'God is the one who give child': An abductive analysis of barriers to postnatal care using the Health Equity Implementation Framework.

Background: Postnatal care is recommended as a means of preventing maternal mortality during the postpartum period, but many women in low- and middle-income countries (LMICs) do not access care during this period. We set out to examine sociocultural preferences that have been portrayed as barriers to care. Methods: We performed an abductive analysis of 63 semi-structured interviews with women who had recently given birth in three regions of Ethiopia using the Health Equity Implementation Framework (HEIF) and an inductive-deductive codebook to understand why women in Ethiopia do not use recommended postnatal care. Results: We found that, in many cases, health providers do not consider women's cultural safety a primary need, but rather as a barrier to care. However, women's perceived refusal to participate in postnatal visits was, for many, an expression of agency and asserting their needs for cultural safety. Trial registration: n/a. Conclusions: We propose adding cultural safety to HEIF as a process outcome, so that implementers consider cultural needs in a dynamic manner that does not ask patients to choose between meeting their cultural needs and receiving necessary health care during the postnatal period.

Optimizing integration of community-based management of possible serious bacterial infection (PSBI) in young infants into primary healthcare systems in Ethiopia and Kenya: successes and challenges.

BACKGROUND: Ethiopia and Kenya have adopted the community-based integrated community case management (iCCM) of common childhood illnesses and newborn care strategy to improve access to treatment of infections in newborns and young infants since 2012 and 2018, respectively. However, the iCCM strategy implementation has not been fully integrated into the health system in both countries. This paper describes the extent of integration of iCCM program at the district/county health system level, related barriers to optimal integration and implementation of strategies. METHODS: From November 2020 to August 2021, Ethiopia and Kenya implemented the community-based treatment of possible serious bacterial infection (PSBI) when referral to a higher facility is not possible using embedded implementation research (eIR) to mitigate the impact of COVID-19 on the delivery of this life-saving intervention. Both projects conducted mixed methods research from April-May 2021 to identify barriers and facilitators and inform strategies and summative evaluations from June-July 2022 to monitor the effectiveness of implementation outcomes including integration of strategies. RESULTS: Strategies identified as needed for successful implementation and sustainability of the management of PSBI integrated at the primary care level included continued coaching and support systems for frontline health workers, technical oversight from the district/county health system, and ensuring adequate supply of commodities. As a result, support and technical oversight capacity and collaborative learning were strengthened between primary care facilities and community health workers, resulting in improved bidirectional linkages. Improvement of PSBI treatment was seen with over 85% and 81% of estimated sick young infants identified and treated in Ethiopia and Kenya, respectively. However, perceived low quality of service, lack of community trust, and shortage of supplies remained barriers impeding optimal PSBI services access and delivery. CONCLUSION: Pragmatic eIR identified shared and unique contextual challenges between and across the two countries which informed the design and implementation of strategies to optimize the integration of PSBI management into the health system during the COVID-19 pandemic. The eIR participatory design also strengthened ownership to operationalize the implementation of identified strategies needed to improve the health system's capacity for PSBI treatment.

Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic.

BACKGROUND: In Ethiopia, neonatal mortality is persistently high. The country has been implementing community-based treatment of possible serious bacterial infection (PSBI) in young infants when referral to a hospital is not feasible since 2012. However, access to and quality of PSBI services remained low and were worsened by COVID-19. From November 2020 to June 2022, we conducted implementation research to mitigate the impact of COVID-19 and improve PSBI management implementation uptake and delivery in two woredas in Ethiopia. METHODS: In April-May 2021, guided by implementation research frameworks, we conducted formative research to understand the PSBI management implementation challenges, including those due to the COVID-19 pandemic. Through a participatory process engaging stakeholders, we designed adaptive implementation strategies to bridge identified gaps using mechanism mapping to achieve implementation outcomes. Strategies included training and coaching, supportive supervision and mentorship, technical support units, improved supply of essential commodities, and community awareness creation about PSBI and COVID-19. We conducted cross-sectional household surveys in the two woredas before (April 2021) and after the implementation of strategies (June 2022) to measure changes in targeted outcomes. RESULTS: We interviewed 4,262 and 4,082 women who gave live birth 2-14 months before data collection and identified 374 and 264 PSBI cases in April 2021 and June 2022, respectively. The prevalence of PSBI significantly decreased (p-value = 0.018) from 8.7% in April 2021 to 6.4% while the mothers' care-seeking behavior from medical care for their sick newborns increased significantly from 56% to 91% (p-value <0.01). Effective coverage of severely ill young infants that took appropriate antibiotics significantly improved from 33% [95% CI: 25.5-40.7] to 62% [95% CI: 51.0-71.6]. Despite improvements in the uptake of PSBI treatment, persisting challenges at the facility and systems levels impeded optimal PSBI service delivery and uptake, including perceived low quality of service, lack of community trust, and shortage of supplies. CONCLUSION: The participatory design and implementation of adaptive COVID-19 strategies effectively improved the uptake and delivery of PSBI treatment. Support systems were critical for frontline health workers to deliver PSBI services and create a resilient community health system to provide quality PSBI care during the pandemic. Additional strategies are needed to address persistent gaps, including improvement in client-provider interactions, supply of essential drugs, and increased social mobilization strategies targeting families and communities to further increase uptake.

