Quality of maternal and newborn hospital care in Brazil: a quality improvement cycle using the WHO assessment and quality tool.

BACKGROUND: Increasing efforts toward quality improvement (QI) are necessary in low- and middle-income countries (LMICs) to reduce maternal and perinatal mortality and morbidity and to promote respectful care. In Brazil, perinatal health indicators are below targets in several states despite universal access to perinatal services and very high rates of institutional births, indicating poor quality of care (QoC) as a key issue to be addressed. However, research efforts to develop and test QoC improvement interventions are scarce. OBJECTIVES: We assessed the effects of a 1-year comprehensive QI cycle using a World Health Organization (WHO) assessment and quality tool on maternal and newborn care at hospital level and documented QIs obtained after a 1-year comprehensive QI cycle. METHODS: Uncontrolled, unblinded, pre-post study carried out in six maternity hospitals in Pernambuco, Brazil, accounting for 29 128 live births in 2014. A standards-based and participatory approach based on a WHO quality assessment and improvement tool for maternal and neonatal care at hospital level was used. A national team of assessors supervised by international experts carried out baseline and final assessments. An action plan was developed and implemented to address key quality gaps emerging from the baseline assessment and from two supportive supervision visits. RESULTS: At baseline, hospitals presented a variety of quality gaps, the majority common to all participating centers. Gaps in case management of normal and complicated deliveries and in respectful and holistic care were predominant, in both teaching/tertiary and secondary care hospitals. After one year, several improvements were observed, particularly in respectful care during labor and at delivery, in case management of normal labor and delivery and in neonatal care. CONCLUSIONS: A systematic participatory approach based on a WHO tool produced important QIs in a relatively short time and should be considered for use for large-scale QI programs in Brazil and other LMICs. Its comprehensive, peer-to-peer and action-oriented nature and its capability to document QI over time and to build a QI culture represent important comparative advantages over other QI interventions.

Report on an international workshop on kangaroo mother care: lessons learned and a vision for the future.

BACKGROUND: Globally, complications of prematurity are the leading cause of death in children under five. Preterm infants who survive their first month of life are at greater risk for various diseases and impairments in infancy, childhood and later life, representing a heavy social and economic burden for families, communities and health and social systems. Kangaroo mother care (KMC) is recommended as a beneficial and effective intervention for improving short- and long-term preterm birth outcomes in low- and high-income settings. Nevertheless, KMC is not as widely used as it should be. The International Network on KMC runs biennial workshops and congresses to help improve the coverage and quality of KMC worldwide. This paper reports the results of the two-day workshop held in November 2016, where 92 participants from 33 countries shared experiences in a series of round tables, group work sessions and plenaries. FINDINGS: Barriers to and enablers of KMC are discussed with regard to parents, health workers and the health system. Key factors for effective implementation and uptake relate to appropriate training for health staff, adherence to protocols and the creation of a welcoming environment for families. Recommendations for planning for national programmes are made according to a six-stage change model. Resources and the cost of making progress are discussed in terms of investment, maintenance, and acceleration and scaling-up costs. KMC training requirements are presented according to three levels of care. To ensure quality KMC, key requisites are proposed for the different KMC components and for sensitive communication with caregivers. The group attending to the monitoring and evaluation of KMC at a national and subnational level highlight the lack of standard indicator definitions. Key priorities for investment include health services research, harmonisation of indicators, development of a costing tool, programming and scaling up, and the follow-up of preterm infants. CONCLUSION: It is hoped that this report will help to further scale-up and sustain KMC through a systematic approach that includes raising commitment, identifying key strategies to address the main barriers and using existing facilitators, ensuring training and quality, agreeing on indicators for monitoring and evaluation, and advancing implementation research.

Effectiveness of an action-oriented educational intervention in ensuring long term improvement of knowledge, attitudes and practices of community health workers in maternal and infant health: a randomized controlled study.

