Safe infant feeding in healthcare facilities: Assessment of infection prevention and control conditions and behaviors in India, Malawi, and Tanzania.

Infants need to receive care in environments that limit their exposure to pathogens. Inadequate water, sanitation, and hygiene (WASH) environments and suboptimal infection prevention and control practices in healthcare settings contribute to the burden of healthcare-associated infections, which are particularly high in low-income settings. Specific research is needed to understand infant feeding preparation in healthcare settings, a task involving multiple behaviors that can introduce pathogens and negatively impact health. To understand feeding preparation practices and potential risks, and to inform strategies for improvement, we assessed facility WASH environments and observed infant feeding preparation practices across 12 facilities in India, Malawi, and Tanzania serving newborn infants. Research was embedded within the Low Birthweight Infant Feeding Exploration (LIFE) observational cohort study, which documented feeding practices and growth patterns to inform feeding interventions. We assessed WASH-related environments and feeding policies of all 12 facilities involved in the LIFE study. Additionally, we used a guidance-informed tool to carry out 27 feeding preparation observations across 9 facilities, enabling assessment of 270 total behaviors. All facilities had 'improved' water and sanitation services. Only 50% had written procedures for preparing expressed breastmilk; 50% had written procedures for cleaning, drying, and storage of infant feeding implements; and 33% had written procedures for preparing infant formula. Among 270 behaviors assessed across the 27 feeding preparation observations, 46 (17.0%) practices were carried out sub-optimally, including preparers not handwashing prior to preparation, and cleaning, drying, and storing of feeding implements in ways that do not effectively prevent contamination. While further research is needed to improve assessment tools and to identify specific microbial risks of the suboptimal behaviors identified, the evidence generated is sufficient to justify investment in developing guidance and programing to strengthen infant feeding preparation practices to ensure optimal newborn health.

Implementation of the INTERGROWTH-21st gestational dating and fetal and newborn growth standards in Nairobi, Kenya: women's experiences with ultrasound and newborn assessment.

BACKGROUND: In order to make further gains in preventing newborn deaths, effective interventions are needed. Ultrasounds and newborn anthropometry are proven interventions to identify preterm birth complications, the leading cause of newborn deaths. The INTERGROWTH-21st global gestational dating and fetal and newborn growth standards prescribe optimal growth in any population. Jacaranda Health in Kenya was the first low-resource health facility to implement the standards and evaluate their feasibility and acceptability. OBJECTIVE: To capture patients' perceptions of ultrasound and newborn care before and during implementation of the INTERGROWTH-21st standards. METHODS: The study was conducted over two years before and during the introduction of the INTERGROWTH-21st standards. Fifty pregnant and/or newly delivered women were selected for in-depth interviews and focus group discussions using convenience and purposive sampling. Interviews were conducted by research assistants using semi-structured guides once in the pre-implementation phase and twice in the implementation phase. Interviews were transcribed, double-coded by two independent researchers and thematically analyzed together. Demographic information was obtained from hospital records. RESULTS: Patients reported being generally satisfied with ultrasound care when providers communicated effectively. Women reported a priority for ultrasound was that it allowed them to feel reassured. However, a clear need for better pre-screening information emerged consistently from patients. Women noted that factors facilitating their choosing to have an ultrasound included ensuring the well-being of the fetus and learning the sex. Barriers included wait times and financial constraints. Patients were generally satisfied with care using the newborn standards. CONCLUSIONS: As the INTERGROWTH-21st standards are implemented worldwide, understanding ways to facilitate implementation is critical. Increased and standardized communication about ultrasound should be provided before the procedure to increase satisfaction and uptake. Considering patient perspectives when integrating new standards or guidelines into routine clinical care will inform effective strategies in care provision, thus improving maternal and newborn health and survival.

Cross-sectional observational assessment of quality of newborn care immediately after birth in health facilities across six sub-Saharan African countries.

