Quality of maternal and newborn hospital care in Brazil: a quality improvement cycle using the WHO assessment and quality tool.

BACKGROUND: Increasing efforts toward quality improvement (QI) are necessary in low- and middle-income countries (LMICs) to reduce maternal and perinatal mortality and morbidity and to promote respectful care. In Brazil, perinatal health indicators are below targets in several states despite universal access to perinatal services and very high rates of institutional births, indicating poor quality of care (QoC) as a key issue to be addressed. However, research efforts to develop and test QoC improvement interventions are scarce. OBJECTIVES: We assessed the effects of a 1-year comprehensive QI cycle using a World Health Organization (WHO) assessment and quality tool on maternal and newborn care at hospital level and documented QIs obtained after a 1-year comprehensive QI cycle. METHODS: Uncontrolled, unblinded, pre-post study carried out in six maternity hospitals in Pernambuco, Brazil, accounting for 29 128 live births in 2014. A standards-based and participatory approach based on a WHO quality assessment and improvement tool for maternal and neonatal care at hospital level was used. A national team of assessors supervised by international experts carried out baseline and final assessments. An action plan was developed and implemented to address key quality gaps emerging from the baseline assessment and from two supportive supervision visits. RESULTS: At baseline, hospitals presented a variety of quality gaps, the majority common to all participating centers. Gaps in case management of normal and complicated deliveries and in respectful and holistic care were predominant, in both teaching/tertiary and secondary care hospitals. After one year, several improvements were observed, particularly in respectful care during labor and at delivery, in case management of normal labor and delivery and in neonatal care. CONCLUSIONS: A systematic participatory approach based on a WHO tool produced important QIs in a relatively short time and should be considered for use for large-scale QI programs in Brazil and other LMICs. Its comprehensive, peer-to-peer and action-oriented nature and its capability to document QI over time and to build a QI culture represent important comparative advantages over other QI interventions.

Visitas domiciliares inovadoras e a saúde materno­infantil / Visitas domiciliarias innovadoras y la salud materno infantil / Innovative home visits and maternal and child health

OBJETIVO: Avaliar o efeito de um programa de Visitas Domiciliares Inovadoras (VDI), que é baseado em um guia de orientação, nos conhecimentos e práticas de saúde das mães em relação aos cuidados da criança e durante os períodos pré/pós-natal, e indicadores de saúde materno-infantil (ISMI). MÉTODOS: Estudo transversal e analítico que comparou 195 gestantes e mães que receberam VDI (grupo 1) com o grupo 2, de visitas domiciliares convencionais (VDC), realizado em Unidades de Saúde da Família (USF) de Recife, Pernambuco, entre 2015 a 2016. Dividiram-se 16 equipes de saúde da família em dois grupos: oito equipes receberam treinamento para VDI e oito não receberam. Houve dez VDI com a utilização do guia, durante a gestação e durante os nove meses da criança. As VDC ocorreram uma vez/mês, durante o mesmo período das VDI, mas sem o guia. Após nove meses, as participantes foram entrevistadas através de questionário com conteúdos relacionados à saúde materno-infantil. RESULTADOS: 93 gestantes (49 do grupo 1 e 44 do 2) e 102 mães de crianças (57 do grupo 1 e 45 do 2) responderam aos questionários. Os resultados mostraram melhores indicadores de pré-natal (p=0,005), melhor conhecimento sobre métodos contraceptivos (p<0,001) e melhores indicadores de amamentação exclusiva e de alimentação complementar adequada (p<0,001) no grupo 1. CONCLUSÃO: A VDI pode contribuir para melhorar os indicadores de saúde materno-infantil e os conhecimentos e as práticas de saúde das mães relacionados aos cuidados com as crianças e à gestação.