BACKGROUND: The potential role of Community Health Workers (CHWs) in improving maternal and child health outcomes, particularly in low and middle-income countries and in disadvantaged communities, is receiving increased attention. Adequate and focused training is among the key requisites for enhancing CHWs performances and research is necessary to identify effective training methods. METHODS: A randomized controlled study was designed to assess the effectiveness of a training course in improving knowledge, attitudes and practices (KAP) of CHWs regarding maternal and infant health. Seventy-eight CHWs belonging to Family Health Units in the city of Recife, Brazil were randomly allocated to intervention and control groups. The intervention group took part in a four-day interactive training course based on an action-oriented guide to perform home visits to pregnant women and their infants throughout pregnancy and infancy until 9 months of age. KAP in intervention group after training and after 1 year were compared to control group and to baseline. RESULTS: Fifty-nine CHWs completed all KAP assessments (31 in intervention and 28 in control group). Baseline characteristics were similar in both groups. At 1 year from training, the intervention group had higher overall KAP score (120.65 vs. 108.19, p <  0.001) as well as knowledge (47.45 vs. 40.54, p <  0.001), practice (53.45 vs. 49.11, p <  0.001) and attitudes scores (19.74 vs. 18.81, p = 0.047) than the control group. Moreover, at 1 year from training, the intervention group maintained significant improvements in overall KAP score (120.65 vs. 106.55, p <  0.001) as well as in knowledge (45.45 vs. 42.13, p <  0.001), and practice (53.45 vs. 45.29, p <  0.001) scores with respect to baseline. In the control group, overall KAP (106.59 vs. 108.19, p = 0.345) as well as separate knowledge, attitudes and practices scores remained unchanged. CONCLUSIONS: A four-day interactive training course on action-oriented home visits to pregnant women and infants produced a sustained improvement of CHWs' KAP and may represent a model to ensure retention of acquired competences. TRIAL REGISTRATION: RBR-9gchqr . Date registered: July 21, 2018 (Retrospectively registered).

Improving the quality of hospital care for children by supportive supervision: a cluster randomized trial, Kyrgyzstan.

OBJECTIVE: To determine whether periodic supportive supervision after a training course improved the quality of paediatric hospital care in Kyrgyzstan, where inappropriate care was common but in-hospital postnatal mortality was low. METHODS: In a cluster, randomized, parallel-group trial, 10 public hospitals were allocated to a 4-day World Health Organization (WHO) course on hospital care for children followed by periodic supportive supervision by paediatricians for 1 year, while 10 hospitals had no intervention. We assessed prospectively 10 key indicators of inappropriate paediatric case management, as indicated by WHO guidelines. The primary indicator was the combination of the three indicators: unnecessary hospitalization, increased iatrogenic risk and unnecessary painful procedures. An independent team evaluated the overall quality of care. FINDINGS: We prospectively reviewed the medical records of 4626 hospitalized children aged 2 to 60 months. In the intervention hospitals, the mean proportion of the primary indicator decreased from 46.9% (95% confidence interval, CI: 24.2 to 68.9) at baseline to 6.8% (95% CI: 1.1 to 12.1) at 1 year, but was unchanged in the control group (45.5%, 95% CI: 25.2 to 67.9, to 64.7%, 95% CI: 43.3 to 86.1). At 1 year, the risk ratio for the primary indicator in the intervention versus the control group was 0.09 (95% CI: 0.06 to 0.13). The proportions of the other nine indicators also decreased in the intervention group (P < 0.0001 for all). Overall quality of care improved significantly in intervention hospitals. CONCLUSION: Periodic supportive supervision for 1 year after a training course improved both adherence to WHO guidelines on hospital care for children and the overall quality of paediatric care.

Health services for children in western Europe.

Western European health systems are not keeping pace with changes in child health needs. Non-communicable diseases are increasingly common causes of childhood illness and death. Countries are responding to changing needs by adapting child health services in different ways and useful insights can be gained through comparison, especially because some have better outcomes, or have made more progress, than others. Although overall child health has improved throughout Europe, wide inequities remain. Health services and social and cultural determinants contribute to differences in health outcomes. Improvement of child health and reduction of suffering are achievable goals. Development of systems more responsive to evolving child health needs is likely to necessitate reconfiguring of health services as part of a whole-systems approach to improvement of health. Chronic care services and first-contact care systems are important aspects. The Swedish and Dutch experiences of development of integrated systems emphasise the importance of supportive policies backed by adequate funding. France, the UK, Italy, and Germany offer further insights into chronic care services in different health systems. First-contact care models and the outcomes they deliver are highly variable. Comparisons between systems are challenging. Important issues emerging include the organisation of first-contact models, professional training, arrangements for provision of out-of-hours services, and task-sharing between doctors and nurses. Flexible first-contact models in which child health professionals work closely together could offer a way to balance the need to provide expertise with ready access. Strategies to improve child health and health services in Europe necessitate a whole-systems approach in three interdependent systems-practice (chronic care models, first-contact care, competency standards for child health professionals), plans (child health indicator sets, reliable systems for capture and analysis of data, scale-up of child health research, anticipation of future child health needs), and policy (translation of high-level goals into actionable policies, open and transparent accountability structures, political commitment to delivery of improvements in child health and equity throughout Europe).

