A practice improvement package at scale to improve management of birth asphyxia in Rwanda: a before-after mixed methods evaluation.

BACKGROUND: Helping Babies Breathe (HBB) is a competency-based educational method for an evidence-based protocol to manage birth asphyxia in low resource settings. HBB has been shown to improve health worker skills and neonatal outcomes, but studies have documented problems with skills retention and little evidence of effectiveness at large scale in routine practice. This study examined the effect of complementing provider training with clinical mentorship and quality improvement as outlined in the second edition HBB materials. This "system-oriented" approach was implemented in all public health facilities (n = 172) in ten districts in Rwanda from 2015 to 2018. METHODS: A before-after mixed methods study assessed changes in provider skills and neonatal outcomes related to birth asphyxia. Mentee knowledge and skills were assessed with HBB objective structured clinical exam (OSCE) B pre and post training and during mentorship visits up to 1 year afterward. The study team extracted health outcome data across the entirety of intervention districts and conducted interviews to gather perspectives of providers and managers on the approach. RESULTS: Nearly 40 % (n = 772) of health workers in maternity units directly received mentorship. Of the mentees who received two or more visits (n = 456), 60 % demonstrated competence (received > 80% score on OSCE B) on the first mentorship visit, and 100% by the sixth. In a subset of 220 health workers followed for an average of 5 months after demonstrating competence, 98% maintained or improved their score. Three of the tracked neonatal health outcomes improved across the ten districts and the fourth just missed statistical significance: neonatal admissions due to asphyxia (37% reduction); fresh stillbirths (27% reduction); neonatal deaths due to asphyxia (13% reduction); and death within 30 min of birth (19% reduction, p = 0.06). Health workers expressed satisfaction with the clinical mentorship approach, noting improvements in confidence, patient flow within the maternity, and data use for decision-making. CONCLUSIONS: Framing management of birth asphyxia within a larger quality improvement approach appears to contribute to success at scale. Clinical mentorship emerged as a critical element. The specific effect of individual components of the approach on provider skills and health outcomes requires further investigation.

Do male engagement and couples' communication influence maternal health care-seeking? Findings from a household survey in Mozambique.

BACKGROUND: This study explored effects of couples' communication and male participation in birth preparedness and complication readiness (BPCR) on delivery in a health facility ("institutional delivery"). A cross-sectional, baseline household survey was conducted in November 2016 prior to an integrated maternal and child health project in Nampula and Sofala Provinces in Mozambique. METHODS: The study used the Knowledge, Practices and Coverage survey tool, a condensed version of the Demographic and Health Survey and other tools. The sample included 1422 women. Multivariable logit regression models tested the association of institutional delivery with couples' communication and four elements of BPCR both with and without male partners: 1) saving money, 2) arranging transport, 3) choosing a birth companion, and 4) choosing a delivery site; controlling for partners' attendance in antenatal care and social and demographic determinants (education, wealth, urban/rural location, and province). RESULTS: The odds that women would deliver in a health facility were 46% greater (adjusted odds ratio (aOR) = 1.46, 95% confidence interval (CI) = 1.02-2.10, p = 0.04) amongst women who discussed family planning with their partners than those who did not. Approximately half of this effect was mediated through BPCR. When a woman arranged transport on her own, there was no significant increase in institutional delivery, but with partner involvement, there was a larger, significant association (aOR = 4.31, 2.64-7.02). Similarly, when a woman chose a delivery site on her own, there was no significant association with institutional delivery (aOR 1.52,0.81-2.83), but with her partner, there was a larger and significant association (aOR 1.98, 1.16-3.36). Neither saving money nor choosing a birth companion showed a significant association with institutional delivery-with or without partner involvement. The odds of delivering in a facility were 28% less amongst poor women whose partners did not participate in BPCR than wealthy women, but when partners helped choose a place of delivery and arrange transport, this gap was nearly eliminated. CONCLUSIONS: Our findings add to growing global evidence that men play an important role in improving maternal and newborn health, particularly through BPCR, and that couples' communication is a key approach for promoting high-impact health behaviors.

