Toward communities as systems: a sequential mixed methods study to understand factors enabling implementation of a skilled birth attendance intervention in Nampula Province, Mozambique

Abstract

BackgroundSkilled birth attendance, institutional deliveries, and provision of quality, respectful care are key practices to improve maternal and neonatal health outcomes. In Mozambique, the government has prioritized improved service delivery and demand for these practices, alongside “humanization of the birth process.” An intervention implemented in Nampula province beginning in 2009 saw marked improvement in institutional delivery rates. This study uses a sequential explanatory mixed methods case study design to explore the contextual factors that may have contributed to the observed increase in institutional deliveries.MethodsA descriptive time series analysis was conducted using clinic register data from 2009 to 2014 to assess institutional delivery coverage rates in two primary health care facilities, in two districts of Nampula province. Site selection was based on facilities exhibiting an initial increase in institutional deliveries from 2009 to 2011, similarity of health system attributes, and accessibility for study participation. Using a modified Delphi technique, two expert panels—each composed of ten stakeholders familiar with maternal health implementation at facility, district, provincial, and national levels—were convened to formulate the “story” of the implementation and to identify contextual factors to use in developing semi-structured interview guides. Thirty-four key informant interviews with facility MCH nurses, facility managers, traditional birth attendants, community leaders, and beneficiaries were then conducted and analyzed using the Consolidated Framework for Implementation Research through inductive and deductive coding.ResultsThe two sites’ skilled birth attendance coverage of estimated live births reached 80 and 100%, respectively. Eight contextual and human factors were found as dominant themes. Though both sites achieved increases, implementation context differed significantly with compelling examples of both respectful and disrespectful care. In one site, facility and community actors worked together as complementary systems to sustain improved care and institutional deliveries. In the other, community actors sustained implementation and institutional deliveries largely in absence of health system counterparts.ConclusionFindings support global health recommendations for combined health system and community interventions for improved MNH outcomes including delivery of respectful care, and further suggest the capacity of communities to act as systems both in partnership to and independent of the formal health system.Electronic supplementary materialThe online version of this article (10.1186/s12978-018-0574-8) contains supplementary material, which is available to authorized users.

Factors Associated with Underutilization of Maternity Health Care Cascade in Mozambique: Analysis of the 2015 National Health Survey

“…Overall, our result points to the multifaceted, though amenable, sociodemographic and economic challenges that women-baby pairs are still facing in Mozambique; the identified socioeconomic factors associated with non-utilization of the health care cascade likely share the same developmental roots and come under the responsibility of sectors beyond the Ministry of Health. Other studies [37][38][39] had previously shown the sociodemographic and economic status of women as determinants of their ability to attend health care in Mozambique. Some other studies from sub-Saharan Africa had also pointed to similar factors in the early 2000s [28,[40][41][42].…”

Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review

“…Common qualitative methods utilized across the studies included focus group discussions and key informant interviews. Mixed methods studies used review of financial records [15], routine facility, or surveillance indicators [13,17,22,28,43], health worker questionnaires or other quantitative study process indicators [10,20,23,28,29], or validated surveys to calculate measures such as organizational readiness and provider burnout [24] in conjunction with qualitative research. CFIR constructs can be scored quantitatively and compared across cases according to strength and valence [44].…”

“…The unit of analysis for most of the articles was health providers in facilities or communities involved in implementation (n = 19), followed by organizations (e.g., health facilities, district health offices) involved in implementation (n = 12), patients benefiting from the intervention (n = 7), and policymakers and health system leaders at national or subnational levels (n = 5). Nine of the studies focused upon more than one unit of analysis [10,13,14,16,30,35,39,40,42].…”

Factors influencing participation dynamics in research for development interventions with multi-stakeholder platforms: A metric approach to studying stakeholder participation

“…This study aims to contribute the literature by providing scarce quantitative evidence about MSPs’ contribution using descriptive statistics and time series approach. Existing studies on participation that uses a time series approach do not explicitly refer to MSPs and either have very limited in scope [29,30] or uses participation as an explanatory or independent factor rather than a dependent variable [31–36]. This study is one of the first studies that focuses on understanding participation dynamics and various factors contributing to these dynamics within R4Ds and investigates participation as the dependent variable.…”