Assessing patient autonomy in the context of TeamBirth, a quality improvement intervention to improve shared decision-making during labor and birth.

BACKGROUND: Respectful maternity care includes shared decision-making (SDM). However, research on SDM is lacking from the intrapartum period and instruments to measure it have only recently been developed. TeamBirth is a quality improvement initiative that uses team huddles to improve SDM during labor and birth. Team huddles are structured meetings including the patient and full care team when the patient's preferences, care plans, and expectations for when the next huddle will occur are reviewed. METHODS: We used patient survey data (n = 1253) from a prospective observational study at four U.S. hospitals to examine the relationship between TeamBirth huddles and SDM. We measured SDM using the Mother's Autonomy in Decision-Making (MADM) scale. Linear regression models were used to assess the association between any exposure to huddles and the MADM score and between the number of huddles and the MADM score. RESULTS: In our multivariable model, experiencing a huddle was significantly associated with a 3.13-point higher MADM score. When compared with receiving one huddle, experiencing 6+ huddles yielded a 3.64-point higher MADM score. DISCUSSION: Patients reporting at least one TeamBirth huddle experienced significantly higher SDM, as measured by the MADM scale. Our findings align with prior research that found actively involving the patient in their care by creating structured opportunities to discuss preferences and choices enables SDM. We also demonstrated that MADM is sensitive to hospital-based quality improvement, suggesting that future labor and birth interventions might adopt MADM as a patient-reported experience measure.

Improving communication and teamwork during labor: A feasibility, acceptability, and safety study.

BACKGROUND: TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery. METHODS: We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth. RESULTS: A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P < 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures. CONCLUSIONS: Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.

The Atlas Context Data Repository: A Feasible, Acceptable, and Useful Prototype for Context Data Collection and Future Predictive Analysis.

BACKGROUND: Evidence from health care and other fields indicates that context matters for successful implementation of quality improvement initiatives. Most context assessment frameworks and tools are evidence-informed; that is, based on literature and expert opinion/consensus. Quantitative evidence is lacking on which aspects of context most strongly predict implementation success. Implementers need this evidence to prioritize contextual factors for assessment and action. METHODS: The Atlas Initiative developed a prototype of surveys and data collection processes for populating the Atlas Context Data Repository, a large database that will enable statistical analyses of the relationship between context and implementation success. The prototype was piloted with eight US health care sites to assess its feasibility, acceptability, and utility for individual implementers and for use at scale. The researchers collected and analyzed quantitative data from the repository surveys, shared context assessment reports with sites, interviewed sites about their experiences, and held internal team debriefs. RESULTS: Sites found the Atlas prototype feasible and acceptable to implement and the context assessment reports useful for understanding their strengths and challenges. The Atlas Initiative successfully recruited repository participants and supported survey administration. The sample data, although too small to make predictive inferences, had reasonable distributions and low missingness. CONCLUSION: The results indicate that the Atlas Context Data Repository can be feasibly implemented at scale with minor modifications to the prototype, that the repository database can support future statistical analyses when it has more data, and that participation in the repository is valuable and worthwhile for sites.

COVID-19 Vaccine To Vaccination: Why Leaders Must Invest In Delivery Strategies Now.

Worldwide, leaders are implementing nonpharmaceutical interventions to slow transmission of the novel coronavirus while pursuing vaccines that confer immunity to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. In this article we describe lessons learned from past pandemics and vaccine campaigns about the path to successful vaccine delivery. The historical record suggests that to have a widely immunized population, leaders must invest in evidence-based vaccine delivery strategies that generate demand, allocate and distribute vaccines, and verify coverage. To generate demand, there must be an understanding of the roots of vaccine hesitancy, involvement of trusted sources of authority in advocacy for vaccination, and commitment to longitudinal engagement with communities. To allocate vaccines, qualified organizations and expert coalitions must be allowed to determine evidence-based vaccination approaches and generate the political will to ensure the cooperation of local and national governments. To distribute vaccines, the people and organizations with expertise in manufacturing, supply chains, and last-mile distribution must be positioned to direct efforts. To verify vaccine coverage, vaccination tracking systems that are portable, interoperable, and secure must be identified. Lessons of past pandemics suggest that nations should invest in evidence-informed strategies to ensure that coronavirus disease 2019 (COVID-19) vaccines protect individuals, suppress transmission, and minimize disruption to health services and livelihoods.

Mixed-methods, descriptive and observational cohort study examining feeding and growth patterns among low birthweight infants in India, Malawi and Tanzania: the LIFE study protocol.

