Educating Families on Urgent Maternal Warning Signs: Learning From a Pilot to Improve Training and Tools for Maternal and Child Home Visiting Programs.

Early recognition of the warning signs of pregnancy-related complications and provision of timely, quality care could prevent many maternal deaths. We piloted a maternal warning signs education intervention with five Maryland-based maternal, infant, and early childhood home visiting programs serving populations disproportionately affected by adverse maternal outcomes. The intervention included a 1.5-hr online training for home visitors, monthly collaborative calls with program managers, and a client education toolkit with a 3-min video, illustrated handout of 15 urgent maternal warning signs, magnet with the same, and discussion guide for home visitor-client interactions. A mixed-methods formative evaluation assessed the acceptability, feasibility, and utilization of different components of the intervention. Home visiting program staff reported that the materials were highly acceptable and easily understood by diverse client populations. They valued the illustrations, simple language, and translation of materials in multiple languages. Program managers found implementation a relatively simple process, feasible for in-person and remote visits. Despite positive reception, not all components of the toolkit were used consistently. Program managers and staff also identified the need for more guidance and tools to help clients communicate with health care providers and advocate for their health care needs. Feedback from pilot sites was used to adapt the training and tools, including adding content on patient self-advocacy. Home visiting programs have a unique ability to engage families during pregnancy and the postpartum period. This pilot offers lessons learned on strategies and tools that home visiting programs can use to improve early recognition and care-seeking for urgent maternal warning signs.

Assessing the neonatal health policy landscape in low- and middle-income countries: Findings from the 2018 WHO SRMNCAH policy survey.

Background: We aimed to describe the availability of newborn health policies across the continuum of care in low- and middle-income countries (LMICs) and to assess the relationship between the availability of newborn health policies and their achievement of global Sustainable Development Goal and Every Newborn Action Plan (ENAP) neonatal mortality and stillbirth rate targets in 2019. Methods: We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) Policy Survey and extracted key newborn health service delivery and cross-cutting health systems policies that align with the WHO health system building blocks. We constructed composite measures to represent packages of newborn health policies for five components along the continuum of care: antenatal care (ANC), childbirth, postnatal care (PNC), essential newborn care (ENC), and management of small and sick newborns (SSNB). We used descriptive analyses to present the differences in the availability of newborn health service delivery policies by World Bank income group in 113 LMICs. We employed logistic regression analysis to assess the relationship between the availability of each composite newborn health policy package and achievement of global neonatal mortality and stillbirth rate targets by 2019. Results: In 2018, most LMICs had existing policies regarding newborn health across the continuum of care. However, policy specifications varied widely. While the availability of the ANC, childbirth, PNC, and ENC policy packages was not associated with having achieved global NMR targets by 2019, LMICs with existing policy packages on the management of SSNB were 4.4 times more likely to have reached the global NMR target (adjusted odds ratio (aOR) = 4.40; 95% confidence interval (CI) = 1.09-17.79) after controlling for income group and supporting health systems policies. Conclusions: Given the current trajectory of neonatal mortality in LMICs, there is a dire need for supportive health systems and policy environments for newborn health across the continuum of care. Adoption and implementation of evidence-informed newborn health policies will be a crucial step in putting LMICs on track to meet global newborn and stillbirth targets by 2030.

Maternal health policy environment and the relationship with service utilization in low- and middle-income countries.

Background: The extent to which a favorable policy environment influences health care utilization and outcomes for pregnant and postpartum women is largely unknown. In this study, we aimed to describe the maternal health policy environment and examines its relationship with maternal health service utilization in low- and middle-income countries (LMICs). Methods: We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) policy survey linked with key contextual variables from global databases, as well as UNICEF data on antenatal care (ANC), institutional delivery, and postnatal care (PNC) utilization in 113 LIMCs. We grouped maternal health policy indicators into four categories - national supportive structures and standards, service access, clinical guidelines, and reporting and review systems. For each category and overall, we calculated summative scores accounting for available policy indicators in each country. We explored variations of policy indicators by World Bank income group using χ2 tests and fitted logistic regression models for ≥85% coverage for each of four or more antenatal care visits (ANC4+), institutional delivery, PNC for the mothers, and for all ANC4+, institutional delivery, and PNC for mothers, adjusting for policy scores and contextual variables. Results: The average scores for the four policy categories were as follows: 3 for national supportive structures and standards (score range = 0-4), 5.5 for service access (score range = 0-7), 6. for clinical guidelines (score range = 0-10), and 5.7 for reporting and review systems (score range = 0-7), for an average total policy score of 21.1 (score range = 0-28) across LMICs. After adjusting for country context variables, for each unit increase in the maternal health policy score, the odds of ANC4+>85% increased by 37% (95% confidence interval (CI) = 1.13-1.64) and the odds of all ANC4+, institutional deliveries and PNC>85% by 31% (95% CI = 1.07-1.60). Conclusions: Despite the availability of supportive structures and free maternity service access policies, there is a dire need for stronger policy support for clinical guidelines and practice regulations, as well as national reporting and review systems for maternal health. A more favorable policy environment for maternal health can improve adoption of evidence-based interventions and increase utilization of maternal health services in LMICs.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

BACKGROUND AND OBJECTIVE: The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS: In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS: Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS: Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Changes in the health systems and policy environment for maternal and newborn health, 2008-2018: An analysis of data from 78 low-income and middle-income countries.

