Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions.

BACKGROUND: The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns. RESULTS: The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems. CONCLUSIONS: Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.

Does setting adolescent-friendly standards improve the quality of care in clinics? Evidence from South Africa.

OBJECTIVE: To determine whether setting and implementing adolescent-friendly standards improves the quality of adolescent services in clinics. DESIGN: The evaluation used a quasi-experimental case-control design. SETTING/PARTICIPANTS: Eleven public health clinics involved in the adolescent-friendly program [The National Adolescent Friendly Clinic Initiative (NAFCI)] and 11 control clinics. INTERVENTION: This included implementation of a set of 10 adolescent-friendly standards and 41 corresponding criteria. MAIN OUTCOME MEASURES: Percentage scores were achieved for each standard and criterion. Clinics were awarded a Gold Star if they achieved an overall clinic score (average standard score) of >or=90%, a Silver Star for a score between 60 and 89% and a Bronze Star for a score between 30 and 59%. RESULTS: The NAFCI clinics performed better than the control clinics on most criteria. The combined average overall clinic score of all the NAFCI clinics (79.9%) was significantly higher (P = 0.005) than the overall score for the control group clinics (60.9%). Results showed that the longer NAFCI was implemented at a clinic, the higher the score and the more likely that clinic would be accredited as an 'adolescent friendly' clinic. NAFCI clinics performed significantly better than the control clinics on criteria specific to the provision of adolescent-friendly services including knowledge of adolescent rights and non-judgmental attitudes of staff. CONCLUSION: Setting and implementing standards and criteria improves the quality of adolescent services in clinics. The standards and criteria should be set on the basis of the characteristics of adolescent-friendly services and quality of care indicators. Best results are achieved when a facilitator trained in quality improvement methodologies supports clinics.