Promoting effective child development practices in the first year of life: does timing make a difference?

BACKGROUND: There is an increasing need for parenting programs aimed at promoting parent-child interaction. A variety of interventions have been proposed. The use of audiovisual materials for parents has been shown to be effective but limited information is available on the optimal timing for its use, particularly for new parents during the first year of life of their children. The aim of this study is to compare the effectiveness of a video administered at two different times to first-time parents in modifying parental knowledge, attitudes and intentions with regards to effective care practices. METHODS: Open randomized controlled trial carried out in a referral mother and child hospital. Eligible parents were randomly assigned to receive a video at one month (early intervention) or at seven months (late intervention) of age of their child. The video addressed four specific activities related to early child development: reading aloud to the baby, early exposure to music, promotion of early socialization for parents and for children. The primary outcome was the proportion of parents who declared that their knowledge, attitudes and intentions changed after having seen the video at one or seven months of age of the child. RESULTS: One hundred and five families were randomly allocated either to the early (53) or to the late (52) intervention group. For 99 families (52 in the early and 47 in the late group) a complete outcome evaluation was available. Parents included in the early administration group more frequently reported modifications in their knowledge of the suggested practices while parents in the late group more frequently reported a change in their attitudes. This finding was consistent across all four practices. The video was found to influence parental intentions in the great majority of interviewed parents with no significant difference between groups (82.7% and 87.2% in the early and late intervention group, respectively). CONCLUSIONS: Audiovisual materials can be an effective complementary tool in programs aimed at supporting parents, particularly those dealing with their first baby. The results provide some useful insights into the differential benefits of using audiovisual aids at different times during the first year of life of the baby. TRIAL REGISTRATION: ClinicalTrials.gov NCT02120430.

Neurodevelopmental effects of low-level prenatal mercury exposure from maternal fish consumption in a Mediterranean cohort: study rationale and design.

BACKGROUND: Mercury is a neurotoxic environmental pollutant. However, the literature on the neurodevelopmental effect of low-level prenatal mercury exposure from maternal fish intake is inconsistent. We assessed the association between prenatal mercury exposure and infant neurodevelopment in coastal areas of 4 Mediterranean countries. METHODS: This was a prospective cohort study that planned to enroll approximately 1700 mother-infant pairs. Pregnant women and their newborn children were recruited in selected hospitals of the study areas. Biological samples, including maternal hair and cord blood, were collected from mothers and children, and the concentrations of mercury and other elements were measured. Exposures to lifestyle, environmental, and social factors were assessed through questionnaires. The main outcome was child neurodevelopment at 18 months, as measured by the Bayley Scales of Infant and Toddler Development, Third Edition. CONCLUSIONS: This cohort has a number of strengths. First, mercury concentration was measured in several biological samples, which allows for a better understanding of mercury kinetics and is useful for sensitivity analyses. Therefore, we expect to be able to adjust for the potential confounding effects of lifestyle and social factors and for the effects of other elements that were measured in the biological samples. Finally, this is a multinational study and thus permits assessment of the relation between mercury and child neurodevelopment in different populations.

Associations of prenatal mercury exposure from maternal fish consumption and polyunsaturated fatty acids with child neurodevelopment: a prospective cohort study in Italy.