Screening and management of pre-eclampsia and eclampsia in antenatal and labor and delivery services: findings from cross-sectional observation studies in six sub-Saharan African countries.

BACKGROUND: Preeclampsia and eclampsia (PE/E) are major contributors to maternal and neonatal deaths in developing countries, associated with 10-15% of direct maternal deaths and nearly a quarter of stillbirths and newborn deaths, many of which are preventable with improved care. We present results related to WHO-recommended interventions for screening and management of PE/E during antenatal care (ANC) and labor and delivery (L & D) from a study conducted in six sub-Saharan African countries. METHODS: From 2010 to 2012, cross-sectional studies which directly observed provision of ANC and L & D services in six sub-Saharan African countries were conducted. Results from 643 health facilities of different levels in Ethiopia (n = 19), Kenya (n = 509), Madagascar (n = 36), Mozambique (n = 46), Rwanda (n = 72), and Tanzania (n = 52), were combined for this analysis. While studies were sampled separately in each country, all used standardized observation checklists and inventory assessment tools. RESULTS: 2920 women receiving ANC and 2689 women in L & D were observed. Thirty-nine percent of ANC clients were asked about PE/E danger signs, and 68% had their blood pressure (BP) taken correctly (range 48-96%). Roughly half (46%) underwent testing for proteinuria. Twenty-three percent of women in L & D were asked about PE/E danger signs (range 11-34%); 77% had their BP checked upon admission (range 59-85%); and 6% had testing for proteinuria. Twenty-five cases of severe PE/E were observed: magnesium sulfate (MgSO4) was used in 15, not used in 5, and for 5 use was unknown. The availability of MgSO4 in L & D varied from 16% in Ethiopia to 100% in Mozambique. CONCLUSIONS: Observed ANC consultations and L & D cases showed low use of WHO-recommended practices for PE/E screening and management. Availability of MgSO4 was low in multiple countries, though it was on the essential drug list of all surveyed countries. Country programs are encouraged to address gaps in screening and management of PE/E in ANC and L & D to contribute to lower maternal and perinatal mortality.

Facility-based active management of the third stage of labour: assessment of quality in six countries in sub-Saharan Africa.

OBJECTIVE: To assess the quality of facility-based active management of the third stage of labour in Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and the United Republic of Tanzania. METHODS: Between 2009 and 2012, using a cross-sectional design, 2317 women in 390 health facilities were directly observed during the third stage of labour. Observers recorded the use of uterotonic medicines, controlled cord traction and uterine massage. Facility infrastructure and supplies needed for active management were audited and relevant guidelines reviewed. FINDINGS: Most (94%; 2173) of the women observed were given oxytocin (2043) or another uterotonic (130). The frequencies of controlled cord traction and uterine massage and the timing of uterotonic administration showed considerable between-country variation. Of the women given a uterotonic, 1640 (76%) received it within three minutes of the birth. Uterotonics and related supplies were generally available onsite. Although all of the study countries had national policies and/or guidelines that supported the active management of the third stage of labour, the presence of guidelines in facilities varied across countries and only 377 (36%) of 1037 investigated providers had received relevant training in the previous three years. CONCLUSION: In the study countries, quality and coverage of the active management of the third stage of labour were high. However, to improve active management, there needs to be more research on optimizing the timing of uterotonic administration. Training on the use of new clinical guidelines and implementation research on the best methods to update such training are also needed.

Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa.