Navigating and manipulating childbirth services in Afar, Ethiopia: A qualitative study of cultural safety in the birthing room.

Access to maternal health services has increased in Ethiopia during the past decades. However, increasing the demand for government birthing facility use remains challenging. In Ethiopia's Afar Region, these challenges are amplified given the poorly developed infrastructure, pastoral nature of communities, distinct cultural traditions, and the more nascent health system. This paper features semi-structured interviews with 22 women who were purposively sampled to explore their experiences giving birth in government health facilities in Afar. We used thematic analysis informed by a cultural safety framework to interpret findings. Our findings highlight how women understand, wield, and relinquish power and agency in the delivery room in government health facilities in Afar, Ethiopia. We found that Afari women are treated as 'others', that they manipulate their care as they negotiate 'cultural safety' in the health system, and that they use trust as a pathway towards more cultural safety. As the cultural safety framework calls for recognizing and navigating the diverse and fluid power dynamics of healthcare settings, the onus of negotiating power dynamics cannot be placed on Afari women, who are already multiply marginalized due to their ethnicity and gender. Health systems must adopt cultural safety in order to ensure health quality. Providers, particularly in regions with rich cultural diversity, must be trained in the cultural safety framework in order to be aware of and challenge the multidimensional power dynamics present in health encounters.

'The objective was about not blaming one another': a qualitative study to explore how collaboration is experienced within quality improvement collaboratives in Ethiopia.

BACKGROUND: Quality improvement collaboratives are a common approach to improving quality of care. They rely on collaboration across and within health facilities to enable and accelerate quality improvement. Originating in high-income settings, little is known about how collaboration transfers to low-income settings, despite the widespread use of these collaboratives. METHOD: We explored collaboration within quality improvement collaboratives in Ethiopia through 42 in-depth interviews with staff of two hospitals and four health centers and three with quality improvement mentors. Data were analysed thematically using a deductive and inductive approach. RESULTS: There was collaboration at learning sessions though experience sharing, co-learning and peer pressure. Respondents were used to a blaming environment, which they contrasted to the open and non-blaming environment at the learning sessions. Respondents formed new relationships that led to across facility practical support. Within facilities, those in the quality improvement team continued to collaborate through the plan-do-study-act cycles, although this required high engagement and support from mentors. Few staff were able to attend learning sessions and within facility transfer of quality improvement knowledge was rare. This affected broader participation and led to some resentment and resistance. Improved teamwork skills and behaviors occurred at individual rather than facility or systems level, with implications for sustainability. Challenges to collaboration included unequal participation, lack of knowledge transfer, high workloads, staff turnover and a culture of dependency. CONCLUSION: We conclude that collaboration can occur and is valued within a traditionally hierarchical system, but may require explicit support at learning sessions and by mentors. More emphasis is needed on ensuring quality improvement knowledge transfer, buy-in and system level change. This could include a modified collaborative design to provide facility-level support for spread.

Using the Implementation Research Logic Model to design and implement community-based management of possible serious bacterial infection during COVID-19 pandemic in Ethiopia.