BACKGROUND: Mercury is a neurotoxin, and limited prenatal exposure to it can affect long-term child neurodevelopment. However, results of epidemiologic studies of such exposure have been inconsistent. We examined the association of prenatal mercury exposure from maternal fish consumption with child neurodevelopment in northern Italy. METHODS: A population-based cohort of 606 children and their mothers was studied from pregnancy to age 18 months. Mercury levels were measured in maternal hair and blood during pregnancy and in umbilical cord blood and breast milk. Levels of polyunsaturated fatty acids (PUFAs) were measured in maternal serum. Maternal and child intakes of fish were assessed by using a food frequency questionnaire. The Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) was used to evaluate child neurodevelopment. Multivariate linear regression was used to examine the association of mercury exposure with BSID-III scores, after controlling for maternal fish intake, PUFAs during pregnancy, and several other confounders. RESULTS: Mean weekly fish intake during pregnancy was less than 2 servings. Mercury concentrations in biological samples were low (mean, 1061 ng/g in hair) and moderately correlated with fish intake, particularly of carnivorous species. Maternal ω-3 PUFA concentrations were poorly correlated with fish intake. Maternal intelligence quotient (IQ) and child intake of fish were significantly associated with neurodevelopment scores. In multivariate models, the level of Hg exposure was not associated with neurodevelopmental performance at 18 months. CONCLUSIONS: In this Italian population, neurodevelopment at 18 months was associated with child intake of fresh fish and maternal IQ rather than with mercury exposure. The expected beneficial effect of maternal fish intake (from maternal ω-3 PUFAs) was not found.

Environmental inequalities among children in Europe--evaluation of scientific evidence and policy implications.

BACKGROUND: Socio-economic inequalities in the living environment are major contributing factors to health inequalities. Consequently, protecting children from undesirable environmental exposures by taking socio-economic conditions into account has been identified as a policy priority area in Europe. This review aims to evaluate the evidence on environmental inequalities among children in Europe and to discuss its policy implications. METHODS: A systematic literature search was conducted in various literature databases. Further sources for information were reviews, international reports and working documents for a WHO expert meeting on environmental inequalities in 2009. One major inclusion criterion for publications was consideration of socio-economic factors as influencing factors, not merely as confounder. RESULTS: The overall pattern based on the available fragmentary data is that children living in adverse social circumstances suffer from multiple and cumulative exposures. A low socio-economic position is associated with an increased exposure of children to traffic-related air pollution, noise, lead, environmental tobacco smoke, inadequate housing and residential conditions and less opportunities for physical activity. For most topics and exposures reviewed here there were no studies investigating the modification of the exposure-response function by socio-economic factors. Due to a variety of methodological approaches and studies on one hand and lack of data for many topics and countries on the other hand it was not possible to quantify the magnitude of environmental inequalities. CONCLUSION: Action is needed along the whole causal pathway of the social divide in environmental hazards with priority to policy measures aiming at removing socially determined differences in environmental conditions.

Progress towards the achievement of MDG4 in the Commonwealth of Independent States: uncertain data, clear priorities.

Data on under five mortality in the twelve countries of the Commonwealth of Independent States show important fluctuations over time due to variations in quality of data, definitions of neonatal deaths and methods of mortality estimation. Despite the uncertainties regarding mortality trends, the analysis of health and social information from different sources offers clues to identify priority areas and key strategic directions for accelerating the achievement of the 4th Millennium Development Goal. Neonatal deaths represent from 40% to over 50% of under five deaths in all these countries. Maternal mortality was above 50 per 100,000 in 2005, despite the good coverage with antenatal care and births assisted by skilled birth attendants. The scanty information on quality of perinatal care indicates widespread substandard care at all levels. Stunting in children under five is above 10% in ten out of twelve countries and coexists with emerging overweight. Exclusivity and duration of breastfeeding fall short of what is recommended. There are important inequalities in child and maternal mortality, malnutrition and access and use of health services within countries. Taken as a whole, the available information clearly indicates that priority should be given to improvement of the health of women in reproductive age and of the quality of perinatal care, including the establishment of reliable data collection systems. To achieve this, action will need to focus on strengthening the capacity of the health system to improve the technical content of service provision, and on improving access and appropriate use of services by the most disadvantaged groups. The involvement of other sectors will be necessary to improve reproductive health and nutrition at community level and to tackle inequity. Comparisons between countries with similar socioeconomic background but different health policies seem to indicate that gradual progression towards universal coverage with essential health care through a national health insurance system is associated with larger reduction of child mortality than troubled transition towards a privatized and unregulated health system.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 2: Review of the results of quality cycles and of factors influencing change.