BACKGROUND: Political, social, economic, and health system determinants play an important role in creating an enabling environment for maternal and newborn health. This study assesses changes in health systems and policy indicators for maternal and newborn health across 78 low- and middle-income countries (LMICs) during 2008-2018, and examines contextual factors associated with policy adoption and systems changes. METHODS: We compiled historical data from WHO, ILO, and UNICEF surveys and databases to track changes in ten maternal and newborn health systems and policy indicators prioritized for tracking by global partnerships. Logistic regression was used to examine the odds of systems and policy change based on indicators of economic growth, gender equality, and country governance with available data from 2008 to 2018. RESULTS: From 2008 to 2018, many LMICs (44/76; 57·9%) substantially strengthened systems and policies for maternal and newborn health. The most frequently adopted policies were national guidelines for kangaroo mother care, national guidelines for use of antenatal corticosteroids, national policies for maternal death notification and review, and the introduction of priority medicines in Essential Medicines Lists. The odds of policy adoption and systems investments were significantly greater in countries that experienced economic growth, had strong female labor participation, and had strong country governance (all p < 0·05). CONCLUSIONS: The widespread adoption of priority policies over the past decade is a notable step in creating an environment supportive for maternal and newborn health, but continued leadership and resources are needed to ensure robust implementation that translates into improved health outcomes.

Development of an instrument to measure awareness and mitigation of bias in maternal healthcare.

BACKGROUND: Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psychometrically valid instrument for use in the evaluation of implicit bias training. OBJECTIVE: This study aimed to develop a valid and reliable instrument to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice. STUDY DESIGN: We conducted an instrument development and validation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses). RESULTS: Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals. CONCLUSION: We developed a reliable and valid instrument for measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.

Understanding variation in person-centered maternity care: Results from a household survey of postpartum women in 6 regions of Ethiopia.

BACKGROUND: Effective communication, respect and dignity, and emotional support are critical for a positive childbirth experience that is responsive to the needs and preferences of women. OBJECTIVE: This study evaluated the performance of a person-centered maternity care scale in a large, representative household sample of postpartum women, and it describes differences in person-centered maternity care across individuals and communities in Ethiopia. STUDY DESIGN: The study used data from 2019 and 2020 from a representative sample of postpartum women in 6 regions of Ethiopia. It measured person-centered maternity care using a scale previously validated in other settings. To assess the scale validity in Ethiopia, we conducted cognitive interviews, measured internal consistency, and evaluated construct validity. Then, we fit univariable and multivariable linear regression models to test for differences in mean person-centered maternity care scores by individual and community characteristics. Lastly, multilevel modeling separated variance in person-centered maternity care scores within and between communities. RESULTS: Effective communication and support of women's autonomy scored lowest among person-centered maternity care domains. Of 1575 respondents, 704 (44.7%) were never asked their permission before examinations and most said that providers rarely (n=369; 23.4%) or never (n=633; 40.2%) explained why procedures were done. Person-centered maternity care was significantly higher for women with greater wealth, more formal education, and those aged >20 years. Variation in person-centered maternity care scores between individuals within the same community (τ2=58.3) was nearly 3 times greater than variation between communities (σ2=21.2). CONCLUSION: Ethiopian women reported widely varying maternity care experiences, with individuals residing within the same community reporting large differences in how they were treated by providers. Poor patient-provider communication and inadequate support of women's autonomy contributed most to poor person-centered maternity care.

Correction: The Potential of Digital Data Collection Tools for Long-lasting Insecticide-Treated Net Mass Campaigns in Nigeria: Formative Study.

[This corrects the article DOI: 10.2196/23648.].

The Potential of Digital Data Collection Tools for Long-lasting Insecticide-Treated Net Mass Campaigns in Nigeria: Formative Study.

BACKGROUND: Nigeria has the world's largest malaria burden, accounting for 27% of the world's malaria cases and 23% of malaria mortality globally. This formative study describes the operational process of the mass distribution of long-lasting insecticide-treated nets (LLINs) during a campaign program in Nigeria. OBJECTIVE: This study aims to assess whether and how digital data collection and management tools can change current practices and help resolve major implementation issues. METHODS: Qualitative data on the technical features and operational processes of paper-based and information and communication technology (ICT)-based systems in the Edo and Kwara states from June 2 to 30, 2017, were collected on the basis of documented operation manuals, field observations, and informant interviews. During the LLIN campaign in Edo State, we recruited 6 local government area focal persons and monitors and documented daily review meetings during household mobilization (9 days) and net distribution (5 days) to understand the major program implementation issues associated with the following three aspects: logistic issues, technical issues, and demand creation. Each issue was categorized according to the expected degree (low, mid, and high) of change by the ICT system. RESULTS: The net campaign started with microplanning and training, followed by a month-long implementation process, which included household mobilization, net movement, net distribution, and end process monitoring. The ICT system can improve management and oversight issues related to data reporting and processes through user-centered interface design, built-in data quality control logic flow or algorithms, and workflow automation. These often require more than 50% of staff time and effort in the current paper-based practice. Compared with the current paper-based system, the real-time system is expected to reduce the time to payment compensation for health workers by about 20 days and produce summary campaign statistics for at least 20 to 30 days. CONCLUSIONS: The ICT system can facilitate the measurement of population coverage beyond program coverage during an LLIN campaign with greater data reliability and timeliness, which are often compromised due to the limited workforce capacity in a paper-based system.

Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia.

BACKGROUND: Actionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO's Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme's Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO's quality of maternal and newborn care standards. METHODS: We used cross-sectional data from Performance Monitoring for Action Ethiopia's 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume. RESULTS: Indices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices. CONCLUSION: SARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness.

Assessing Barriers to Effective Coverage of Health Services for Adolescents in Low- and Middle-Income Countries: A Scoping Review.

PURPOSE: Understanding barriers to health services, as experienced by adolescents, is important to expand effective and equitable coverage; however, there is limited discussion on methods for conducting barrier assessments and translating findings into action. METHODS: We conducted a scoping review of literature published between 2005 and 2019 on barriers to health services for adolescents in low- and middle-income countries. The review was guided by a framework that conceptualized barriers across multiple dimensions of access (availability, geographic accessibility, affordability, and acceptability), utilization, and effective coverage. RESULTS: We identified 339 studies that assessed barriers related to at least one dimension of the operational framework. Acceptability (93%) and availability (88%) of health services were the most frequently studied access dimensions; affordability (45%) and geographic access (32%) were studied less frequently. Less than half (40%) of the studies evaluated utilization, and none of the 339 studies assessed effective coverage. Attention to equity stratifiers (e.g., income, disability) was limited. Topics studied reflected only a subset of the major causes of adolescent death and disability. CONCLUSIONS: Holistic, equity-oriented approaches are needed to better understand barriers across multiple dimensions that together determine whether health services are accessible, used, and effectively meet the needs of different adolescent groups.

Aid alignment: a longer term lens on trends in development assistance for health in Uganda.

BACKGROUND: Over the past decade, development assistance for health (DAH) in Uganda has increased dramatically, surpassing the government's own expenditures on health. Yet primary health care and other priorities identified in Uganda's health sector strategic plan remain underfunded. METHODS: Using data available from the Creditor Reporting System (CRS), National Health Accounts (NHA), and government financial reports, we examined trends in how donors channel DAH and the extent to which DAH is aligned with sector priorities. The study follows the flow of DAH from the donor to the implementing organization, specifying the modality used for disbursing funds and categorizing funds based on program area or support function. FINDINGS: Despite efforts to improve alignment through the formation of a sector-wide approach (SWAp) for health in 1999 and the creation of a fund to pool resources for identified priorities, increasingly DAH is provided as short-term, project-based support for disease-specific initiatives, in particular HIV/AIDS. CONCLUSION: These findings highlight the need to better align external resources with country priorities and refocus attention on longer-term sector-wide objectives.

As good as physicians: patient perceptions of physicians and non-physician clinicians in rural primary health centers in India.

BACKGROUND: Attracting physicians to rural areas has been a long-standing challenge in India. Government efforts to address the shortage of rural physicians include posting non-physician clinicians (NPCs) at primary health centers (PHCs) in select areas. Performance assessments of NPCs have typically focused on the technical quality of their care with little attention to the perspectives of patients. This study investigates patient views of physicians (Medical Officers) and NPCs in terms of patient satisfaction, perceived quality, and provider trust. NPCs include: Indian system of medicine physicians (AYUSH Medical Officers) and clinicians with 3 years of training, such as Rural Medical Assistants (RMAs). At PHCs without clinicians, paramedics provide clinical care, although they are not trained for this. METHODS: PHCS IN THE STATE OF CHHATTISGARH WERE STRATIFIED BY PROVIDER TYPE: Medical Officer, AYUSH Medical Officer, RMA, or paramedic. PHCs were randomly sampled in each group. A total of 1,082 exiting patients were sampled from138 PHCs. Factor analysis was used to identify perceived quality domains. Multiple regression analysis was used to test for group differences. RESULTS: Patients of Medical Officers and NPCs reported similar levels of satisfaction, trust, and perceived quality, with scores of 84% for Medical Officers, 80% for AYUSH Medical Officers, and 85% for RMAs. While there were no significant differences in these outcomes between these groups, scores for paramedical staff were significantly lower, at 73%. CONCLUSIONS: Physicians and NPCs performed similarly in terms of patient satisfaction, trust, and perceived quality. From a patient's perspective, this supports the use and scale up of NPCs in primary care settings in India. Leaving clinician posts vacant undermines public trust and quality perceptions of government health services.