OBJECTIVE: To present information on the quality of newborn care services and health facility readiness to provide newborn care in 6 African countries, and to advocate for the improvement of providers' essential newborn care knowledge and skills. DESIGN: Cross-sectional observational health facility assessment. SETTING: Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and Tanzania. PARTICIPANTS: Health workers in 643 facilities. 1016 health workers were interviewed, and 2377 babies were observed in the facilities surveyed. MAIN OUTCOME MEASURES: Indicators of quality of newborn care included (1) provision of immediate essential newborn care: thermal care, hygienic cord care, and early and exclusive initiation of breast feeding; (2) actual and simulated resuscitation of asphyxiated newborn infants; and (3) knowledge of health workers on essential newborn care, including resuscitation. RESULTS: Sterile or clean cord cutting instruments, suction devices, and tables or firm surfaces for resuscitation were commonly available. 80% of newborns were immediately dried after birth and received clean cord care in most of the studied facilities. In all countries assessed, major deficiencies exist for essential newborn care supplies and equipment, as well as for health worker knowledge and performance of key routine newborn care practices, particularly for immediate skin-to-skin contact and breastfeeding initiation. Of newborns who did not cry at birth, 89% either recovered on their own or through active steps taken by the provider through resuscitation with initial stimulation and/or ventilation. 11% of newborns died. Assessment of simulated resuscitation using a NeoNatalie anatomic model showed that less than a third of providers were able to demonstrate ventilation skills correctly. CONCLUSIONS: The findings shared in this paper call attention to the critical need to improve health facility readiness to provide quality newborn care services and to ensure that service providers have the necessary equipment, supplies, knowledge and skills that are critical to save newborn lives.

Competence of health workers in emergency obstetric care: an assessment using clinical vignettes in Brong Ahafo region, Ghana.

OBJECTIVES: To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities. DESIGN: Cross-sectional Health Facility Assessment linked to population-based surveillance data. SETTING: 7 districts in Brong Ahafo region, Ghana. PARTICIPANTS: Most experienced delivery care providers in all 64 delivery facilities in the 7 districts. PRIMARY OUTCOME MEASURES: Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant. RESULTS: Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores. CONCLUSIONS: Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care. TRIAL REGISTRATION NUMBER: NCT00623337.

Innovative approaches for improving maternal and newborn health--A landscape analysis.

BACKGROUND: Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added value to health systems remains incompletely understood. This study's aim was to analyze the landscape of innovative MNH approaches and related published evidence. METHODS: Systematic literature review and descriptive analysis based on the MNH continuum of care framework and the World Health Organization health system building blocks, analyzing the range and nature of currently published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science, CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source and extracted data according to our study protocol. RESULTS: Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in which they had not been applied previously. Many aim at the direct organization and delivery of maternal and newborn health services or are primarily health workforce interventions. Innovative approaches also include health technologies, interventions based on community ownership and participation, and novel models of financing and policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health care delivery. CONCLUSIONS: Future implementation and evaluation efforts need to assess innovations' effects on health outcomes and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability. Measuring equity is an important aspect to identify and target population groups at risk of service inequity. Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their sustainable integration into health systems.

Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC. RESULTS: Marked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks. CONCLUSIONS: There are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

Psychosocial support and resilience building among health workers in Sierra Leone: interrelations between coping skills, stress levels, and interpersonal relationships.

BACKGROUND: In low- and middle-income countries, a shortage of properly trained, supervised, motivated and equitably distributed health workers often hinder the delivery of lifesaving interventions. Various health workforce bottlenecks can be addressed by tackling well-being and interpersonal relationships of health workers with their colleagues and clients. This paper uses data from the Helping Health Workers Cope (HHWC) project in a rural district of Sierra Leone to achieve three objectives. First, we describe the effect of counseling and psychosocial training on coping skills, stress levels, and provider-provider and provider-client relationships. Second, we examine whether a change in coping skills is associated with a change in relationships. Finally, we qualitatively identify key ways through which the uptake of coping skills is linked to a change in relationships. METHODS: The HHWC project was implemented from February 2012 to June 2013 in Kono district in the Eastern province of Sierra Leone, with the neighboring district of Tonkolili selected as the control site. The evaluation followed a mixed-methods approach, which included a quantitative survey, in-depth interviews and focus group discussions with health workers and clients. Mean values of the variables of interest were compared across sub-populations, and correlation analyses were performed between changes in coping skills, stress levels, and changes in relationships. RESULTS: Overall, the results demonstrate that the HHWC intervention had a positive effect on coping skills, stress levels and provider-provider and provider-client relationships. Furthermore, associations were observed between changes in coping skills and changes in relationships as well as changes in stress management skills and changes in relationships. CONCLUSIONS: Psychosocial education can have major impacts on health worker well-being and the quality of health care delivery. Integrating psychosocial counseling and training interventions into health worker pre-service and in-service curricula would allow the positive effects of the HHWC intervention to be scaled up across Sierra Leone and beyond. A roll out of the HHWC approach alongside health system strengthening initiatives could have major implications for improving health and chances of survival.