BACKGROUND: Community-based treatment of possible serious bacterial infection (PSBI) in young infants, when referral to a hospital is not possible, can result in high treatment coverage and low case fatality. However, in Ethiopia, the coverage of PSBI treatment remains low, worsened by COVID-19. To understand the challenges of delivery of PSBI treatment and design and test adaptative strategies to mitigate the impact of COVID-19 on neonatal mortality, we did implementation research (IR) employing Implementation Research Logic Model (IRLM). In this paper, we describe IRLM application experiences in designing, implementing, and evaluating strategies to improve community-based treatment of PSBI during the COVID-19 pandemic in Ethiopia. METHODS: This IR was conducted between November 2020-April 2022 at Dembecha and Lume woredas of Amhara and Oromia regions, respectively. We employed narrative reviews, formative assessment and facilitated stakeholder engagement to develop the PSBI treatment IRLM to identify barriers, understand the conceptual linkages among determinants, choose implementation strategies, elicit mechanisms, and link to implementation outcomes. In addition, we used the IRLM to structure the capture of emerging implementation challenges and resulting strategy adaptations throughout implementation. RESULTS: This IR identified COVID-19 and multiple pre-existing contextual factors. We designed and implemented implementation strategies to address these challenges. These adaptive strategies were implemented with sufficient strength to maintain the delivery of PSBI services and improve mothers' care-seeking behavior for their sick young infants. The IRLM offers us a clear process and path to prioritize implementation challenges, choose strategies informed by mechanisms of action, and where the adaptive implementation of community-based management of PSBI would lead to high-implementation fidelity and change in mother behavior to seek care for their sick young infants. The IRLM was also an effective tool for stakeholder engagement, easily explained and used to structure discussion and decision-making during co-design meetings. CONCLUSIONS: The use of the IRLM helps us to specify the conceptual links between the implementation challenges, strategies, mechanisms of action, and outcomes to explore the complex community-based management of PSBI during complex contexts to improve high-fidelity implementation and integration of PSBI treatment in the primary healthcare delivery systems through active engagement of stakeholders.

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.

"Even though they insult us, the delivery they give us is the greatest thing": a qualitative study contextualizing women's experiences with facility-based maternal health care in Ethiopia.

BACKGROUND: Globally, amidst increased utilization of facility-based maternal care services, there is continued need to better understand women's experience of care in places of birth. Quantitative surveys may not sufficiently characterize satisfaction with maternal healthcare (MHC) in local context, limiting their interpretation and applicability. The purpose of this study is to untangle how contextual and cultural expectations shape women's care experience and what women mean by satisfaction in two Ethiopian regions. METHODS: Health center and hospital childbirth care registries were used to identify and interview 41 women who had delivered a live newborn within a six-month period. We used a semi-structured interview guide informed by the Donabedian framework to elicit women's experiences with MHC and delivery, any prior delivery experiences, and recommendations to improve MHC. We used an inductive analytical approach to compare and contrast MHC processes, experiences, and satisfaction. RESULTS: Maternal and newborn survival and safety were central to women's descriptions of their MHC experiences. Women nearly exclusively described healthy and safe deliveries with healthy outcomes as 'satisfactory'. The texture behind this 'satisfaction', however, was shaped by what mothers bring to their delivery experiences, creating expectations from events including past births, experiences with antenatal care, and social and community influences. Secondary to the absence of adverse outcomes, health provider's interpersonal behaviors (e.g., supportive communication and behavioral demonstrations of commitment to their births) and the facility's amenities (e.g., bathing, cleaning, water, coffee, etc) enhanced women's experiences. Finally, at the social and community levels, we found that family support and material resources may significantly buffer against negative experiences and facilitate women's overall satisfaction, even in the context of poor-quality facilities and limited resources. CONCLUSION: Our findings highlight the importance of understanding contextual factors including past experiences, expectations, and social support that influence perceived quality of MHC and the agency a woman has to negotiate her care experience. Our finding that newborn and maternal survival primarily drove women's satisfaction suggests that quantitative assessments conducted shortly following delivery may be overly influenced by these outcomes and not fully capture the complexity of women's care experience.

An innovative intervention to improve respectful maternity care in three Districts in Ethiopia.

BACKGROUND: Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions. METHODS: Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data. RESULTS: Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations. CONCLUSION: This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner.

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.

Sustainability Assessment of a District-Wide Quality Improvement on Newborn Care Program in Rural Rwanda: A Mixed-Method Study.