BACKGROUND: Information about the use of the findings of quality assessments in maternal and neonatal (MN) care is lacking and the development of tools capable to effectively address quality gaps is a key priority. Furthermore, little is known about factors that act as barriers or facilitators to change at facility level. Based on the extensive experience made with the WHO Quality Assessment and Improvement MN (QA/QI MN) tool, an overview is provided of the improvements in quality of care (QoC) which were obtained over time and of the factors influencing change. METHODS: All documented reports on the implementation of the WHO QA/QI MN tool were searched and screened for inclusion. Reports were considered if bringing evidence from both the baseline assessment and the reassessment. Changes were considered in four domains: maternal care, neonatal care, infrastructure and policies, with reference made to WHO maternal and neonatal care standards. The observed improvements were categorized according to intensity and extent across the sample of health facilities. Factors influencing change were categorized into internal and external and further classified as barriers or facilitators. RESULTS: Changes were documented after an average period of 1.2 years from first assessment in 27 facilities belonging to 9 different countries in Central and Eastern Europe (3), Central Asia (3), sub-Saharan Africa (2) and Latin America (1). Improvements were observed in all areas of care but were greater and more frequently observed in areas related to appropriate case management and respectful care for both mothers and newborns. Although widespread across most facilities and countries, the observed improvements were not covering all the quality gaps observed at the baseline assessment nor were always sufficient to achieve standard care. Factors facilitating change as well as barriers were mainly related to the capacity of the managers and head of units to involve and motivate their staff members. CONCLUSIONS: The use of WHO QA/QI MN tool proved effective in promoting significant changes in quality of care. The review of observed improvements and of factors influencing change at facility level shows that participatory assessment tools that promote a constructive dialogue with hospital managers and staff and support them in acquiring capacity in this role are crucial to implement effective quality cycles.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 1: Review of implementation features and observed quality gaps in 25 countries.

BACKGROUND: A substantial proportion of maternal and neonatal mortality and morbidity is attributable to gaps in quality of care. A systematic, standard-based tool for quality assessment and improvement for maternal and neonatal hospital care (QA/QI MN tool) was developed in 2009 by the World Health Organization (WHO). The tool guides the assessment process along the whole continuum from admission to discharge, collects the views of the recipients of care and engages hospital mangers and staff in identifying gaps and drafting an action plan. METHODS: Publications describing use of the WHO QA/QI MN tool from 2009 to 2017 and reports retrievable from WHO or other development partners' websites were searched and considered for inclusion in the review. Only assessments of hospitals were considered. Quality gaps were classified as regarding case management in maternal care, case management in neonatal care, hospital infrastructure, hospital policies and according to severity and frequency. Quotations from women regarding key issues in effective communication, respect and dignity, emotional support and costs incurred were selected. RESULTS: In the period 2009-2017, use of the WHO QA/QI MN tool was documented in 25 countries, belonging to Central and Eastern Europe (8), Central Asia (4), Sub-Saharan Africa (11), Latin America (1) and Middle East (1). Overall, 133 hospitals were assessed. The tool allowed to identify in great detail serious quality gaps including: insufficient or incomplete adherence to recommended evidence-based procedures for normal childbirth and maternal and neonatal complications; excess of inappropriate or unnecessary interventions; insufficient infection control; failure to provide respectful care, adequate communication and emotional support to mothers and babies; poor use of information generated locally to analyse processes and outcomes. These gaps were observed in all countries. Significant differences were observed among facilities belonging to the same health systems, ie, with very similar staffing, infrastructure and equipment. CONCLUSIONS: The experience made, the largest of this kind, provides comprehensive and detailed insight into the existing quality gaps in a wide variety of settings. QI cycles at facility level should be primarily based on assessments made by multidisciplinary teams of professionals to identify the parts of the care pathways which require improvement through a participatory approach involving managers, staff and patients.

Addressing inequities in child health and development: towards social justice.

