Effect of the data-informed platform for health intervention on the culture of data use for decision-making among district health office staff in North Shewa Zone, Ethiopia: a cluster-randomised controlled trial.

BACKGROUND: Similar to other low and middle-income countries, Ethiopia faces limitations in using local health data for decision-making.We aimed to assess the effect of an intervention, namely the data-informed platform for health, on the culture of data-based decision making as perceived by district health office staff in Ethiopia's North Shewa Zone. METHODS: By designating district health offices as 'clusters', a cluster-randomised controlled trial was implemented. Out of a total of 24 districts in the zone, 12 districts were allocated to intervention arm and the other 12 in the control group arms. In the intervention arm district health office teams were supported in four-monthly cycles of data-driven decision-making over 20 months. This support included: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritizing; and (e) a consultative process to develop, commit to, and follow up on action plans. To measure the culture of data use for decision-making in both intervention and control arms, we interviewed 120 health management staff (5 per district office). Using a Likert scale based standard Performance of Routine Information System Management tool, the information is categorized into six domains:- evidence-based decision making, emphasis on data quality, use of information, problem solving, responsibility and motivation. After converting the Likert scale responses into percentiles, difference-in-difference methods were applied to estimate the net effect of the intervention. In intervention districts, analysis of variance was used to summarize variation by staff designation. RESULTS: The overall decision-making culture in health management staff showed a net improvement of 13% points (95% C.I:9, 18) in intervention districts. The net effect of each of the six domains in turn was an 11% point increase (95% C.I:7, 15) on culture of evidence based decision making, a 16% point increase (95% C.I:8, 24) on emphasis on data quality, a 20% point increase (95% C.I:12, 28) on use of information, a 21% point increase (95% C.I:13, 29) on problem solving, and a 10% point increase (95% C.I:4, 16) on responsibility and motivation. In terms of variation by staff designation within intervention districts, statistically significant differences were observed only for problem solving and responsibility. CONCLUSION: The data-informed platform for health strategy resulted in a measurable improvement in data use and structured decision-making culture by using existing systems, namely the Performance Monitoring Team meetings. The intervention supported district health offices in identifying and solving problems through a structured process. After further research, DIPH intervention could also be applied to other health administration and facility levels. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT05310682, Dated 25/03/ 2022.

Socioeconomic inequity in coverage and quality of maternal postnatal care in Ethiopia.

OBJECTIVE: High-quality postnatal care is vital for improving maternal health. This study examined the relationship between household socioeconomic status and both coverage and quality of postnatal care in Ethiopia. METHOD: Cross-sectional household survey data were collected in October-November 2013 from 12 zones in 4 regions of Ethiopia. Women reporting a live birth in the 3-24 months prior to the survey were interviewed about the care they received before, during and after delivery and their demographic characteristics. Using mixed effect logistic and linear regression, the associations between household socioeconomic status and receiving postnatal care, location of postnatal care (health facility vs. non-health facility), cadre of person providing care and the number of seven key services (including physical checks and advice) provided at a postnatal visit, were estimated. RESULTS: A total of 16% (358/2189) of women interviewed reported receiving at least one postnatal care visit within 6 weeks of delivery. Receiving a postnatal care visit was strongly associated with socioeconomic status with women from the highest socioeconomic group having twice the odds of receiving postnatal care compared to women in the poorest quintile (OR [95% CI]: 1.98 [1.29, 3.05]). For each increasing socioeconomic status quintile there was a mean increase of 0.24 postnatal care services provided (95% CI: 0.06-0.43, p = 0.009) among women who did not give birth in a facility. There was no evidence that number of postnatal care services was associated with socioeconomic status for women who gave birth in a facility. There was no evidence that socioeconomic status was associated with the provider or location of postnatal care visits. CONCLUSION: Postnatal care in Ethiopia shows evidence of socio-economic inequity in both coverage and quality. This demonstrates the need to focus on quality improvement as well as coverage, particularly among the poorest women who did not deliver in a facility.

Population cause of death estimation using verbal autopsy methods in large-scale field trials of maternal and child health: lessons learned from a 20-year research collaboration in Central Ghana.