INTRODUCTION: Ending preventable deaths of newborns and children under 5 will not be possible without evidence-based strategies addressing the health and care of low birthweight (LBW, <2.5 kg) infants. The majority of LBW infants are born in low- and middle-income countries (LMICs) and account for more than 60%-80% of newborn deaths. Feeding promotion tailored to meet the nutritional needs of LBW infants in LMICs may serve a crucial role in curbing newborn mortality rates and promoting growth. The Low Birthweight Infant Feeding Exploration (LIFE) study aims to establish foundational knowledge regarding optimal feeding options for LBW infants in low-resource settings throughout infancy. METHODS AND ANALYSIS: LIFE is a formative, multisite, observational cohort study involving 12 study facilities in India, Malawi and Tanzania, and using a convergent parallel, mixed-methods design. We assess feeding patterns, growth indicators, morbidity, mortality, child development and health system inputs that facilitate or hinder care and survival of LBW infants. ETHICS AND DISSEMINATION: This study was approved by 11 ethics committees in India, Malawi, Tanzania and the USA. The results will be disseminated through peer-reviewed publications and presentations targeting the global and local research, clinical, programme implementation and policy communities. TRIAL REGISTRATION NUMBERS: NCT04002908 and CTRI/2019/02/017475.

Just-in-time postnatal education programees to improve newborn care practices: needs and opportunities in low-resource settings.

Worldwide, many newborns die in the first month of life, with most deaths happening in low/middle-income countries (LMICs). Families' use of evidence-based newborn care practices in the home and timely care-seeking for illness can save newborn lives. Postnatal education is an important investment to improve families' use of evidence-based newborn care practices, yet there are gaps in the literature on postnatal education programees that have been evaluated to date. Recent findings from a 13 000+ person survey in 3 states in India show opportunities for improvement in postnatal education for mothers and families and their use of newborn care practices in the home. Our survey data and the literature suggest the need to incorporate the following strategies into future postnatal education programming: implement structured predischarge education with postdischarge reinforcement, using a multipronged teaching approach to reach whole families with education on multiple newborn care practices. Researchers need to conduct robust evaluation on postnatal education models incorporating these programee elements in the LMIC context, as well as explore whether this type of education model can work for other health areas that are critical for families to survive and thrive.

Family planning methods among women in a vaginal microbicide feasibility study in rural KwaZulu-Natal, South Africa.

This study investigated contraceptive use among women in rural KwaZulu-Natal, South Africa. Of 866 sexually active women not intending pregnancy and screened for a microbicide feasibility study, 466 (54%) reported currently using modern contraceptives: injectables (31%), condoms (12%), sterilization (60%) and pills (4%). Multivariable logistic regression analyses revealed statistically significantly higher odds of current contraceptive use among married vs. engaged/unmarried women (aOR 1.64), multiparous vs. nulliparous (aOR 4.45) and women who completed secondary education or above vs. primary or less (aOR 1.64). Significantly lower odds of use were observed among women aged 40+ vs. age 15-19 (aOR 0.38). Age, marital status, education level and parity were associated with different contraceptive method choices. Among 195 women followed longitudinally for 9 months, contraceptive use increased significantly from 56% to 70%, largely due to increased condom use (15% to 28%). Results highlight the importance of integrating family planning and HIV/STI prevention counseling and informing promotion of further contraceptive uptake among women not intending pregnancy.

Increasing Contraceptive Use Among Young Married Couples in Bihar, India: Evidence From a Decade of Implementation of the PRACHAR Project.

BACKGROUND: Evidence on effective behavior change programming for sexual and reproductive health among married youth aged 15-24 in developing countries is lacking. To address this gap, we examined monitoring, evaluation, and special study data from the Promoting Change in Reproductive Behavior of Adolescents (PRACHAR) Project, which was implemented between 2001 and 2012 in Bihar, India, over 3 phases using 2 different implementation models (NGO- and government-led). METHODS: We conducted a synthesis of evidence from multiple PRACHAR studies to identify key findings on intervention effectiveness, scalability, and sustained effects on behaviors. Data were triangulated from quantitative population-based quasi-experimental evaluations from each project phase; the project's performance monitoring database; and qualitative studies with beneficiaries. RESULTS: PRACHAR's original comprehensive NGO-led model, which included behavior change elements and multiple overlapping communication channels (including home visits and small-group meetings), increased contraceptive use among young married couples, and these outcomes were sustained 4-8 years after project interventions ended. Several program elements were critical to the effectiveness of PRACHAR, including use of a socioecological intervention model with emphasis on behavior change efforts; use of a gender-synchronized approach that engages both male and female partners; and intensity of interventions calibrated to different moments in the life cycle of adolescents and youth. While the hybrid government-NGO model of PRACHAR implementation reached greater scale than the original NGO-led model, comparison of results suggests trade-offs in effectiveness of interventions and sustained impacts. CONCLUSIONS: A decade of learning from the PRACHAR Project in Bihar, India, finds that comprehensive programming with gender-synchronized interventions tailored to specific life stages and aimed at different levels of the socioecological model can effectively increase contraceptive use among married young people in a conservative context. Shifting from a more intensive NGO-led model to less intensive government implementation enhances scalability but may have diminished impact on reach and long-lasting effectiveness.

