A qualitative evaluation and conceptual framework on the use of the Birth weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) matrix for perinatal health in Uganda.

BACKGROUND: Perinatal mortality (newborn deaths in the first week of life and stillbirths) continues to be a significant global health threat, particularly in resource-constrained settings. Low-tech, innovative solutions that close the quality-of-care gap may contribute to progress toward the Sustainable Development Goals for health by 2030. From 2012 to 2018, the Saving Mothers, Giving Life Initiative (SMGL) implemented the Birth weight and Age-at-Death Boxes for Intervention and Evaluation System (BABIES) matrix in Western Uganda. The BABIES matrix provides a simple, standardized way to track perinatal health outcomes to inform evidence-based quality improvement strategies. METHODS: In November 2017, a facility-based qualitative evaluation was conducted using in-depth interviews with 29 health workers in 16 health facilities implementing BABIES in Uganda. Data were analyzed using directed content analysis across five domains: 1) perceived ease of use, 2) how the matrix was used, 3) changes in behavior or standard operating procedures after introduction, 4) perceived value of the matrix, and 5) program sustainability. RESULTS: Values in the matrix were easy to calculate, but training was required to ensure correct data placement and interpretation. Displaying the matrix on a highly visible board in the maternity ward fostered a sense of accountability for health outcomes. BABIES matrix reports were compiled, reviewed, and responded to monthly by interprofessional teams, prompting collaboration across units to fill data gaps and support perinatal death reviews. Respondents reported improved staff communication and performance appraisal, community engagement, and ability to track and link clinical outcomes with actions. Midwives felt empowered to participate in the problem-solving process. Respondents were motivated to continue using BABIES, although sustainability concerns were raised due to funding and staff shortages. CONCLUSIONS: District-level health systems can use data compiled from the BABIES matrix to inform policy and guide implementation of community-centered health practices to improve perinatal heath. Future work may consider using the Conceptual Framework on Use of the BABIES Matrix for Perinatal Health as a model to operationalize concepts and test the impact of the tool over time.

Client and provider factors associated with companionship during labor and birth in Kigoma Region, Tanzania.

BACKGROUND: Labor and birth companionship is a key aspect of respectful maternity care. Lack of companionship deters women from accessing facility-based delivery care, though formal and informal policies against companionship are common in sub-Saharan African countries. AIM: To identify client and provider factors associated with labor and birth companionship DESIGN: Cross-sectional evaluation among delivery clients and providers in 61 health facilities in Kigoma Region, Tanzania, April-July 2016. METHODS: Multilevel, mixed effects logistic regression analyses were conducted on linked data from providers (n = 249) and delivery clients (n = 935). Outcome variables were Companion in labor and Companion at the time of birth. FINDINGS: Less than half of women reported having a labor companion (44.7%) and 12% reported having a birth companion. Among providers, 26.1% and 10.0% reported allowing a labor and birth companion, respectively. Clients had significantly greater odds of having a labor companion if their provider reported the following traits: working more than 55 hours/week (aOR 2.46, 95% CI 1.23-4.97), feeling very satisfied with their job (aOR 3.66, 95% CI 1.36-9.85), and allowing women to have a labor companion (aOR 3.73, 95% CI 1.58-8.81). Clients had significantly lower odds of having a labor companion if their provider reported having an on-site supervisor (aOR 0.48, 95% CI 0.24-0.95). Clients had significantly greater odds of having a birth companion if they self-reported labor complications (aOR 2.82, 95% CI 1.02-7.81) and had a labor companion (aOR 44.74, 95% CI 11.99-166.91). Clients had significantly greater odds of having a birth companion if their provider attended more than 10 deliveries in the last month (aOR 3.43, 95% CI 1.08-10.96) compared to fewer deliveries. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These results suggest that health providers are the gatekeepers of companionship, and the work environment influences providers' allowance of companionship. Facilities where providers experience staff shortages and high workload may be particularly responsive to programmatic interventions that aim to increase staff acceptance of birth companionship.