Low and middle-income countries continue to use Verbal autopsies (VAs) as a World Health Organisation-recommended method to ascertain causes of death in settings where coverage of vital registration systems is not yet comprehensive. Whilst the adoption of VA has resulted in major improvements in estimating cause-specific mortality in many settings, well documented limitations have been identified relating to the standardisation of the processes involved. The WHO has invested significant resources into addressing concerns in some of these areas; there however remains enduring challenges particularly in operationalising VA surveys for deaths amongst women and children, challenges which have measurable impacts on the quality of data collected and on the accuracy of determining the final cause of death. In this paper we describe some of our key experiences and recommendations in conducting VAs from over two decades of evaluating seminal trials of maternal and child health interventions in rural Ghana. We focus on challenges along the entire VA pathway that can impact on the success rates of ascertaining the final cause of death, and lessons we have learned to optimise the procedures. We highlight our experiences of the value of the open history narratives in VAs and the training and skills required to optimise the quality of the information collected. We describe key issues in methods for ascertaining cause of death and argue that both automated and physician-based methods can be valid depending on the setting. We further summarise how increasingly popular information technology methods may be used to facilitate the processes described. Verbal autopsy is a vital means of increasing the coverage of accurate mortality statistics in low- and middle-income settings, however operationalisation remains problematic. The lessons we share here in conducting VAs within a long-term surveillance system in Ghana will be applicable to researchers and policymakers in many similar settings.

District health managers perspectives of introducing a new service: a qualitative study of the community-based newborn care programme in Ethiopia.

BACKGROUND: The planning, resourcing, implementation and monitoring of new programmes by district health managers is integral for success and sustainability. Ethiopia introduced the Community-Based Newborn Care programme in 2014 to improve newborn survival: an innovative component allowed community health workers to provide antibiotics for young infants with possible serious bacterial infection when referral was not possible. Informed by the World Health Organization health system building block framework, we aimed to study the capacity and operational challenges of introducing this new health service from the perspective of programme implementers and managers at the district level 20 months after programme initiation. METHODS: This qualitative study was part of a programme evaluation. From November to December of 2015, we conducted 28 semi-structured interviews with staff at district health offices, health centres and implementing Non-Governmental Organisations in 15 districts of four regions of Ethiopia. Verbatim transcripts were analysed using a priori and emerging themes. RESULTS: In line with the government's commitment to treat sick newborns close to their homes, participants reported that community health workers had been successfully trained to provide injectable antibiotics. However, the Community-Based Newborn Care programme was scaled up without allowing the health system to adapt to programme needs. There were inadequate processes and standards to ensure consistent availability of (1) trained staff for technical supervision, (2) antibiotics and (3) monitoring data specific to the programme. Furthermore, Non-Governmental Organizations played a central implementing role, which had implications for the long-term district level ownership and thus for the sustainability of the programme. CONCLUSION: In settings where sustainable local implementation depends on district-level health teams, new programmes should assess health system preparedness to absorb the service, and plan accordingly. Our findings can inform policy makers and implementers about the pre-conditions for a health system to introduce similar services and maximize long-term success.

The effect of implementation strength of basic emergency obstetric and newborn care (BEmONC) on facility deliveries and the met need for BEmONC at the primary health care level in Ethiopia.

BACKGROUND: Basic emergency obstetric and newborn care (BEmONC) is a primary health care level initiative promoted in low- and middle-income countries to reduce maternal and newborn mortality. Tailored support, including BEmONC training to providers, mentoring and monitoring through supportive supervision, provision of equipment and supplies, strengthening referral linkages, and improving infection-prevention practice, was provided in a package of interventions to 134 health centers, covering 91 rural districts of Ethiopia to ensure timely BEmONC care. In recent years, there has been a growing interest in measuring program implementation strength to evaluate public health gains. To assess the effectiveness of the BEmONC initiative, this study measures its implementation strength and examines the effect of its variability across intervention health centers on the rate of facility deliveries and the met need for BEmONC. METHODS: Before and after data from 134 intervention health centers were collected in April 2013 and July 2015. A BEmONC implementation strength index was constructed from seven input and five process indicators measured through observation, record review, and provider interview; while facility delivery rate and the met need for expected obstetric complications were measured from service statistics and patient records. We estimated the dose-response relationships between outcome and explanatory variables of interest using regression methods. RESULTS: The BEmONC implementation strength index score, which ranged between zero and 10, increased statistically significantly from 4.3 at baseline to 6.7 at follow-up (p < .05). Correspondingly, the health center delivery rate significantly increased from 24% to 56% (p < .05). There was a dose-response relationship between the explanatory and outcome variables. For every unit increase in BEmONC implementation strength score there was a corresponding average of 4.5 percentage points (95% confidence interval: 2.1-6.9) increase in facility-based deliveries; while a higher score for BEmONC implementation strength of a health facility at follow-up was associated with a higher met need. CONCLUSION: The BEmONC initiative was effective in improving institutional deliveries and may have also improved the met need for BEmONC services. The BEmONC implementation strength index can be potentially used to monitor the implementation of BEmONC interventions.

