Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial.

BACKGROUND: High levels of maternal and newborn mortality and morbidity remain a daunting reality in many low-income countries. Several interventions delivered during antenatal care have been shown to improve maternal and newborn outcomes, but stockouts of medical supplies at point of care can prevent implementation of these services. We aimed to evaluate whether a supply chain strategy based on the provision of kits could improve quality of care. METHODS: We did a pragmatic, stepped-wedge, cluster-randomised controlled trial at ten antenatal care clinics in Mozambique. Clinics were eligible if they were not already implementing the proposed antenatal care package; they served at least 200 new pregnant women per year; they had Maternal and Child Health (MCH) nurses; and they were willing to participate. All women attending antenatal care visits at the participating clinics were included in the trial. Participating clinics were randomly assigned to shift from control to intervention on prespecified start dates. The intervention involved four components (kits with medical supplies, a cupboard to store these supplies, a tracking sheet to monitor stocks, and a one-day training session). The primary outcomes were the proportion of women screened for anaemia and proteinuria, and the proportion of women who received mebendazole in the first antenatal care visit. The intervention was delivered under routine care conditions, and analyses were done according to the intention-to-treat principle. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201306000550192. FINDINGS: Between March, 2014, and January, 2016, 218 277 antenatal care visits were registered, with 68 598 first and 149 679 follow-up visits. We found significant improvements in all three primary outcomes. In first visits, 5519 (14·6%) of 37 826 women were screened for anaemia in the control period, compared with 30 057 (97·7%) of 30 772 in the intervention period (adjusted odds ratio 832·40; 99% CI 666·81-1039·11; p<0·0001); 3739 (9·9%) of 37 826 women were screened for proteinuria in the control period, compared with 29 874 (97·1%) of 30 772 in the intervention period (1875·18; 1447·56-2429·11; p<0·0001); and 17 926 (51·4%) of 34 842 received mebendazole in the control period, compared with 24 960 (88·2%) of 28 294 in the intervention period (1·88; 1·70-2·09; p<0·0001). The effect was immediate and sustained over time, with negligible heterogeneity between sites. INTERPRETATION: A supply chain strategy that resolves stockouts at point of care can result in a vast improvement in quality during antenatal care visits, when compared with the routine national process for procurement and distribution of supplies. FUNDING: Government of Flanders and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: a qualitative study.

BACKGROUND: Maternal mortality remains a daunting problem in Mozambique and many other low-resource countries. High quality antenatal care (ANC) services can improve maternal and newborn health outcomes and increase the likelihood that women will seek skilled delivery care. This study explores the factors influencing provider uptake of the recommended package of ANC interventions in Mozambique. METHODS: This study used qualitative research methods including key informant interviews with stakeholders from the health sector and a total of five focus group discussions with women with experience with ANC or women from the community. Study participants were selected from three health centers located in Maputo city, Tete, and Cabo Delgado provinces in Mozambique. Staff responsible for the medicines/supply chain at national, provincial and district level were interviewed. A check list was implemented to confirm the availability of the supplies required for ANC. Deductive content analysis was conducted. RESULTS: Three main groups of factors were identified that hinder the implementation of the ANC package in the study setting: a) system or organizational: include chronic supply chain deficiencies, failures in the continuing education system, lack of regular audits and supervision, absence of an efficient patient record system and poor environmental conditions at the health center; b) health care provider factors: such as limited awareness of current clinical guidelines and a resistant attitude to adopting new recommendations; and c) Users: challenges with accessing ANC, poor recognition amongst women about the purpose and importance of the specific interventions provided through ANC, and widespread perception of an unfriendly environment at the health center. CONCLUSIONS: The ANC package in Mozambique is not being fully implemented in the three study facilities, and a major barrier is poor functioning of the supply chain system. Recommendations for improving the implementation of antenatal interventions include ensuring clinical protocols based on the ANC model. Increasing the community understanding of the importance of ANC would improve demand for high quality ANC services. The supply chain functioning could be strengthened through the introduction of a kit system with all the necessary supplies for ANC and a simple monitoring system to track the stock levels is recommended.