Geographic Access Modeling of Emergency Obstetric and Neonatal Care in Kigoma Region, Tanzania: Transportation Schemes and Programmatic Implications.

BACKGROUND: Access to transportation is vital to reducing the travel time to emergency obstetric and neonatal care (EmONC) for managing complications and preventing adverse maternal and neonatal outcomes. This study examines the distribution of travel times to EmONC in Kigoma Region, Tanzania, using various transportation schemes, to estimate the proportion of live births (a proxy indicator of women needing delivery care) with poor geographic access to EmONC services. METHODS: The 2014 Reproductive Health Survey of Kigoma Region identified 4 primary means of transportation used to travel to health facilities: walking, cycling, motorcycle, and 4-wheeled motor vehicle. A raster-based travel time model was used to map the 2-hour travel time catchment for each mode of transportation. Live birth density distributions were aggregated by travel time catchments, and by administrative council, to estimate the proportion of births with poor access. RESULTS: Of all live births in Kigoma Region, 13% occurred in areas where women can reach EmONC facilities within 2 hours on foot, 33% in areas that can be reached within 2 hours only by motorized vehicles, and 32% where it is impossible to reach EmONC facilities within 2 hours. Over 50% of births in 3 of the 8 administrative councils had poor estimated access. In half the councils, births with poor access could be reduced to no higher than 12% if all female residents had access to motorized vehicles. CONCLUSION: Significant differences in geographic access to EmONC in Kigoma Region, Tanzania, were observed both by location and by primary transportation type. As most of the population may only have good EmONC access when using mechanized or motorized vehicles, bicycles and motorcycles should be incorporated into the health transportation strategy. Collaboration between private transportation sectors and obstetric service providers could improve access to EmONC services among most populations. In areas where residents may not access EmONC facilities within 2 hours regardless of the type of transportation used, upgrading EmONC capacity among nearby non-EmONC facilities may be required to improve accessibility.

Perceptions of the risk for Ebola and health facility use among health workers and pregnant and lactating women--Kenema District, Sierra Leone, September 2014.

With an estimated maternal mortality ratio of 1,100 per 100,000 live births and a neonatal mortality rate of 49 per 1,000 live births, Sierra Leone has the highest maternal mortality ratio and the fourth highest neonatal mortality rate in the world, accounting for 2,400 maternal and 11,200 newborn deaths annually. By straining the fragile health care infrastructure, the Ebola virus disease (Ebola) epidemic might put pregnant women and their newborns at even greater risk for adverse outcomes.

A network study exploring factors that promote or erode interaction among diverse community health workers in rural Ethiopia.

Task shifting in response to the health workforce shortage has resulted in community-based health workers taking on increasing responsibility. Community health workers are expected to work collaboratively, though they are often a heterogeneous group with a wide range of training and experience. Interpersonal relationships are at the very core of effective teamwork, yet relational variables have seldom been the focus of health systems research in low resource, rural settings. This article helps fill this knowledge gap by exploring the dyadic level, or relational, characteristics of community maternal and newborn health workers and the individual and collective influence of these characteristics on interaction patterns. Network data were collected from community health workers (N = 194) in seven rural kebeles of Amhara region, Ethiopia from November 2011 to January 2012. Multiple Regression Quadratic Assignment Procedure was used to fit regression models for frequency of work interactions, a proxy for teamwork. Strong and consistent evidence was found in support of Trust and Past training together as important relational factors for work interactions; less consistent evidence was found across sites in support of Homophily, Distance and Shared motivations. Our findings also point to a typology of network structure across sites, where one set of networks was characterized by denser and stronger health worker ties relative to their counterparts. Our results suggest that the development of interventions that promote trust and incorporate cross-cadre training is an important step in encouraging collective action. Moreover, assessing the structure of health worker networks may be an effective means of evaluating health systems strengthening efforts in rural, low-resource settings.

Knowledge and skills retention among frontline health workers: community maternal and newborn health training in rural Ethiopia.