Inequities have a profound impact on the health and development of children globally. While inequities are greatest in the world's poorest countries, even in rich nations poorer children have poorer health and developmental outcomes. From birth through childhood to adolescence, morbidity, mortality, growth and development are socially determined, resulting in the most disadvantaged having the highest risk of poor health outcomes. Inequities in childhood impact across the life course. We consider four categories of actions to promote equity: strengthening individuals, strengthening communities, improving living and working conditions, and promoting healthy macropolicies. Inequities can be reduced but action to reduce inequities requires political will. The International Society for Social Paediatrics and Child Health (ISSOP) calls on governments, policy makers, paediatricians and professionals working with children and their organisations to act to reduce child health inequity as a priority. ISSOP recommends the following: governments act to reduce child poverty; ensure rights of all children to healthcare, education and welfare are protected; basic health determinants such as adequate nutrition, clean water and sanitation are available to all children. Paediatric and child health organisations ensure that their members are informed of the impact of inequities on children's well-being and across the life course; include child health inequities in curricula for professionals in training; publish policy statements relevant to their country on child health inequities; advocate for evidence-based pro-equity interventions using a child rights perspective; advocate for affordable, accessible and quality healthcare for all children; promote research to monitor inequity as well as results of interventions in their child populations. Paediatricians and child health professionals be aware of the impact of social determinants of health on children under their care; ensure their clinical services are accessible and acceptable to all children and families within the constraints of their country's health services; engage in advocacy at community and national level.

Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment.

BACKGROUND: Major concerns about the quality of basic hospital care for children have been raised in developing countries, but no formal assessment applying international standards has been done in the Commonwealth of Independent States. METHODS: We assessed 17 hospitals in Kazakhstan, the Republic of Moldova, and the Russian Federation with a generic WHO hospital assessment framework adapted for use in the WHO European region. WHO management guidelines for paediatric care in peripheral hospitals were used as standards. FINDINGS: Hospital access for children was generally good. Good health networks existed, and skilled and committed doctors cared for children. Case-fatality rates were low. However, unnecessary and lengthy hospital stays were common, and most children received excessive and ineffective treatment (in one country median number of drugs prescribed concurrently was 5, IQR 2-6). Several conditions were systematically overdiagnosed, especially neurological disease, or overinvestigated, such as acute diarrhoea. Reasons for these practices included absence of clear evidence-based clinical guidelines, regulations tying duration of admission to financial reimbursement, generalisation of disease-control methods from rare problems to common illnesses, and regulations maintaining financial and professional status of some subspecialties. Many disincentives to efficient practice existed. INTERPRETATION: To improve quality of hospital care for children in the Commonwealth of Independent States, several issues must be addressed, including: adoption of international guidelines for inpatient management; complementary guidelines for outpatient management; reforms to health regulations governing admission and discharge criteria; improvement of quality of training, availability of medical information, and systems to promote and certify quality of care.

New developments in children's environmental health in Europe.

Important developments have taken place in Europe regarding children's environmental health (CEH) over the last few years. In 1999 the Third Ministerial Conference on Environment and Health identified CEH as a priority area and started a process of scientific review and policy development that culminated at the Fourth Ministerial Conference held in Budapest in June 2004 with the adoption of the Children's Environment and Health Action Plan for Europe (CEHAPE). The rationale of the CEHAPE is based on a thorough review of the scientific evidence on CEH and on a study that quantified for the first time the burden of disease related to the main environmental exposures of children and adolescents in Europe. The Action Plan suggests actions and policies to achieve the four main priority goals: clean air, safe water, chemical and physical agents, and injuries. Over the same period, the European Commission (EC) has strengthened its focus on environment and health issues, has supported research on CEH, and has developed a proposal for a new EU regulatory framework for chemicals that has clear implications for children and for the reproductive period. The proposed new system, called REACH (Registration, Evaluation, and Authorization of Chemicals), currently under examination by the European Parliament, aims at reducing risks to human health and improvement of environmental quality through the better and earlier identification of the properties of chemical substances. The EC also adopted policies and action plans that are very relevant to children, such as the EU European Environment and Health Strategy, referred to as the SCALE initiative (Science, Children, Awareness, Legislation, Evaluation), and the 2004-2010 Environment and Health Action Plan.