BACKGROUND: Poor quality of care at health facilities is a barrier to pregnant women and their families accessing skilled care. Increasing evidence from low resource countries suggests care women receive during labor and childbirth is sometimes rude, disrespectful, abusive, and not responsive to their needs. However, little is known about how frequently women experience these behaviors. This study is one of the first to report prevalence of respectful maternity care and disrespectful and abusive behavior at facilities in multiple low resource countries. METHODS: Structured, standardized clinical observation checklists were used to directly observe quality of care at facilities in five countries: Ethiopia, Kenya, Madagascar, Rwanda, and the United Republic of Tanzania. Respectful care was represented by 10 items describing actions the provider should take to ensure the client was informed and able to make choices about her care, and that her dignity and privacy were respected. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Clinical observers' open-ended comments were also analyzed to identify examples of disrespect and abuse. RESULTS: A total of 2164 labor and delivery observations were conducted at hospitals and health centers. Encouragingly, women overall were treated with dignity and in a supportive manner by providers, but many women experienced poor interactions with providers and were not well-informed about their care. Both physical and verbal abuse of women were observed during the study. The most frequently mentioned form of disrespect and abuse in the open-ended comments was abandonment and neglect. CONCLUSIONS: Efforts to increase use of facility-based maternity care in low income countries are unlikely to achieve desired gains if there is no improvement in quality of care provided, especially elements of respectful care. This analysis identified insufficient communication and information sharing by providers as well as delays in care and abandonment of laboring women as deficiencies in respectful care. Failure to adopt a patient-centered approach and a lack of health system resources are contributing structural factors. Further research is needed to understand these barriers and develop effective interventions to promote respectful care in this context.

Evaluation of the effectiveness of care groups in expanding population coverage of Key child survival interventions and reducing under-5 mortality: a comparative analysis using the lives saved tool (LiST).

BACKGROUND: Globally, less than half of Countdown Countries will achieve the Millennium Development Goal of reducing the under-5 mortality rate (U5MR) by two-thirds by 2015. There is growing interest in community-based delivery mechanisms to help accelerate progress. One promising approach is the use of a form of participatory mothers' groups, called Care Groups, for expanding coverage of key child survival interventions, an essential feature for achieving mortality impact. METHODS: In this study we evaluate the effectiveness of Care Group projects conducted in 5 countries in Africa and Asia in comparison to other United States Agency for International Development-funded child survival projects in terms of increasing coverage of key child survival interventions and reducing U5MR (estimated using the Lives Saved Tool, or LiST). Ten Care Group and nine non-Care Group projects were matched by country and year of program implementation. RESULTS: In Care Group project areas, coverage increases were more than double those in non-Care Group project areas for key child survival interventions (p = 0.0007). The mean annual percent change in U5MR modelled in LiST for the Care Group and non-Care Group projects was -4.80% and -3.14%, respectively (p = 0.09). CONCLUSIONS: Our findings suggest that Care Groups may provide a promising approach to significantly increase key child survival interventions and increase reductions in U5MR. Evaluations of child survival programs should be a top priority in global health to build a greater evidence base for effective approaches for program delivery.

Uterotonic use immediately following birth: using a novel methodology to estimate population coverage in four countries.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in developing countries. While incidence of PPH can be dramatically reduced by uterotonic use immediately following birth (UUIFB) in both community and facility settings, national coverage estimates are rare. Most national health systems have no indicator to track this, and community-based measurements are even more scarce. To fill this information gap, a methodology for estimating national coverage for UUIFB was developed and piloted in four settings. METHODS: The rapid estimation methodology consisted of convening a group of national technical experts and using the Delphi method to come to consensus on key data elements that were applied to a simple algorithm, generating a non-precise national estimate of coverage of UUIFB. Data elements needed for the calculation were the distribution of births by location and estimates of UUIFB in each of those settings, adjusted to take account of stockout rates and potency of uterotonics. This exercise was conducted in 2013 in Mozambique, Tanzania, the state of Jharkhand in India, and Yemen. RESULTS: Available data showed that deliveries in public health facilities account for approximately half of births in Mozambique and Tanzania, 16% in Jharkhand and 24% of births in Yemen. Significant proportions of births occur in private facilities in Jharkhand and faith-based facilities in Tanzania. Estimated uterotonic use for facility births ranged from 70 to 100%. Uterotonics are not used routinely for PPH prevention at home births in any of the settings. National UUIFB coverage estimates of all births were 43% in Mozambique, 40% in Tanzania, 44% in Jharkhand, and 14% in Yemen. CONCLUSION: This methodology for estimating coverage of UUIFB was found to be feasible and acceptable. While the exercise produces imprecise estimates whose validity cannot be assessed objectively in the absence of a gold standard estimate, stakeholders felt they were accurate enough to be actionable. The exercise highlighted information and practice gaps and promoted discussion on ways to improve UUIFB measurement and coverage, particularly of home births. Further follow up is needed to verify actions taken. The methodology produces useful data to help accelerate efforts to reduce maternal mortality.