Background: Neonatal mortality continues to be a global challenge, particularly in low- and middle-income countries. There is growing work to reduce mortality through improving quality of systems and care, but less is known about sustainability of improvements in the setting post initial implementation. We conducted a 12-month sustainability assessment of All Babies Count (ABC), a district-wide quality improvement project including mentoring and improvement collaborative designed to improve quality and reduce neonatal mortality in two districts in rural Rwanda. Methods: We measured changes in key neonatal process, coverage, and outcome indicators between the completion of ABC implementation and 12 months after the completion. In addition, we conducted 4 focus group discussions and 15 individual in-depth interviews with health providers and facility and district leaders to understand factors that influenced sustainability of improvements. We used an inductive, content analytic approach to derive six themes related to the ABC sustainability to explain quantitative results. Findings: Twelve months after the completion of ABC implementation, we found continued improvements in core quality, coverage, and neonatal outcomes. During ABC, the percentage of women with 4 antenatal visits increased from 12% to 30% and remained stable 12 months post-ABC (30%, p = 0.7) with an increase in facility-based delivery from 92.6% at the end of ABC to 95.8% (p = 0.01) at 12-month post-ABC. During ABC intervention, the 2 districts decreased neonatal mortality from 30.1 to 19.4 deaths per 1,000 live births with maintenance of the lower mortality 12 months post-ABC (19.4 deaths per 1,000 live births, p = 0.7). Leadership buy-in and development of self-reliance encouraging internally generated solutions emerged as key factors to sustain improvements while staff turnover, famine, influx of refugees, and unintended consequences of new national newborn care policies threatened sustainability. Interpretation: Despite discontinuity of key ABC support, health facilities kept the momentum of good practices and were able to maintain or increase the level of prenatal, neonatal quality of care and outcomes over a period of 12 months following the end of initial ABC implementation. Additional studies are needed to determine the longer-term sustainability beyond one year.

The All Babies Count Initiative: Impact of a Health System Improvement Approach on Neonatal Care and Outcomes in Rwanda.

INTRODUCTION: Poor-quality care contributes to a significant portion of neonatal deaths globally. The All Babies Count (ABC) initiative was an 18-month district-wide approach designed to improve clinical and system performance across 2 rural Rwandan districts. METHODS: This pre-post intervention study measured change in maternal and newborn health (MNH) quality of care and neonatal mortality. Data from the facility and community health management information system and newly introduced indicators were extracted from facility registers. Medians and interquartile ranges were calculated for the health facility to assess changes over time, and a mixed-effects logistic regression model was created for neonatal mortality. A difference-in-differences analysis was conducted to compare the change in district neonatal mortality with the rest of rural Rwanda. RESULTS: Improvements were seen in multiple measures of facility readiness and MNH quality of care, including antenatal care coverage, preterm labor management, and postnatal care quality. District hospital case fatality decreased, with a statistically significant reduction in district neonatal mortality (odds ratio [OR]=0.54; 95% confidence interval [CI]=0.36, 0.83) and among preterm/low birth weight neonates (OR=0.47; 95% CI=0.25, 0.90). Neonatal mortality was reduced from 30.1 to 19.6 deaths/1,000 live births in the intervention districts and remained relatively stable in the rest of rural Rwanda (difference in differences -12.9). CONCLUSION: The ABC initiative contributed to improved MNH quality of care and outcomes in rural Rwanda. A combined clinical and health system improvement approach could be an effective strategy to improve quality and reduce neonatal mortality.

Mitigating the mistreatment of childbearing women: evaluation of respectful maternity care intervention in Ethiopian hospitals.

OBJECTIVES: There is a lack of evidence on approaches to mitigating mistreatment during facility-based childbirth. This study compares the experiences of mistreatment reported by childbearing women before and after implementation of a respectful maternity care intervention. DESIGN: A pre-post study design was undertaken to quantify changes in women's experiences of mistreatment during facility-based childbirth before and after the respectful maternity care intervention. INTERVENTION: A respectful maternity care intervention was implemented in three hospitals in southern Ethiopia between December 2017 and September 2018 and it included training of service providers, placement of wall posters in labour rooms and post-training supportive visits for quality improvement. OUTCOME MEASURES: A 25-item questionnaire asking women about mistreatment experiences was administered to 388 women (198 in the pre-intervention, 190 in the post-intervention). The outcome variable was the number of mistreatment components experienced by women, expressed as a score out of 25. Multilevel mixed-effects Poisson modelling was used to assess the change in mistreatment score from pre-intervention to post-intervention periods. RESULTS: The number of mistreatment components experienced by women was reduced by 18% when the post-intervention group was compared with the pre-intervention group (adjusted regression coefficient (Aß)=0.82, 95% CI 0.74 to 0.91). Women who had a complication during pregnancy (Aß=1.17, 95% CI 1.01 to 1.34) and childbirth (Aß=1.16, 95% CI 1.03 to 1.32) experienced a greater number of mistreatment components. On the other hand, women who gave birth by caesarean birth after trial of vaginal birth (Aß=0.76, 95% CI 0.63 to 0.92) and caesarean birth without trial of vaginal birth (Aß=0.68, 95% CI 0.47 to 0.98) experienced a lesser number of mistreatment components compared with those who had vaginal birth. CONCLUSIONS: Women reported significantly fewer mistreatment experiences during childbirth following implementation of the intervention. Given the variety of factors that lead to mistreatment in health facilities, interventions designed to mitigate mistreatment need to involve structural changes.