OBJECTIVE: To assess the effect of an Innovative Home Visits (IHV) program, which is based on an action-oriented guide, on mothers' knowledge and practices related to child health care, prenatal and postpartum care, and maternal and child health indicators (MCHI). METHODS: Analytical cross-sectional study that compared 195 pregnant women and mothers who received IHV (group 1) with group 2, which received conventional home visits (CHV). The study was carried out in Family Health Care (FHC) centers in Recife, Pernambuco, between 2015 and 2016. 16 family health teams were divided into 2 groups: eight teams received training to perform IHV and eight did not receive training. There were ten IHV using the guide during pregnancy and the first nine months of the child's life. CHV occurred once a month in the same period IHV were carried out, but they did not use the guide. After nine months, the participants were interviewed using a questionnaire with contents related to maternal and child health. RESULTS: 93 pregnant women (49 of group 1 and 44 of group 2) and 102 mothers (57 of group 1 and 45 of group 2) answered the questionnaire. The results showed better prenatal care indicators (p=0.005), better knowledge about contraceptive methods (p<0.001) and better indicators of exclusive breastfeeding and adequate complementary feeding (p<0.001) in group 1. CONCLUSION: The IHV program can contribute to improving MCHI and mothers' knowledge and practices related to child health care and pregnancy.

OBJETIVO: Evaluar el efecto de un programa de Visitas Domiciliarias Innovadoras (VDI) que está basado en una guía de orientación, en los conocimientos y las prácticas de salud de las madres con respecto a los cuidados del niño y durante los períodos pre/posnatal y los indicadores de salud materno infantil (ISMI). MÉTODOS: Estudio transversal y analítico que ha comparado 195 embarazadas y madres que recibieron las VDI (grupo 1) con el grupo 2 de las visitas domiciliarias convencionales (VDC) realizado en las Unidades de Salud de la Familia (USF) de Recife, Pernambuco, entre 2015 y 2016. Se dividieron 16 equipos de salud de la familia en dos grupos: ocho equipos recibieron el entrenamiento para las VDI y ocho no. Hubo diez VDI con la utilización de la guía durante el embarazo y durante los nueve meses del niño. Las VDC se dieron una vez/mes durante el mismo periodo de las VDI pero sin la guía. Después de los nueve meses las participantes fueron entrevistadas a través de cuestionario con contenidos relacionados con la salud materno infantil. RESULTADOS: 93 embarazadas (49 del grupo 1 y 44 del grupo 2) y 102 madres de niños (57 del grupo 1 y 45 del grupo 2) contestaron los cuestionarios. Los resultados mostraron mejores indicadores de prenatal (p=0,005), mejor conocimiento sobre los métodos de contracepción (p<0,001) y mejores indicadores para el amamantamiento exclusivo y de alimentación complementaria adecuada (p<0,001) en el grupo 1. CONCLUSIÓN: La VDI puede contribuir para la mejoría de los indicadores de la salud materno infantil y los conocimientos y las prácticas de salud de las madres relacionadas con los cuidados de los niños y el embarazo.

Effectiveness of an action-oriented educational intervention in ensuring long term improvement of knowledge, attitudes and practices of community health workers in maternal and infant health: a randomized controlled study.

BACKGROUND: The potential role of Community Health Workers (CHWs) in improving maternal and child health outcomes, particularly in low and middle-income countries and in disadvantaged communities, is receiving increased attention. Adequate and focused training is among the key requisites for enhancing CHWs performances and research is necessary to identify effective training methods. METHODS: A randomized controlled study was designed to assess the effectiveness of a training course in improving knowledge, attitudes and practices (KAP) of CHWs regarding maternal and infant health. Seventy-eight CHWs belonging to Family Health Units in the city of Recife, Brazil were randomly allocated to intervention and control groups. The intervention group took part in a four-day interactive training course based on an action-oriented guide to perform home visits to pregnant women and their infants throughout pregnancy and infancy until 9 months of age. KAP in intervention group after training and after 1 year were compared to control group and to baseline. RESULTS: Fifty-nine CHWs completed all KAP assessments (31 in intervention and 28 in control group). Baseline characteristics were similar in both groups. At 1 year from training, the intervention group had higher overall KAP score (120.65 vs. 108.19, p <  0.001) as well as knowledge (47.45 vs. 40.54, p <  0.001), practice (53.45 vs. 49.11, p <  0.001) and attitudes scores (19.74 vs. 18.81, p = 0.047) than the control group. Moreover, at 1 year from training, the intervention group maintained significant improvements in overall KAP score (120.65 vs. 106.55, p <  0.001) as well as in knowledge (45.45 vs. 42.13, p <  0.001), and practice (53.45 vs. 45.29, p <  0.001) scores with respect to baseline. In the control group, overall KAP (106.59 vs. 108.19, p = 0.345) as well as separate knowledge, attitudes and practices scores remained unchanged. CONCLUSIONS: A four-day interactive training course on action-oriented home visits to pregnant women and infants produced a sustained improvement of CHWs' KAP and may represent a model to ensure retention of acquired competences. TRIAL REGISTRATION: RBR-9gchqr . Date registered: July 21, 2018 (Retrospectively registered).