Comparing estimates of child mortality reduction modelled in LiST with pregnancy history survey data for a community-based NGO project in Mozambique.

BACKGROUND: There is a growing body of evidence that integrated packages of community-based interventions, a form of programming often implemented by NGOs, can have substantial child mortality impact. More countries may be able to meet Millennium Development Goal (MDG) 4 targets by leveraging such programming. Analysis of the mortality effect of this type of programming is hampered by the cost and complexity of direct mortality measurement. The Lives Saved Tool (LiST) produces an estimate of mortality reduction by modelling the mortality effect of changes in population coverage of individual child health interventions. However, few studies to date have compared the LiST estimates of mortality reduction with those produced by direct measurement. METHODS: Using results of a recent review of evidence for community-based child health programming, a search was conducted for NGO child health projects implementing community-based interventions that had independently verified child mortality reduction estimates, as well as population coverage data for modelling in LiST. One child survival project fit inclusion criteria. Subsequent searches of the USAID Development Experience Clearinghouse and Child Survival Grants databases and interviews of staff from NGOs identified no additional projects. Eight coverage indicators, covering all the project's technical interventions were modelled in LiST, along with indicator values for most other non-project interventions in LiST, mainly from DHS data from 1997 and 2003. RESULTS: The project studied was implemented by World Relief from 1999 to 2003 in Gaza Province, Mozambique. An independent evaluation collecting pregnancy history data estimated that under-five mortality declined 37% and infant mortality 48%. Using project-collected coverage data, LiST produced estimates of 39% and 34% decline, respectively. CONCLUSIONS: LiST gives reasonably accurate estimates of infant and child mortality decline in an area where a package of community-based interventions was implemented. This and other validation exercises support use of LiST as an aid for program planning to tailor packages of community-based interventions to the epidemiological context and for project evaluation. Such targeted planning and assessments will be useful to accelerate progress in reaching MDG4 targets.

Systematic review of Doppler for detecting intrapartum fetal heart abnormalities and measuring perinatal mortality in low- and middle-income countries.

BACKGROUND: Using Doppler to improve detection of intrapartum fetal heart rate (FHR) abnormalities coupled with appropriate, timely intrapartum care in low- and middle-income countries (LMIC) can save lives. OBJECTIVE: To review studies using Doppler to improve detection of intrapartum FHR abnormalities and intrapartum care quality in LMIC health facilities. SEARCH STRATEGY: PubMed, Web of Science, Embase, Global Health, and Scopus were searched from inception to October 2018 by combining terms for Doppler, perinatal outcomes, and FHR monitoring. SELECTION CRITERIA: Selected studies compared Doppler and Pinard stethoscope for detecting/monitoring intrapartum FHR, or described provider and maternal preferences for FHR monitoring in LMIC settings. DATA COLLECTION AND ANALYSIS: Two team members independently screened and collected data. Risk of bias was assessed by Cochrane EPOC criteria. RESULTS: Eleven studies from eight countries were included. Doppler was superior at detecting abnormal intrapartum FHR as compared with Pinard stethoscope, but was not associated with improved perinatal outcomes. Using Doppler on admission helped to accurately measure perinatal deaths occurring after facility admission. CONCLUSION: Studies and program learning are needed to translate improved detection of FHR abnormalities to improved case management in LMICs. Doppler should be used to calculate a facility indicator of intrapartum care quality. PROSPERO registration: CRD42019121924.

Measuring sustainability as a programming tool for health sector investments: report from a pilot sustainability assessment in five Nepalese health districts.