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 impacts of quality improvement on maternal and newborn health: preliminary findings from a health system integrated intervention in four Ethiopian regions.

BACKGROUND: Quality improvement (QI) methods are effective in improving healthcare delivery using sustainable, collaborative, and cost-effective approaches. Systems-integrated interventions offer promise in terms of producing sustainable impacts on service quality and coverage, but can also improve important data quality and information systems at scale. METHODS: This study assesses the preliminary impacts of a first phase, quasi-experimental, QI health systems intervention on maternal and neonatal health outcomes in four pilot districts in Ethiopia. The intervention identified, trained, and coached QI teams to develop and test change ideas to improve service delivery. We use an interrupted time-series approach to evaluate intervention effects over 32-months. Facility-level outcome indicators included: proportion of mothers receiving four antenatal care visits, skilled delivery, syphilis testing, early postnatal care, proportion of low birth weight infants, and measures of quality delivery of childbirth services. RESULTS: Following the QI health systems intervention, we found a significant increase in the rate of syphilis testing (ß = 2.41, 95% CI = 0.09,4.73). There were also large positive impacts on health worker adherence to safe child birth practices just after birth (ß = 8.22, 95% CI = 5.15, 11.29). However, there were limited detectable impacts on other facility-usage indicators. Findings indicate early promise of systems-integrated QI on the delivery of maternal health services, and increased some service coverage. CONCLUSIONS: This study preliminarily demonstrates the feasibility of complex, low-cost, health-worker driven improvement interventions that can be adapted in similar settings around the world, though extended follow up time may be required to detect impacts on service coverage. Policy makers and health system workers should carefully consider what these findings mean for scaling QI approaches in Ethiopia and other similar settings.

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.

Developmental Outcomes of Preterm and Low Birth Weight Toddlers and Term Peers in Rwanda.

Background: As neonatal care improves in low-resource settings, more preterm or low birth weight (LBW) babies are surviving, but little is known about their long-term outcomes. Globally, preterm and/or LBW babies are at increased risk of mortality, malnutrition, and developmental delay. Objectives: We aim to describe the differences in development in rural Rwandan children at 24-36 months of age born preterm and/or LBW compared to their peers born term or normal birth weight (term/NBW), and to assess factors associated with poor development. Methods: We conducted a cross-sectional study using secondary data analysis from two combined datasets from 2014, using Ages and Stages Questionnaire (ASQ-3) for developmental assessment and anthropometrics for nutritional status (stunting and wasting). Demographic and clinical factors associated with poor developmental outcomes in univariate regression at α = 0.20 were included in a full model; we used backward stepwise penalized multivariable logistic regression to identify a final model at α = 0.05. Findings: In total, 445 children were included; 405 term/NBW, and 40 preterm and/or LBW. Half of them (n = 234; 52.6%) had developmental delay, including 207 (51.1%) among term/NBW and 27 (67.5%) among preterm and/or LBW (p = 0.048). In the final model, term/NBW children with stunting alone had a significant increase in the odds of developmental delay (OR 2.05, 95% CI 1.37-3.07), and children with wasting had a borderline statistically significant increased odds of developmental delay (OR 5.79, 95% CI 0.98-34.39). Being preterm and/or LBW and not stunted completely predicted delay. Conclusion: Half of the children had developmental delay in our sample from rural Rwanda. Preterm and/or LBW infants were more likely to have developmental delay, and the main predictor of developmental delay was stunting, with high rates of stunting observed also in term/NBW infants. Interventions to reduce undernutrition and prevent prematurity and LBW, alongside investments to promote early stimulation for optimal development, are needed if gains in addressing developmental delay are to be made.