Innovating home visiting to mothers and infants by community health workers: an action-oriented guide / Inovando visitas domiciliares a gestantes e crianças por agentes comunitários de saúde: um guia orientado por ações

Abstract Objectives: to describe the process of development and the structure of an action-oriented guide for home visits (HVs) to mothers and infants by Community Health Workers (CHWs). The guide was adopted in a controlled trial aimed at assessing its efficacy in improving CHWs' performance. Methods: steps to develop the guide included: 1) Review of international and national standards and recommendations for community interventions for maternal and child care; 2) Assessment of perceived needs of CHWs and other Family Health professionals regarding prenatal and postnatal HVs; 3) Identification of elements to construct the guide. Results: the Guide provides action-oriented instructions for 10 HVs during prenatal and postnatal period up to 9 months instead of the 18 HVs currently recommended by Ministry of Health. Specific tasks for each visit including assessment and promotion of early child development (ECD) and an action-oriented risk classification are introduced as standardized operational practice. Conclusions: the described approach to guide construction allows adapting the guide contents to the health system context in Brazil and other countries interested in improving quality of HVs by CHWs. The guide, by identifying tasks to be carried out and actions to be taken at each HV, provides an innovative approach and represents a requisite for a more efficient and effective use of their time.

Resumo Objetivos: descrever o processo de desenvolvimento e a estrutura de um guia orientado por ações para visitas domiciliares (VDs) a mães e crianças por Agentes Comunitários de Saúde (ACSs). O guia foi aplicado em um estudo controlado visando avaliar sua eficácia em melhorar o desempenho dos ACSs. Métodos: os passos para desenvolvimento do guia incluíram: 1)Revisão das recomendações nacionais e internacionais para intervenções na comunidade em saúde materno-infantil; 2) Avaliação das necessidades de ACSs e outros profissionais das Equipes de Saúde da Família sobre VDs nos períodos pré e pós-natal; 3)Identificação dos princípios para construir o guia. Resultados: o Guia traz instruções para 10 VDs nos períodos pré e pós natal até os 9 meses, ao invés de 18 VDs atualmente recomendadas pelo Ministério da Saúde. Tarefas específicas para cada visita incluindo avaliação e promoção do desenvolvimento da primeira infância (DPI) e classificação de risco orientada por ações foram introduzidas como prática padronizada. Conclusões: a abordagem descrita para a construção do guia permite adaptar os conteúdos ao contexto do sistema de saúde do Brasil e de outros países interessados em melhorar a qualidade das VDs por ACSs. O guia, identificando tarefas e ações a serem realizadas a cada VD, oferece uma abordagem inovadora e representa um requisito para utilização mais eficiente e efetiva do tempo.

Nutrición e infección: epidemiología, biología y perspectivas de tratamiento / Nutrition an infection: epidemiology, biology and prospects of treatment

Se sabe desde hace mucho tiempo que entre malnutrición e infección existe una interacción estrecha y compleja. El objetivo del presente trabajo de investigación es, en base a publicaciones recientes en el campo, repasar los términos de esta relación; desde el análisis de los fenómenos y su interpretación biológica, hasta sus implicaciones en términos de salud pública