Sustainability is a critical determinant of scale and impact of health sector development assistance programs. Working with USAID/Nepal implementing partners, we adapted a sustainability assessment framework to help USAID test how an evaluation tool could inform its health portfolio management. The essential first process step was to define the boundaries of the local system being examined. This local system-the unit of analysis of the study-was defined as the health district.We developed a standardized set of assessment tools to measure 53 indicators. Data collection was carried out over 4 weeks by a Nepalese agency. Scaling and combining indicators into six component indices provided a map of progress toward sustainable maternal, child, health, and family planning results for the five districts included in this pilot study, ranked from "no sustainability" to "beginning of sustainability."We conclude that systematic application of the Sustainability Framework could improve the health sector investment decisions of development agencies. It could also give districts an information base on which to build autonomy and accountability. The ability to form and test hypotheses about the sustainability of outcomes under various funding strategies-made possible by this approach-will be a prerequisite for more efficiently meeting the global health agenda.

Tracking facility-based perinatal deaths in Tanzania: Results from an indicator validation assessment.

BACKGROUND: Globally, an estimated 2.7 million babies die in the neonatal period annually, and of these, about 0.7 million die from intrapartum-related events. In Tanzania 51,000 newborn deaths and 43,000 stillbirths occur every year. Approximately two-thirds of these deaths could be potentially prevented with improvements in intrapartum and neonatal care. Routine measurement of fetal intrapartum deaths and newborn deaths that occur in health facilities can help to evaluate efforts to improve the quality of intrapartum care to save lives. However, few examples exist of indicators on perinatal mortality in the facility setting that are readily available through health management information systems (HMIS). METHODS: From November 2016 to April 2017, health providers at 10 government health facilities in Kagera region, Tanzania, underwent refresher training on perinatal death classification and training on the use of handheld Doppler devices to assess fetal heart rate upon admission to maternity services. Doppler devices were provided to maternity services at the study facilities. We assessed the validity of an indicator to measure facility-based pre-discharge perinatal mortality by comparing perinatal outcomes extracted from the HMIS maternity registers to a gold standard perinatal death audit. RESULTS: Sensitivity and specificity of the HMIS neonatal outcomes to predict gold standard audit outcomes were both over 98% based on analysis of 128 HMIS-gold standard audit pairs. After this validation, we calculated facility perinatal mortality indicator from HMIS data using fresh stillbirths and pre-discharge newborn death as the numerator and women admitted in labor with positive fetal heart tones as the denominator. Further emphasizing the validity of the indicator, FPM values aligned with expected mortality by facility level, with lowest rates in health centers (range 0.3%- 0.5%), compared to district hospitals (1.5%- 2.9%) and the regional hospital (4.2%). CONCLUSION: This facility perinatal mortality indicator provides an important health outcome measure that facilities can use to monitor levels of perinatal deaths occurring in the facility and evaluate impact of quality of care improvement activities.

Care Groups II: A Summary of the Child Survival Outcomes Achieved Using Volunteer Community Health Workers in Resource-Constrained Settings.

The Care Group approach, described in detail in a companion paper in this journal, uses volunteers to convey health promotion messages to their neighbors. This article summarizes the available evidence on the effectiveness of the Care Group approach, drawing on articles published in the peer-reviewed literature as well as data from unpublished but publicly available project evaluations and summary analyses of these evaluations. When implemented by strong international NGOs with adequate funding, Care Groups have been remarkably effective in increasing population coverage of key child survival interventions. There is strong evidence that Care Groups can reduce childhood undernutrition and reduce the prevalence of diarrhea. Finally, evidence from multiple sources, comprising independent assessments of mortality impact, vital events collected by Care Group Volunteers themselves, and analyses using the Lives Saved Tool (LiST), that Care Groups are effective in reducing under-5 mortality. For example, the average decline in under-5 mortality, estimated using LiST, among 8 Care Group projects was 32%. In comparison, among 12 non-Care Group child survival projects, the under-5 mortality declined, on average, by an estimated 11%. Care Group projects cost in the range of US$3-$8 per beneficiary per year. The cost per life saved is in the range of $441-$3,773, and the cost per disability-adjusted life year (DALY) averted is in the range of $15-$126. The Care Group approach, when implemented as described, appears to be highly cost-effective based on internationally accepted criteria. Care Groups represent an important and promising innovative, low-cost approach to increasing the coverage of key child survival interventions in high-mortality, resource-constrained settings. Next steps include further specifying the adjustments needed in government health systems to successfully incorporate the Care Group approach, testing the feasibility of these adjustments and of the effectiveness of Care Groups in pilot programs in government health systems, and finally assessing effectiveness at scale under routine field conditions in government health programs.

