Uptake of, barriers and enablers to the utilization of postnatal care services in Thyolo, Malawi.

BACKGROUND: Postnatal care (PNC) ensures early assessments for danger signs during the postpartum period and is to be provided within 24 h of birth, 48-72 h, 7-14 days, and six weeks after birth. This study assessed the uptake of and the barriers and facilitators to receiving PNC care among mothers and babies. METHODS: A concurrent mixed-method study employing a retrospective register review and a qualitative descriptive study was conducted in Thyolo from July to December 2020. Postnatal registers of 2019 were reviewed to estimate the proportion of mothers and newborns that received PNC respectively. Focus Group Discussions (FGDs) among postnatal mothers, men, health care workers, and elderly women and in-depth interviews with midwives, and key health care workers were conducted to explore the barriers and enablers to PNC. Observations of the services that mothers and babies received within 24 h of birth, at 48-72 h, 7-14 days, and six weeks after birth were conducted. Descriptive statistics were tabulated for the quantitative data using Stata while the qualitative data were managed using NVivo and analysed following a thematic approach. RESULTS: The uptake of PNC services was at 90.5%, 30.2%, and 6.1% among women and 96.5%, 78.8%, and 13.7% among babies within 48 h of birth, 3 to 7 and 8 to 42 days respectively. The barriers to PNC services included the absence of a baby or mother, limited understanding of PNC services, lack of male involvement, and economic challenges. Cultural and religious beliefs, advice from community members, community activities, distance, lack of resources, and poor attitude of health care workers also impeded the utilisation of PNC services. The enablers included the mother's level of education, awareness of the services, economic resources, community-based health support, adequacy and attitude of health workers, seeking treatment for other conditions, and other clinic activities. CONCLUSION: Optimisation of uptake and utilization of PNC services for mothers and neonates will require the involvement of all stakeholders. The success of PNC services lies in the communities, health services, and mothers understanding the relevance, time points, and services that need to be delivered to create demand for the services. There is a need to assess the contextual factors for a better response in improving the uptake of PNC services and in turn inform the development of strategies for optimizing the uptake of PNC services.

Exploring and prioritising strategies for improving uptake of postnatal care services in Thyolo, Malawi: A qualitative study.

Although postnatal care services form a critical component of the cascade of care in maternal, newborn, and child health the uptake of these services has remained low worldwide. This study explored and prioritised the strategies for optimising the uptake of postnatal care (PNC) services in Malawi. A qualitative descriptive study followed by nominal group techniques was conducted at three health facilities in Malawi from July to December 2020 and in October 2021. We conducted focus group discussions among postnatal mothers, fathers, healthcare workers, elderly women, and grandmothers. We conducted in-depth interviews with midwives and key health managers. Nominal group techniques were used to prioritise the main strategies for the provision of PNC. The demand strategies include appointment date reminders, provision of free health passport books, community awareness campaigns, and involvement of men in the services. The supply strategies included training health providers, improving clinic operations: task-shifting and hours of operation, having infrastructure for the services, and linkage to other services. Having services delivered near end-user residences was a crosscutting strategy. Refresher training and improvement in the clinic operations especially on hours of operation, appointment date reminders, and linkage to care were the prioritised strategies. There is a need to use acceptable and contextualised strategies to optimise the uptake and delivery of postnatal care services. Educating the healthcare workers and the community on postnatal services is key to increasing the demand and supply of the services.

Engaging the private sector to deliver quality maternal and newborn health services for universal health coverage: lessons from policy dialogues.

The private health sector is becoming increasingly important in discussions on improving the quality of care for maternal and newborn health (MNH). Yet information rarely addresses what engaging the private sector for MNH means and how to do it. In 2019, the Network for Improving Quality of Care for Maternal, Newborn and Child Health (the Network) initiated exploratory research to better understand how to ensure that the private sector delivers quality care and what the public sector must do to facilitate and sustain this process. This article details the approach and lessons learnt from two Network countries, Ghana and Nigeria, where teams explored the mechanisms for engaging the private sector in delivering MNH services with quality. The situational analyses in Ghana and Nigeria revealed challenges in engaging the private sector, including lack of accurate data, mistrust and an unlevel playing field. Challenging market conditions hindered a greater private sector role in delivering quality MNH services. Based on these analyses, participants at multistakeholder workshops recommended actions addressing policy/administration, regulation and service delivery. The findings from this research help strengthen the evidence base on engaging the private sector to deliver quality MNH services and show that this likely requires engagement with broader health systems factors. In recognition of this need for a balanced approach and the new WHO private sector strategy, the WHO has updated the tools and process for countries interested in conducting this research. The Nigerian Ministry of Health is stewarding additional policy dialogues to further engage the private sector.

Implementing maternal and newborn health quality of care standards in healthcare facilities to improve the adoption of respectful maternity care in Bangladesh, Ghana and Tanzania: a controlled before and after study.

INTRODUCTION: Many women worldwide cannot access respectful maternity care (RMC). We assessed the effect of implementing maternal and newborn health (MNH) quality of care standards on RMC measures. METHODS: We used a facility-based controlled before and after design in 43 healthcare facilities in Bangladesh, Ghana and Tanzania. Interviews with women and health workers and observations of labour and childbirth were used for data collection. We estimated difference-in-differences to compare changes in RMC measures over time between groups. RESULTS: 1827 women and 818 health workers were interviewed, and 1512 observations were performed. In Bangladesh, MNH quality of care standards reduced physical abuse (DiD -5.2;-9.0 to -1.4). The standards increased RMC training (DiD 59.0; 33.4 to 84.6) and the availability of policies and procedures for both addressing patient concerns (DiD 46.0; 4.7 to 87.4) and identifying/reporting abuse (DiD 45.9; 19.9 to 71.8). The control facilities showed greater improvements in communicating the delivery plan (DiD -33.8; -62.9 to -4.6). Other measures improved in both groups, except for satisfaction with hygiene. In Ghana, the intervention improved women's experiences. Providers allowed women to ask questions and express concerns (DiD 37.5; 5.9 to 69.0), considered concerns (DiD 14.9; 4.9 to 24.9), reduced verbal abuse (DiD -8.0; -12.1 to -3.8) and physical abuse (DiD -5.2; -11.4 to -0.9). More women reported they would choose the facility for another delivery (DiD 17.5; 5.5 to 29.4). In Tanzania, women in the intervention facilities reported improvements in privacy (DiD 24.2; 0.2 to 48.3). No other significant differences were observed due to improvements in both groups. CONCLUSION: Institutionalising care standards and creating an enabling environment for quality MNH care is feasible in low and middle-income countries and may facilitate the adoption of RMC.

Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study.

INTRODUCTION: Facility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes. METHODS: We conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO's Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for 'comparison'. We interviewed 43 facility managers and 818 providers, observed 1516 client-provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality. RESULTS: EMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems. CONCLUSION: Institutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.