Using the WHO safe childbirth checklist to improve essential care delivery as part of the district-wide maternal and newborn health quality improvement initiative, a time series study.

BACKGROUND: Care bundles are a set of three to five evidence-informed practices which, when performed collectively and reliably, may improve health system performance and patient care. To date, many studies conducted to improve the quality of essential birth care practices (EBPs) have focused primarily on provider- level and have fallen short of the predicted impact on care quality, indicating that a systems approach is needed to improve the delivery of reliable quality care. This study evaluates the effect of integrating the use of the World Health Organization Safe Childbirth Checklist (WHO-SCC) into a district-wide system improvement collaborative program designed to improve and sustain the delivery of EBPs as measured by "clinical bundle" adherence over-time. METHODS: The WHO-SCC was introduced in the context of a district-wide Maternal and Newborn Health (MNH) collaborative quality of care improvement program in four agrarian Ethiopia regions. Three "clinical bundles" were created from the WHO-SCC: On Admission, Before Pushing, and Soon After Birth bundles. The outcome of each bundle was measured using all- or- none adherence. Adherence was assessed monthly by reviewing charts of live births. A time-series analysis was employed to assess the effectiveness of system-level interventions on clinical bundle adherence. STATA version 13.1 was used to analyze the trend of each bundle adherence overtime. Autocorrelation was checked to assess if the assumption of independence in observations collected overtime was valid. Prais-Winsten was used to minimize the effect of autocorrelation. FINDINGS: Quality improvement interventions targeting the three clinical bundles resulted in improved adherence over time across the four MNH collaborative. In Tankua Abergele collaborative (Tigray Region), the overall mean adherence to "On Admission" bundle was 86% with ß = 1.39 (95% CI; 0.47-2.32; P <  0.005) on average monthly. Similarly, the overall mean adherence to the "Before Pushing" bundle in Dugna Fango collaborative; Southern Nations, Nationalities and People's (SNNP) region was 80% with ß = 2.3 (95% CI; 0.89-3.74; P <  0.005) on average monthly. CONCLUSION: Using WHO-SCC paired with a system-wide quality improvement approach improved and sustained quality of EBPs delivery. Further studies should be conducted to evaluate the impact on patient-level outcomes.

Quality of maternal and newborn health care in Ethiopia: a cross-sectional study.

BACKGROUND: Despite reports of universal access to and modest utilization of maternal and newborn health services in Ethiopia, mothers and newborns continue to die from preventable causes. Studies indicate this could be due to poor quality of care provided in health systems. Evidences show that high quality health care prevents more than half of all maternal deaths. In Ethiopia, there is limited knowledge surrounding the status of the quality of maternal and newborn health care in health facilities. This study aims to assess the quality of maternal and neonatal health care provision at the health facility level in four regions in Ethiopia. METHODOLOGY: This study employed a facility-based cross-sectional study design. It included 32 health facilities which were part of the facilities for prototyping maternal and neonatal health quality improvement interventions. Data was collected using a structured questionnaire, key informant interviews and record reviews. Data was entered in Microsoft Excel and exported to STATA for analysis. Descriptive analysis results are presented in texts, tables and graphs. Quality of maternal and neonatal health care was measured by input, process and outputs components. The components were developed by computing scores using standards used to measure the three components of the quality of maternal and neonatal health care. RESULT: The study was done in a total of 32 health facilities: 5 hospitals and 27 health centers in four regions. The study revealed that the average value of the quality of the maternal and neonatal health care input component among health facilities was 62%, while the quality of the process component was 43%. The quality of the maternal and neonatal health output component was 48%. According to the standard cut-off point for MNH quality of care, only 5 (15.6%), 3 (9.3%) and 3 (10.7%) of health facilities met the expected input, process and output maternal and neonatal health care quality standards, respectively. CONCLUSION: This study revealed that the majority of health facilities did not meet the national MNH quality of care standards. Focus should be directed towards improving the input, process and output standards of the maternal and neonatal health care quality, with the strongest focus on process improvement.

The Ethiopia healthcare quality initiative: design and initial lessons learned.

OBJECTIVE: To describe the development, implementation and initial outcomes of a national quality improvement (QI) intervention in Ethiopia. DESIGN: Retrospective descriptive study of initial prototype phase implementation outcomes. SETTING: All public facilities in one selected prototype district in each of four agrarian regions. PARTICIPANTS: Facility QI teams composed of managers, healthcare workers and health extension workers. INTERVENTIONS: The Ethiopian Federal Ministry of Health (FMoH) and the Institute for Healthcare Improvement co-designed a three-pronged approach to accelerate health system improvement nationally, which included developing a national healthcare quality strategy (NHQS); building QI capability at all health system levels and introducing scalable district MNH QI collaboratives across four regions, involving healthcare providers and managers. OUTCOME MEASURES: Implementation outcomes including fidelity, acceptability, adoption and program effectiveness. RESULTS: The NHQS was launched in 2016 and governance structures were established at the federal, regional and sub-regional levels to oversee implementation. A total of 212 federal, regional and woreda managers have been trained in context-specific QI methods, and a national FMoH-owned in-service curriculum has been developed. Four prototype improvement collaboratives have been completed with high fidelity and acceptability. About 102 MNH change ideas were tested and a change package was developed with 83 successfully tested ideas. CONCLUSION: The initial successes observed are attributable to the FMoH's commitment in implementing the initiative, the active engagement of all stakeholders and the district-wide approach utilized. Challenges included weak data systems and security concerns. The second phase-in 26 district-level collaboratives-is now underway.

Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: A cross-sectional study.