Scaling up high-impact interventions: how is it done?

Building upon the World Health Organization's ExpandNet framework, 12 key principles of scale-up have emerged from the implementation of maternal and newborn health interventions. These principles are illustrated by three case studies of scale up of high-impact interventions: the Helping Babies Breathe initiative; pre-service midwifery education in Afghanistan; and advanced distribution of misoprostol for self-administration at home births to prevent postpartum hemorrhage. Program planners who seek to scale a maternal and/or newborn health intervention must ensure that: the necessary evidence and mechanisms for local ownership for the intervention are well-established; the intervention is as simple and cost-effective as possible; and the implementers and beneficiaries of the intervention are working in tandem to build institutional capacity at all levels and in consideration of all perspectives.

Community-based intervention packages facilitated by NGOs demonstrate plausible evidence for child mortality impact.

INTRODUCTION: Evidence exists that community-based intervention packages can have substantial child and newborn mortality impact, and may help more countries meet Millennium Development Goal 4 (MDG 4) targets. A non-governmental organization (NGO) project using such programming in Mozambique documented an annual decline in under-five mortality rate (U5MR) of 9.3% in a province in which Demographic and Health Survey (DHS) data showed a 4.2% U5MR decline during the same period. To test the generalizability of this finding, the same analysis was applied to a group of projects funded by the US Agency for International Development. Projects supported implementation of community-based intervention packages aimed at increasing use of health services while improving preventive and home-care practices for children under five. METHODS: All projects collect baseline and endline population coverage data for key child health interventions. Twelve projects fitted the inclusion criteria. U5MR decline was estimated by modelling these coverage changes in the Lives Saved Tool (LiST) and comparing with concurrent measured DHS mortality data. RESULTS: Average coverage changes for all interventions exceeded average concurrent trends. When population coverage changes were modelled in LiST, they were estimated to give a child mortality improvement in the project area that exceeded concurrent secular trend in the subnational DHS region in 11 of 12 cases. The average improvement in modelled U5MR (5.8%) was more than twice the concurrent directly measured average decline (2.5%). CONCLUSIONS: NGO projects implementing community-based intervention packages appear to be effective in reducing child mortality in diverse settings. There is plausible evidence that they raised coverage for a variety of high-impact interventions and improved U5MR by more than twice the concurrent secular trend. All projects used community-based strategies that achieved frequent interpersonal contact for health behaviour change. Further study of the effectiveness and scalability of similar packages should be part of the effort to accelerate progress towards MDG 4.

Measuring coverage in MNCH: testing the validity of women's self-report of key maternal and newborn health interventions during the peripartum period in Mozambique.

BACKGROUND: As low-income countries strive to meet targets for Millennium Development Goals 4 and 5, there is growing need to track coverage and quality of high-impact peripartum interventions. At present, nationally representative household surveys conducted in low-income settings primarily measure contact with the health system, shedding little light on content or quality of care. The objective of this study is to validate the ability of women in Mozambique to report on facility-based care they and their newborns received during labor and one hour postpartum. METHODS AND FINDINGS: The study involved household interviews with women in Mozambique whose births were observed eight to ten months previously as part of a survey of the quality of maternal and newborn care at government health facilities. Of 487 women whose births were observed and who agreed to a follow-up interview, 304 were interviewed (62.4%). The validity of 34 indicators was tested using two measures: area under receiver operator characteristic curve (AUC) and inflation factor (IF); 27 indicators had sufficient numbers for robust analysis, of which four met acceptability criteria for both (AUC >0.6 and 0.75