Factors influencing women's preference for health facility deliveries in Jharkhand state, India: a cross sectional analysis.

BACKGROUND: Expanding institutional deliveries is a policy priority to achieve MDG5. India adopted a policy to encourage facility births through a conditional cash incentive scheme, yet 28% of deliveries still occur at home. In this context, it is important to understand the care experience of women who have delivered at home, and also at health facilities, analyzing any differences, so that services can be improved to promote facility births. This study aims to understand women's experience of delivery care during home and facility births, and the factors that influence women's decisions regarding their next place of delivery. METHOD: A community-based cross-sectional survey was undertaken in a district of Jharkhand state in India. Interviews with 500 recently delivered women (210 delivered at facility and 290 delivered at home) included socio-demographic characteristics, experience of their recent delivery, and preference of future delivery site. Data analysis included frequencies, binary and multiple logistic regressions. RESULTS: There is no major difference in the experience of care between home and facility births, the only difference in care being with regard to pain relief through massage, injection and low cost of delivery for those having home births. 75% women wanted to deliver their next child at a facility, main reasons being availability of medicine (29.4%) and perceived health benefits for mother and baby (15%). Women with higher education (AOR = 1.67, 95% CI = 1.04-3.07), women who were above 25 years (AOR = 2.14, 95% CI = 1.26-3.64), who currently delivered at facility (AOR = 5.19, 95% CI = 2.97-9.08) and had health problem post-delivery (AOR = 1.85, 95% CI = 1.08-3.19) were significant predictors of future facility-based delivery. CONCLUSION: The predictors for facility deliveries include, availability of medicines and supplies, potential health benefits for the mother and newborn and the perception of good care from the providers. There is a growing preference for facility delivery particularly among women with higher age group, education, income and those who had antennal checkup. In order to uptake facility births, the quality improvement initiatives should regularly assess and address women's experiences of care.

Determinants of women's satisfaction with maternal health care: a review of literature from developing countries.

BACKGROUND: Developing countries account for 99 percent of maternal deaths annually. While increasing service availability and maintaining acceptable quality standards, it is important to assess maternal satisfaction with care in order to make it more responsive and culturally acceptable, ultimately leading to enhanced utilization and improved outcomes. At a time when global efforts to reduce maternal mortality have been stepped up, maternal satisfaction and its determinants also need to be addressed by developing country governments. This review seeks to identify determinants of women's satisfaction with maternity care in developing countries. METHODS: The review followed the methodology of systematic reviews. Public health and social science databases were searched. English articles covering antenatal, intrapartum or postpartum care, for either home or institutional deliveries, reporting maternal satisfaction from developing countries (World Bank list) were included, with no year limit. Out of 154 shortlisted abstracts, 54 were included and 100 excluded. Studies were extracted onto structured formats and analyzed using the narrative synthesis approach. RESULTS: Determinants of maternal satisfaction covered all dimensions of care across structure, process and outcome. Structural elements included good physical environment, cleanliness, and availability of adequate human resources, medicines and supplies. Process determinants included interpersonal behavior, privacy, promptness, cognitive care, perceived provider competency and emotional support. Outcome related determinants were health status of the mother and newborn. Access, cost, socio-economic status and reproductive history also influenced perceived maternal satisfaction. Process of care dominated the determinants of maternal satisfaction in developing countries. Interpersonal behavior was the most widely reported determinant, with the largest body of evidence generated around provider behavior in terms of courtesy and non-abuse. Other aspects of interpersonal behavior included therapeutic communication, staff confidence and competence and encouragement to laboring women. CONCLUSIONS: Quality improvement efforts in developing countries could focus on strengthening the process of care. Special attention is needed to improve interpersonal behavior, as evidence from the review points to the importance women attach to being treated respectfully, irrespective of socio-cultural or economic context. Further research on maternal satisfaction is required on home deliveries and relative strength of various determinants in influencing maternal satisfaction.

"Neither we are satisfied nor they"-users and provider's perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.

