 ]. Data were collected in collaboration with Maya Health Alliance, a primary care organization providing health services to rural communities in five Guatemalan provinces.…”

“…Reasons for this include the central cultural and spiritual role of traditional midwives in Maya healthcare, but also language barriers for speakers of Mayan languages accessing biomedical healthcare facilities and widespread experiences of discrimination and disrespectful or abusive biomedical care [ 7 8 ]. To address these barriers and improve facility birth rates for high-risk pregnancies, several interventions have been investigated, include the use of maternity homes, mobile health technology, care navigation, and rights-based auditing and accountability initiatives [ 9 10 11 12 13 ].…”

“…Recently we implemented and evaluated a care navigation strategy to improve facility-level care for Indigenous women [ 11 ]. As part of this intervention, traditional midwives identified patients from rural villages needing facility-level care and referred these patients to a care navigator/advocate, who then accompanied the patient through all phases of their care.…”

Indigenous Women Managing Pregnancy Complications in Rural Ecuador

“…In particular, indigenous women are at risk of poor maternal and perinatal health outcomes as they suffer greater social, economic, and emotional vulnerability with extreme levels of health inequalities [2,3,129,155]. Latin America (LATAM) is not an exception, extreme poverty, malnutrition, ethnic and linguistic differences, poor access to basic resources, education and health services [6,15,27,79,106] do not only expose indigenous women to discrimination but also put them at risk of serious pregnancy complications [6,9,17,29,109].…”