INTRODUCTION: We examined the degree to which the skills and knowledge of health workers in Ethiopia were retained 18 months after initial maternal and newborn health training and sought to identify factors associated with 18-month skills assessment performance. METHODS: A nonexperimental, descriptive design was employed to assess 18-month skills performance on the topics of Prevent Problems Before Baby Is Born and Prevent Problems After Baby Is Born. Assessment was conducted by project personnel who also received the maternal and newborn health training and additional training to reliably assess health worker performance. RESULTS: Among the 732 health workers who participated in maternal and newborn health training in 6 rural districts of the Amhara and Oromia regions of Ethiopia (including pretesting before training and a posttraining posttest), 75 health extension workers (78%) and 234 guide team members (37%) participated in 18-month posttest. Among health extension workers in both regions, strong knowledge retention was noted in 10 of 14 care steps for Prevent Problems Before Baby Is Born and in 14 of 16 care steps of Prevent Problems After Baby Is Born. Lower knowledge retention was observed among guide team members in the Amhara region. Across regions, health workers scored lowest on steps that involved nonaction (eg, do not give oxytocin). Educational attainment and age were among the few variables found to significantly predict test performance, although participants varied substantially by other sociodemographic characteristics. DISCUSSION: Results demonstrated an overall strong retention of knowledge and skills among health extension workers and highlighted the need for improvement among some guide team members. Refresher training and development of strategies to improve knowledge of retention of low-performing steps were recommended.

Factors shaping interactions among community health workers in rural Ethiopia: rethinking workplace trust and teamwork.

INTRODUCTION: Worldwide, a shortage of skilled health workers has prompted a shift toward community-based health workers taking on greater responsibility in the provision of select maternal and newborn health services. Research in mid- and high-income settings suggests that coworker collaboration increases productivity and performance. A major gap in this research, however, is the exploration of factors that influence teamwork among diverse community health worker cadres in rural, low-resource settings. The purpose of this study is to examine how sociodemographic and structural factors shape teamwork among community-based maternal and newborn health workers in Ethiopia. METHODS: A cross-sectional survey was conducted with health extension workers, community health development agents, and traditional birth attendants in 3 districts of the West Gojam Zone in the Amhara region of Ethiopia. Communities were randomly selected from Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) sites; health worker participants were recruited using a snowball sampling strategy. Fractional logit modeling and average marginal effects analyses were carried out to identify the influential factors for frequency of work interactions with each cadre. RESULTS: One hundred and ninety-four health workers participated in the study. A core set of factors-trust in coworkers, gender, and cadre-were influential for teamwork across groups. Greater geographic distance and perception of self-interested motivations were barriers to interactions with health extension workers, while greater food insecurity (a proxy for wealth) was associated with increased interactions with traditional birth attendants. DISCUSSION: Interventions that promote trust and gender sensitivity and improve perceptions of health worker motivations may help bridge the gap in health services delivery between low- and high-resource settings. Inter-cadre training may be one mechanism to increase trust and respect among diverse health workers, thereby increasing collaboration. Large-scale, longitudinal research is needed to understand how changes in trust, gender norms, and perceptions of motivations influence teamwork over time.

Community-level correlates of intimate partner violence against women globally: a systematic review.

Intimate partner violence (IPV) against women is a problem facing women around the world, one that has implications for women's health and well-being. The relationship between communities and the occurrence of IPV is an expanding area of research. Although a large number of community characteristics have been examined in relation to IPV, the research as a whole lacks a coherent theoretical focus or perspective. In this systematic review, we provide a comprehensive synthesis of the evidence regarding the community-level correlates of IPV against women. In our review of peer-reviewed research published between January 1, 1990 and January 31, 2011, we identify key community-level correlates, detect gaps, and offer recommendations for future research. Recognizing a difference in approach between U.S. and non-U.S. based research and an over-reliance on a primarily urban, U.S.-based perspective on communities and IPV, we advocate for a global perspective that better reflects the social and economic fabric of communities around the world. Specifically, future research should focus on the most promising, but currently under-studied, community-level correlates of IPV against women, namely gender inequality, gender norms, and adapted measures of collective efficacy/social cohesion.