BACKGROUND: Quality of care provided during childbirth is a critical determinant of preventing maternal mortality and morbidity. In the studies available, quality has been assessed either from the users' perspective or the providers'. The current study tries to bring both perspectives together to identify common key focus areas for quality improvement. This study aims to assess the users' (recently delivered women) and care providers' perceptions of care to understand the common challenges affecting provision of quality maternity care in public health facilities in India. METHODS: A qualitative design comprising of in-depth interviews of 24 recently delivered women from secondary care facilities and 16 health care providers in Uttar Pradesh, India. The data were analysed thematically to assess users' and providers' perspectives on the common themes. RESULTS: The common challenges experienced regarding provision of care were inadequate physical infrastructure, irregular supply of water, electricity, shortage of medicines, supplies, and gynaecologist and anaesthetist to manage complications, difficulty in maintaining privacy and lack of skill for post-delivery counselling. However, physical access, cleanliness, interpersonal behaviour, information sharing and out-of-pocket expenditure were concerns for only users. Similarly, providers raised poor management of referral cases, shortage of staff, non-functioning of blood bank, lack of incentives for work as their concerns. DISCUSSION: The study identified the common themes of care from both the perspectives, which have been foundrelevant in terms of challenges identified in many developing countries including India. The study framework identified new themes like management of emergencies in complicated cases, privacy and cost of care which both the group felt is relevant in the context of providing quality care during childbirth in low resource setting. The key challenges identified by both the groups can be prioritized, when developing quality improvement program in the health facilities. The identified components of care can match the supply with the demand for care and make the services truly responsive to user needs. CONCLUSION: The study highlights infrastructure, human resources, supplies and medicine as priority areas of quality improvement in the facility as perceived by both users and providers, nevertheless the interpersonal aspect of care primarily reported by the users must also not be ignored.

Data-driven decision-making for district health management: a cluster-randomised study in 24 districts of Ethiopia.

BACKGROUND: Use of local data for health system planning and decision-making in maternal, newborn and child health services is limited in low-income and middle-income countries, despite decentralisation and advances in data gathering. An improved culture of data-sharing and collaborative planning is needed. The Data-Informed Platform for Health is a system-strengthening strategy which promotes structured decision-making by district health officials using local data. Here, we describe implementation including process evaluation at district level in Ethiopia, and evaluation through a cluster-randomised trial. METHODS: We supported district health teams in 4-month cycles of data-driven decision-making by: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritising; and (e) a consultative process to develop, commit to and follow up on action plans. 12 districts were randomly selected from 24 in the North Shewa zone of Ethiopia between October 2020 and June 2022. The remaining districts formed the trial's comparison arm. Outcomes included health information system performance and governance of data-driven decision-making. Analysis was conducted using difference-in-differences. RESULTS: 58 4-month cycles were implemented, four or five in each district. Each focused on a health service delivery challenge at district level. Administrators' practice of, and competence in, data-driven decision-making showed a net increase of 77% (95% CI: 40%, 114%) in the regularity of monthly reviews of service performance, and 48% (95% CI: 9%, 87%) in data-based feedback to health facilities. Statistically significant improvement was also found in administrators' use of information to appraise services. Qualitative findings also suggested that district health staff reported enhanced data use and collaborative decision-making. CONCLUSIONS: This study generated robust evidence that 20 months' implementation of the Data-Informed Platform for Health strengthened health management through better data use and appraisal practices, systemised problem analysis to follow up on action points and improved stakeholder engagement. TRIAL REGISTRATION NUMBER: NCT05310682.

A strategy for reducing maternal and newborn deaths by 2015 and beyond.

BACKGROUND: Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030. DISCUSSION: The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact. SUMMARY: Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.

Inequalities in utilisation of essential antenatal services for women with disabilities in Pakistan: analysis of a cross-sectional demographic and health survey of Pakistan 2017-2018.