Peer-driven quality improvement among health workers and traditional birth attendants in Sierra Leone: linkages between providers' organizational skills and relationships.

BACKGROUND: Sierra Leone has among the poorest maternal and child health indicators in the world and investments in public health have been predominately to increase demand for services, with fewer initiatives targeting supply side factors that influence health workers' work environment. This paper uses data from the Quality Circles project in a rural district of Sierra Leone to achieve three objectives. First, we examine the effect of the intervention on organizational skills and relationships among coworkers as well as between health workers and traditional birth attendants. Second, we examine whether changes in organizational skills are associated with changes in relationships among and between formal and informal health providers and between health providers and clients. Third, we aim to further understand these changes through the perspectives of health workers and traditional birth attendants. METHODS: The Quality Circles project was implemented in Kailahun District in the Eastern province of Sierra Leone from August 2011 to June 2013, with adjacent Tonkolili District serving as the control site. Using a mixed-methods approach, the evaluation included a quantitative survey, in-depth interviews and focus group discussions with health workers and traditional birth attendants. Mean values of the variables of interest were compared across sub-populations, and correlation analyses were performed between changes in organizational skills and changes in relationships. RESULTS: The results demonstrate that the Quality Circles intervention had positive effects on organizational skills and relationships. Furthermore, improvements in all organizational skill variables - problem-solving, strategizing and negotiation skills - were strongly associated with a change in the overall relationship variable. CONCLUSIONS: The Quality Circles approach has the potential to support health workers to improve their organizational skills and relationships, which in turn can contribute to improving the interpersonal dimensions of the quality of care in low-resource contexts. This method brings together peers in a structured process for constructive group work and individual skill development, which are important in low-resource contexts where active participation and resourcefulness of health workers can also contribute to better health service delivery.

Quality along the continuum: a health facility assessment of intrapartum and postnatal care in Ghana.

OBJECTIVE: To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate "effective coverage" of skilled attendance in Brong Ahafo, Ghana. METHODS: We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated "effective coverage" of skilled attendance as the proportion of births in facilities of high quality. FINDINGS: Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as "low" or "substandard" for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was "low" or "substandard" in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with "high" or "highest" quality in all dimensions. CONCLUSION: Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated "effective coverage" of skilled attendance at 18%, thus revealing a large "quality gap." Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.

Quality of newborn care: a health facility assessment in rural Ghana using survey, vignette and surveillance data.

OBJECTIVE: To assess the structural capacity for, and quality of, immediate and essential newborn care (ENC) in health facilities in rural Ghana, and to link this with demand for facility deliveries and admissions. DESIGN: Health facility assessment survey and population-based surveillance data. SETTING: Seven districts in Brong Ahafo Region, Ghana. PARTICIPANTS: Heads of maternal/neonatal wards in all 64 facilities performing deliveries. MAIN OUTCOME MEASURES: Indicators include: the availability of essential infrastructure, newborn equipment and drugs, and personnel; vignette scores and adequacy of reasons given for delayed discharge of newborn babies; and prevalence of key immediate ENC practices that facilities should promote. These are matched to the percentage of babies delivered in and admitted to each type of facility. RESULTS: 70% of babies were delivered in health facilities; 56% of these and 87% of neonatal admissions were in four referral level hospitals. These had adequate infrastructure, but all lacked staff trained in ENC and some essential equipment (including incubators and bag and masks) and/or drugs. Vignette scores for care of very low-birth-weight babies were generally moderate-to-high, but only three hospitals achieved high overall scores for quality of ENC. We estimate that only 33% of babies were born in facilities capable of providing high quality, basic resuscitation as assessed by a vignette plus the presence of a bag and mask. Promotion of immediate ENC practices in facilities was also inadequate, with coverage of early initiation of breastfeeding and delayed bathing both below 50% for babies born in facilities; this represents a lost opportunity. CONCLUSIONS: Unless major gaps in ENC equipment, drugs, staff, practices and skills are addressed, strategies to increase facility utilisation will not achieve their potential to save newborn lives. TRIAL REGISTRATION: http://clinicaltrials.gov NCT00623337.