A Cost-Effectiveness Analysis of Community Health Workers in Mozambique.

INTRODUCTION: Community health worker (CHW) programs are a key strategy for reducing mortality and morbidity. Despite this, there is a gap in the literature on the cost and cost-effectiveness of CHW programs, especially in developing countries. METHODS: This study assessed the costs of a CHW program in Mozambique over the period 2010-2012. Incremental cost-effectiveness ratios, comparing the change in costs to the change in 3 output measures, as well as gains in efficiency were calculated over the periods 2010-2011 and 2010-2012. The results were reported both excluding and including salaries for CHWs. RESULTS: The results of the study showed total costs of the CHW program increased from US$1.34 million in 2010 to US$1.67 million in 2012. The highest incremental cost-effectiveness ratio was for the cost per beneficiary covered including CHW salaries, estimated at US$47.12 for 2010-2011. The smallest incremental cost-effectiveness ratio was for the cost per household visit not including CHW salaries, estimated at US$0.09 for 2010-2012. Adding CHW salaries would not only have increased total program costs by 362% in 2012 but also led to the largest efficiency gains in program implementation; a 56% gain in cost per output in the long run as compared with the short run after including CHW salaries. CONCLUSIONS: Our findings can be used to inform future CHW program policy both in Mozambique and in other countries, as well as provide a set of incremental cost per output measures to be used in benchmarking to other CHW costing analyses.

The Ghana vasectomy initiative: facilitating client-provider communication on no-scalpel vasectomy.

OBJECTIVE: In 2003-2004 and 2007-2008, an initiative was implemented to improve client and provider knowledge and acceptance of no-scalpel vasectomy (NSV) in Ghana. METHODS: At eight facilities, physicians were trained in NSV and staff received training in the provision of "male-friendly" services. Health promotion activities provided NSV information to prospective clients. Client-provider communication was assessed via a mystery client study (n=6). Knowledge and acceptance of NSV among potential clients were assessed with baseline and follow-up surveys (each n=200) in 2003-2004 and three follow-up panel surveys in 2008 (each n=240). RESULTS: Trained health staff exhibited improved attitudes and knowledge regarding NSV. Mystery clients reported receiving accurate, nonjudgmental NSV counseling. Awareness of NSV among panel respondents doubled from 31% to 59% in 2003-2004 and remained high (44%) in 2008. The proportion of men who would consider NSV increased from 10% to 19% in 2007-2008. NSV procedures increased three-fold from 2003 (n=26) to 2004 (n=83) and 2007 (n=18) to 2008 (n=53). CONCLUSION: Provider training in client-centered services, coupled with targeted health promotion, improved client and provider knowledge and acceptance of NSV in an African context. PRACTICE IMPLICATIONS: Complementary, sustained provider training and health promotion are needed to maintain NSV service quality and acceptance.

Family planning methods among women in a vaginal microbicide feasibility study in rural KwaZulu-Natal, South Africa

This study investigated contraceptive use among women in rural KwaZulu-Natal, South Africa. Of 866 sexually active women not intending pregnancy and screened for a microbicide feasibility study, 466 (54%) reported currently using modern contraceptives: injectables (31%), condoms (12%), sterilization (6%) and pills (4%). Multivariable logistic regression analyses revealed statistically significantly higher odds of current contraceptive use among married vs. engaged/unmarried women (aOR 1.64), multiparous vs. nulliparous (aOR 4.45) and women who completed secondary education or above vs. primary or less (aOR 1.64). Significantly lower odds of use were observed among women aged 40+ vs. age 15-19 (aOR 0.38). Age, marital status, education level and parity were associated with different contraceptive method choices. Among 195 women followed longitudinally for 9 months, contraceptive use increased significantly from 56% to 70%, largely due to increased condom use (15% to 28%). Results highlight the importance of integrating family planning and HIV/STI prevention counseling and informing promotion of further contraceptive uptake among women not intending pregnancy. (Afr J Reprod Health 2008; 12[2]:45-63)