OBJECTIVES: Although the number of disabled women entering motherhood is growing, there is little quantitative evidence about the utilisation of essential antenatal care (ANC) services by women with disabilities. We examined inequalities in the use of essential ANC services between women with and without disabilities. DESIGN, SETTING AND ANALYSIS: A secondary analysis of cross-sectional data from recent Demographic and Health Survey of Pakistan 2017-2018 was performed using logistic regression. PARTICIPANTS: A total weighted sample of 6791 ever-married women (age 15-49) who had a live birth in the 5 years before the survey were included. OUTCOME MEASURES: Utilisation of ANC: (A) antenatal coverage: (1) received ANC and (2) completed four or more ANC visits and (B) utilisation of essential components of ANC. RESULTS: The percentage of women who were at risk of disability and those living with disability in one or more domains was 11.5% and 2.6%, respectively. The coverage of ANC did not differ by disability status. With utilisation of essential ANC components, consumption of iron was lower (adjusted OR, aOR=0.6; p<0.05), while advice on exclusive breast feeding (aOR=1.6; p<0.05) and urine test (aOR=1.7; p<0.05) was higher among women with disabilities as compared with their counterparts. Similarly, the odds of receiving advice on maintaining a balanced diet was higher (aOR=1.3; p<0.05) among women at risk of any disability as opposed to their counterparts. Differences were also found for these same indicators in subgroup analysis by wealth status (poor/non-poor) and place of residence (urban-rural). CONCLUSION: Our study did not find glaring inequalities in the utilisation of ANC services between women with disabilities and non-disabled women. This was true for urban versus rural residence and among the poor versus non-poor women. Some measures, however, should be made to improve medication compliance among women with disabilities.

Psychosocial support during childbirth: Development and adaptation of WHO's Mental Health Gap Action Programme (mhGAP) for maternity care settings.

INTRODUCTION: Poor psychosocial support and lack of respectful care for women during childbirth are commonplace in health facilities in low- and middle-income countries. While WHO recommends providing supportive care to pregnant women, there is a scarcity of material for building the capacity of maternity staff to provide systematic and inclusive psychosocial support to women in the intrapartum phase, and prevent work stress and burnout in maternity teams. To address this need we adapted WHO's mhGAP for maternity staff to provide psychosocial support in labour room settings in Pakistan. Mental Health Gap Action Programme (mhGAP) is an evidence-based guidance which provides psychosocial support in resource-limited health care settings. This paper aims to describe the adaptation of mhGAP to develop psychosocial support capacity building materials for maternity staff to provide support to maternity patients, and also to staff, in the labour room context. METHODS: Adaptation was conducted within the Human-Centered-Design framework in three phases: inspiration, ideation, and implementation feasibility. In inspiration, a review of national-level maternity service-delivery documents and in-depth interviews of maternity staff were conducted. Ideation involved a multidisciplinary team to develop capacity-building materials by adapting mhGAP. This phase was iterative and included cycles of pretesting, deliberations, and revision of materials. In implementation feasibility, materials were tested via the training of 98 maternity staff and exploring system feasibility via post-training visits to health facilities. RESULTS: Inspiration phase identified gaps in policy directives and implementation and formative study identified limited understanding and skills of staff to assess patients' psychosocial needs and provide appropriate support. Also, it became evident that staff themselves needed psychosocial support. In ideation, team developed capacity-building materials comprising two modules: one dedicated to conceptual understanding, the other to implementing psychosocial support in collaboration with maternity staff. In implementation feasibility, staff found the materials relevant and feasible for the labour room setting. Finally, users and experts endorsed usefulness of the materials. CONCLUSION: Our work in developing psychosocial-support training materials for maternity staff extends the utility of mhGAP to maternity care settings. These materials can be used for capacity-building of maternity staff and their effectiveness can be assessed in diverse maternity care settings.

Comparing the effectiveness of mother-focused interventions to that of mother-child focused interventions in improving maternal postpartum depression outcomes: A systematic review.

BACKGROUND: Most empirically researched interventions for postpartum depression (PPD) tend to target mothers' depression alone. Harmful effects of PPD on physical and mental health of both mother and child has led researchers to investigate the impact of interventions on PPD and child outcomes together. So far, the evidence is limited regarding how these interventions compare with those focusing only on mothers' depression. This review compares the effectiveness of PPD-improving interventions focusing only on mothers with those focusing on mother and child together. METHODS: Nine electronic databases were searched. Thirty-seven studies evaluating mother-focused (n = 30) and mother-child focused interventions (n = 7) were included. Under each category, three theoretical approaches-psychological, psychosocial and mixed-were compared using standardized qualitative procedures. The review's primary outcome was maternal PPD. RESULTS: A higher proportion of mother-focussed interventions [20/30 (66.7%)] brought significant reduction in PPD outcomes as compared to a lower proportion of mother-child focused interventions [4/7 (57.14%)]. Mother-focused mixed approaches [3/3 (100%)] performed better in improving PPD than psychological [16/24 (67%)] or psychosocial approaches [1/3 (33.3%)] alone. Amongst mother-child focused interventions, psychosocial approaches performed well with two-thirds demonstrating positive effects on PPD. CONCLUSION: The evidence strongly favors mother-focused interventions for improving PPD with mixed interventions being more effective. Psychosocial approaches performed better with PPD once child-related elements were added, and also seemed best for child outcomes. Psychological approaches were most practiced and effective for PPD, irrespective of the intervention's focus. Further trials are needed to unpack intervention components that improve PPD and increase uptake, especially in lower-and middle-income countries.

Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff.

INTRODUCTION: Respectful maternity care (RMC) during childbirth is an integral component of quality of care. However, women's experiences of mistreatment are prevalent in many low- and middle-income countries. This is a complex phenomenon that has not been well explored from a behavioral science perspective. We aimed to understand the behavioral drivers of mistreatment during childbirth among maternity care staff at public health facilities in the Sindh province of Pakistan. METHODS: Applying the COM-B (capability-opportunity-motivation that leads to behavior change) model, we conducted semistructured in-depth interviews among clinical and nonclinical staff in public health facilities in Thatta and Sujawal, Sindh, Pakistan. Data were analyzed using thematic deductive analysis, and findings were synthesized using the COM-B model. RESULTS: We identified several behavioral drivers of mistreatment during childbirth: (1) institutional guidelines on RMC and training opportunities were absent, resulting in a lack of providers' knowledge and skills; (2) facilities lacked the infrastructure to maintain patient privacy and confidentiality and did not permit males as birth companions; (3) lack of provider performance monitoring system and patient feedback mechanism contributed to providers not feeling appreciated or recognized. Staff bias against patients from lower castes contributed to patient abuse and mistreatment. The perspectives of clinical and nonclinical staff overlapped regarding potential drivers of mistreatment during childbirth. CONCLUSIONS: Addressing mistreatment during childbirth requires improving the knowledge and capacity of maternity staff on RMC and psychosocial support to enhance their understanding of RMC. At the health facility level, governance and accountability mechanisms in routine supervision and monitoring of staff need to be improved. Patients' feedback should be incorporated for continuous improvement in providing maternity care services that meet patients' preferences and needs.

Promoting Supportive and Respectful Maternity Care in Public Health Facilities in Sindh, Pakistan: A Theory-Informed Health System Intervention.

BACKGROUND: Disrespect, abuse, discrimination, and lack of emotional support characterize intrapartum care in the health systems of many low- and middle-income countries. Although the World Health Organization (WHO) provides frameworks and guidelines to address this issue, no operational model exists that effectively incorporates WHO intrapartum care guidelines into routine public health services. We aimed to develop and pilot-test a theory-driven, service-delivery intervention package linking dignified care with perinatal mental health to promote psychosocially supportive and respectful maternity care (S-RMC) in public health facilities in Sindh, Pakistan. METHODS: Using a mixed-method, pre-post design, the study was implemented in 6 secondary-level public health facilities in 2 rural districts of Southern Sindh, Pakistan. Its development was guided by the COM-B framework and informed by a literature review, formative research, and consultative sessions with implementers. The intervention was implemented in March-September 2021 and compared women's experiences of S-RMC during childbirth at baseline (n=313) and endline (n=314). We used descriptive statistics and linear regression techniques for analysis. RESULTS: A substantial reduction was observed in the cumulative level of overall mistreatment from baseline to endline, yielding a relative change of 50% (P<.001). Similar change was evident across different types of mistreatment: physical abuse (75%), verbal abuse (72%), ineffective communication (60%), nonconfidential care (78%), health system conditions and constraints (25%), noninclusive care (28%), lack of supportive care (52%), and stigma and discrimination (82%). Furthermore, we observed a significant reduction in the proportion of women experiencing symptoms of anxiety and depression before and after the intervention. CONCLUSION: This intervention built the capacity of maternity teams while improving accountability, health information systems, and governance measures. Given its promise to promote supportive and respectful childbirth in public health facilities, a large-scale effectiveness evaluation across diverse settings is warranted.

Understanding the Mechanisms of Change in the Supportive and Respectful Maternity Care Intervention in Sindh, Pakistan: Provider Perspectives.