BACKGROUND: Although Ethiopia has improved access to health care in recent years, quality of care remains low. Health worker motivation is an important determinant of performance and affects quality of care. Low health care workers motivation can be associated with poor health care quality and client experience, non-attendance, and poor clinical outcome. Objective this study sought to determine the extent and variation of health professionals' motivation alongside factors associated with motivation. METHODS: We conducted a facility based cross-sectional study among health extension workers (HEWs) and health care professionals in four regions: Amhara, Oromia, South nations, and nationalities people's region (SNNPR) and Tigray from April 15 to May 10, 2018. We sampled 401 health system workers: skilled providers including nurses and midwives (n = 110), HEWs (n = 210); and non-patient facing health system staff representing case team leaders, facility and district heads, directors, and officers (n = 81). Participants completed a 30-item Likert scale ranking tool which asked questions across 17 domains. We used exploratory factor analysis to explore latent motivation constructs. RESULTS: Of the 397 responses with complete data, 61% (95% CI 56%-66%) self-reported motivation as "very good" or "excellent". Significant variation in motivation was seen across regions with SNNPR scoring significantly lower on a five-point Likert scale by 0.35 points (P = 0.003). The exploratory factor analysis identified a three-factors: personal and altruistic goals; pride and personal satisfaction; and recognition and support. The personal and altruistic goals factor varied across regions with Oromia and SNNPR being significantly lower by 0.13 (P = 0.018) and 0.12 (P = 0.039) Likert points respectively. The pride and personal satisfaction factor were higher among those aged > = 30 years by 0.14 Likert scale points (P = 0.045) relative to those aged between 19-24years. CONCLUSIONS: Overall, motivation was high among participants but varied across region, cadre, and age. Workload, leave, and job satisfaction were associated with motivation.

Effect of data quality improvement intervention on health management information system data accuracy: An interrupted time series analysis.

BACKGROUND: As part of a partnership between the Institute for Healthcare Improvement and the Ethiopian Federal Ministry of Health, woreda-based quality improvement collaboratives took place between November 2016 and December 2017 aiming to accelerate reduction of maternal and neonatal mortality in Lemu Bilbilu, Tanqua Abergele and Duguna Fango woredas. Before starting the collaboratives, assessments found inaccuracies in core measures obtained from Health Management Information System reports. METHODS AND RESULTS: Building on the quality improvement collaborative design, data quality improvement activities were added and we used the World Health Organization review methodology to drive a verification factor for the core measures of number of pregnant women that received their first antenatal care visit, number of pregnant women that received antenatal care on at least four visits, number of pregnant women tested for syphilis and number of births attended by skilled health personnel. Impact of the data quality improvement was assessed using interrupted time series analysis. We found accurate data across all time periods for Tanqua Abergele. In Lemu Bilbilu and Duguna Fango, data quality improved for all core metrics over time. In Duguna Fango, the verification factor for number of pregnant women that received their first antenatal care visit improved from 0.794 (95%CI 0.753, 0.836; p<0.001) pre-intervention by 0.173 (95%CI 0.128, 0.219; p<0.001) during the collaborative; and the verification factor for number of pregnant women tested for syphilis improved from 0.472 (95%CI 0.390, 0.554; p<0.001) pre-intervention by 0.460 (95%CI 0.369, 0.552; p<0.001) during the collaborative. In Lemu Bilbilu, the verification factor for number of pregnant women receiving a fourth antenatal visit rose from 0.589 (95%CI 0.513, 0.664; p<0.001) at baseline by 0.358 (95%CI 0.258, 0.458; p<0.001) post-intervention; and skilled birth attendance rose from 0.917 (95%CI 0.869, 0.965) at baseline by 0.083 (95%CI 0.030, 0.136; p<0.001) during the collaborative. CONCLUSIONS: A Data quality improvement initiative embedded within woreda clinical improvement collaborative improved accuracy of data used to monitor maternal and newborn health services in Ethiopia.

The effect of community maternal and newborn health family meetings on type of birth attendant and completeness of maternal and newborn care received during birth and the early postnatal period in rural Ethiopia.

INTRODUCTION: Maternal and newborn deaths occur predominantly in low-resource settings. Community-based packages of evidence-based interventions and skilled birth attendance can reduce these deaths. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) used community-level health workers to conduct prenatal Community Maternal and Newborn Health family meetings to build skills and care-seeking behaviors among pregnant women and family caregivers. METHODS: Baseline and endline surveys provided data on a random sample of women with a birth in the prior year. An intention-to-treat analysis, plausible net effect calculation, and dose-response analysis examined increases in completeness of care (mean percentage of 17 maternal and newborn health care elements performed) over time and by meeting participation. Regression models assessed the relationship between meeting participation, completeness of care, and use of skilled providers or health extension workers for birth care-controlling for sociodemographic and health service utilization factors. RESULTS: A 151% increase in care completeness occurred from baseline to endline. At endline, women who participated in 2 or more meetings had more complete care than women who participated in fewer than 2 meetings (89% vs 76% of care elements; P < .001). A positive dose-response relationship existed between the number of meetings attended and greater care completeness (P < .001). Women with any antenatal care were nearly 3 times more likely to have used a skilled provider or health extension worker for birth care. Women who had additionally attended 2 or more meetings with family members were over 5 times as likely to have used these providers, compared to women without antenatal care and who attended fewer than 2 meetings (odds ratio, 5.19; 95% confidence interval, 2.88-9.36; P < .001). DISCUSSION: MaNHEP's family meetings complemented routine antenatal care by engaging women and family caregivers in self-care and care-seeking, resulting in greater completeness of care and more highly skilled birth care.