INTRODUCTION: We conducted this qualitative investigation to explore the mechanisms of change in providing respectful care resulting from the supportive and respectful maternity care intervention (S-RMC) in Sindh, Pakistan. METHODS: We applied the principles of realist evaluation methodology with a descriptive explanatory research design. We conducted in-depth interviews with 36 maternity care providers at secondary-level public health facilities where S-RMC was implemented for 6 months. The S-RMC broad components included capacity-building of maternity teams and systemic changes for improvements in governance and accountability within public health facilities. Data were analyzed using a deductive content analysis approach. RESULTS: We identified mechanisms of change, categorized by the S-RMC components: (1) S-RMC training: insight into women's feelings and rights, realization of the value that nonclinical staff can play, understanding of team coordination, orientation in psychosocial components of maternity care; (2) assessment of women's psychosocial vulnerabilities: identification of women's differential needs beyond routine care to provide woman-centered care; (3) psychosocial support: effective engagement with women and within maternity teams and the customization of woman- and companion-focused care; (4) care coordination: improved coordination among clinical and nonclinical staff to provide personalized care and psychosocial support and proper handover to ensure continuity of care; (5) assessment of quality of care: identification of service gaps from women's feedback; and (6) performance review and accountability: monthly performance review meetings to establish team member communication, systematic awareness of the maternity team's performance and challenges, and implementation of collective corrective actions. CONCLUSION: Our findings pointed to S-RMC working along multiple pathways-and concertedly with various health system components-to enable positive processes and behavioral change in maternity teams.

Maternal time investment in caregiving activities to promote early childhood development: evidence from rural India.

Introduction: Intervention strategies that seek to improve early childhood development outcomes are often targeted at the primary caregivers of children, usually mothers. The interventions require mothers to assimilate new information and then act upon it by allocating sufficient physical resources and time to adopt and perform development promoting behaviours. However, women face many competing demands on their resources and time, returning to familiar habits and behaviours. In this study, we explore mothers' allocation of time for caregiving activities for children under the age of 2, nested within a cluster randomised controlled trial of a nutrition and care for development intervention in rural Haryana, India. Methods: We collected quantitative maternal time use data at two time points in rural Haryana, India, using a bespoke survey instrument. Data were collected from 704 mothers when their child was 12 months old, and 603 mothers when their child was 18 months old. We tested for significant differences in time spent by mothers on different activities when children are 12 months of age vs. 18 months of age between arms as well as over time, using linear regression. As these data were collected within a randomised controlled trial, we adjusted for clusters using random effects when testing for significant differences between the two time points. Results: At both time points, no statistically significant difference in maternal time use was found between arms. On average, mothers spent most of their waking time on household chores (over 6 h and 30 min) at both time points. When children were aged 12 months, approximately three and a half hours were spent on childcare activities for children under the age of 2 years. When children were 18 months old, mothers spent more time on income generating activities (30 min) than when the children were 12 years old, and on leisure (approximately 4 h and 30 min). When children were 18 months old, less time was spent on feeding/breastfeeding children (30 min less) and playing with children (15 min). However, mothers spent more time talking or reading to children at 18 months than at 12 months. Conclusion: We find that within a relatively short period of time in early childhood, maternal (or caregiver) time use can change, with time allocation being diverted away from childcare activities to others. This suggests that changing maternal time allocation in resource poor households may be quite challenging, and not allow the uptake of new and/or optimal behaviours.

Can home visits for early child development be implemented with sufficient coverage and quality at scale? Evidence from the SPRING program in India and Pakistan.

Introduction: There is limited evidence from low and middle-income settings on the effectiveness of early child development interventions at scale. To bridge this knowledge-gap we implemented the SPRING home visiting program where we tested integrating home visits into an existing government program (Pakistan) and employing a new cadre of intervention workers (India). We report the findings of the process evaluation which aimed to understand implementation. Methods and materials: We collected qualitative data on acceptability and barriers and facilitators for change through 24 in-depth interviews with mothers; eight focus group discussions with mothers, 12 with grandmothers, and 12 with fathers; and 12 focus group discussions and five in-depth interviews with the community-based agents and their supervisors. Results: Implementation was sub-optimal in both settings. In Pakistan issues were low field-supervision coverage and poor visit quality related to issues scheduling supervision, a lack of skill development, high workloads and competing priorities. In India, issues were low visit coverage - in part due to employing new workers and an empowerment approach to visit scheduling. Coaching caregivers to improve their skills was sub-optimal in both sites, and is likely to have contributed to caregiver perceptions that the intervention content was not new and was focused on play activities rather than interaction and responsivity - which was a focus of the coaching. In both sites caregiver time pressures was a key reason for low uptake among families who received visits. Discussion: Programs need feasible strategies to maximize quality, coverage and supervision including identifying and managing problems through monitoring and feedback loops. Where existing community-based agents are overstretched and system strengthening is unlikely, alternative implementation strategies should be considered such as group delivery. Core intervention ingredients such as coaching should be prioritized and supported during training and implementation. Given that time and resource constraints were a key barrier for families a greater focus on communication, responsivity and interaction during daily activities could have improved feasibility.

Effect of the SPRING home visits intervention on early child development and growth in rural India and Pakistan: parallel cluster randomised controlled trials.

Introduction: Almost 250 million children fail to achieve their full growth or developmental potential, trapping them in a cycle of continuing disadvantage. Strong evidence exists that parent-focussed face to face interventions can improve developmental outcomes; the challenge is delivering these on a wide scale. SPRING (Sustainable Programme Incorporating Nutrition and Games) aimed to address this by developing a feasible affordable programme of monthly home visits by community-based workers (CWs) and testing two different delivery models at scale in a programmatic setting. In Pakistan, SPRING was embedded into existing monthly home visits of Lady Health Workers (LHWs). In India, it was delivered by a civil society/non-governmental organisation (CSO/NGO) that trained a new cadre of CWs. Methods: The SPRING interventions were evaluated through parallel cluster randomised trials. In Pakistan, clusters were 20 Union Councils (UCs), and in India, the catchment areas of 24 health sub-centres. Trial participants were mother-baby dyads of live born babies recruited through surveillance systems of 2 monthly home visits. Primary outcomes were BSID-III composite scores for psychomotor, cognitive and language development plus height for age z-score (HAZ), assessed at 18 months of age. Analyses were by intention to treat. Results: 1,443 children in India were assessed at age 18 months and 1,016 in Pakistan. There was no impact in either setting on ECD outcomes or growth. The percentage of children in the SPRING intervention group who were receiving diets at 12 months of age that met the WHO minimum acceptable criteria was 35% higher in India (95% CI: 4-75%, p = 0.023) and 45% higher in Pakistan (95% CI: 15-83%, p = 0.002) compared to children in the control groups. Discussion: The lack of impact is explained by shortcomings in implementation factors. Important lessons were learnt. Integrating additional tasks into the already overloaded workload of CWs is unlikely to be successful without additional resources and re-organisation of their goals to include the new tasks. The NGO model is the most likely for scale-up as few countries have established infrastructures like the LHW programme. It will require careful attention to the establishment of strong administrative and management systems to support its implementation.

Clean birth kits to improve birth practices: development and testing of a country level decision support tool.

BACKGROUND: Clean birth practices can prevent sepsis, one of the leading causes of both maternal and newborn mortality. Evidence suggests that clean birth kits (CBKs), as part of package that includes education, are associated with a reduction in newborn mortality, omphalitis, and puerperal sepsis. However, questions remain about how best to approach the introduction of CBKs in country. We set out to develop a practical decision support tool for programme managers of public health systems who are considering the potential role of CBKs in their strategy for care at birth. METHODS: Development and testing of the decision support tool was a three-stage process involving an international expert group and country level testing. Stage 1, the development of the tool was undertaken by the Birth Kit Working Group and involved a review of the evidence, a consensus meeting, drafting of the proposed tool and expert review. In Stage 2 the tool was tested with users through interviews (9) and a focus group, with federal and provincial level decision makers in Pakistan. In Stage 3 the findings from the country level testing were reviewed by the expert group. RESULTS: The decision support tool comprised three separate algorithms to guide the policy maker or programme manager through the specific steps required in making the country level decision about whether to use CBKs. The algorithms were supported by a series of questions (that could be administered by interview, focus group or questionnaire) to help the decision maker identify the information needed. The country level testing revealed that the decision support tool was easy to follow and helpful in making decisions about the potential role of CBKs. Minor modifications were made and the final algorithms are presented. CONCLUSION: Testing of the tool with users in Pakistan suggests that the tool facilitates discussion and aids decision making. However, testing in other countries is needed to determine whether these results can be replicated and to identify how the tool can be adapted to meet country specific needs.