Implementation of evidence-based antenatal care in Mozambique: a cluster randomized controlled trial: study protocol.

BACKGROUND: Antenatal care (ANC) reduces maternal and perinatal morbidity and mortality directly through the detection and treatment of pregnancy-related illnesses, and indirectly through the detection of women at increased risk of delivery complications. The potential benefits of quality antenatal care services are most significant in low-resource countries where morbidity and mortality levels among women of reproductive age and neonates are higher.WHO developed an ANC model that recommended the delivery of services scientifically proven to improve maternal, perinatal and neonatal outcomes. The aim of this study is to determine the effect of an intervention designed to increase the use of the package of evidence-based services included in the WHO ANC model in Mozambique. The primary hypothesis is that the intervention will increase the use of evidence-based practices during ANC visits in comparison to the standard dissemination channels currently used in the country. METHODS: This is a demonstration project to be developed through a facility-based cluster randomized controlled trial with a stepped wedge design. The intervention was tailored, based on formative research findings, to be readily applicable to local prenatal care services and acceptable to local pregnant women and health providers. The intervention includes four components: the provision of kits with all necessary medicines and laboratory supplies for ANC (medical and non-medical equipment), a storage system, a tracking system, and training sessions for health care providers. Ten clinics were selected and will start receiving the intervention in a random order. Outcomes will be computed at each time point when a new clinic starts the intervention. The primary outcomes are the delivery of selected health care practices to women attending the first ANC visit, and secondary outcomes are the delivery of selected health care practices to women attending second and higher ANC visits as well as the attitude of midwives in relation to adopting the practices. This demonstration project is pragmatic in orientation and will be conducted under routine conditions. DISCUSSION: There is an urgent need for effective and sustainable scaling-up approaches of health interventions in low-resource countries. This can only be accomplished by the engagement of the country's health stakeholders at all levels. This project aims to achieve improvement in the quality of antenatal care in Mozambique through the implementation of a multifaceted intervention on three levels: policy, organizational and health care delivery levels. The implementation of the trial will probably require a change in accountability and behaviour of health care providers and we expect this change in 'habits' will contribute to obtaining reliable health indicators, not only related to research issues, but also to health care outcomes derived from the new health care model. At policy level, the results of this study may suggest a need for revision of the supply chain management system. Given that supply chain management is a major challenge for many low-resource countries, we envisage that important lessons on how to improve the supply chain in Mozambique and other similar settings, will be drawn from this study. TRIAL REGISTRATION: Pan African Clinical Trial Registry database. Identification number: PACTR201306000550192.

Aproximación Psicométrica al Uso de los Q-Sorts en Contextos de Educación Inicial / Psychometric Evaluation of the Q-Sorts in Initial Education Contexts

La sensibilidad del cuidador se refiere a la pronta y adecuada lectura, interpretación y respuesta a las señales del infante que promueve la construcción de vínculos de apego. La crianza actual incluye, además de la díada mamá-infante, a cuidadores secundarios profesionales (CSP) en centros de educación inicial (CEI). El AQS (Waters, 1995) evalúa las conductas de base segura que el infante despliega con su cuidador; el MBQS (Pederson & Moran, 1995) la sensibilidad del adulto. Se observaron 34 diadas CSP-infante en CEI de prestación indirecta del IMSS con el apoyo del AQS y el MBQS para explorar la configuración factorial de los constructos planteados por la teoría del apego para cuidadores primarios -sensibilidad y conductas de base segura- (Bowlby 1969, 1973; Ainsworth & Wittig, 1969; Ainsworth, Blehar, Waters & Wall, 1978) con CSP en CEI. Se identificó que el Q-Sort del apego adaptado (QSA) explica un 52.99% de la varianza (α=.69) y se diferencia del AQS en la Inconsistencia en el vínculo con la CSP. Para la sensibilidad, el QSCCSP (Q-Sort del Comportamiento del CSP) explicó el 45.35% de la varianza (α=.91) reduciendo el número de factores del MBQS y disminuyendo la especificidad de los mismos.

As more women enter the workforce either as half or full time, it is now the norm in many societies for children to be placed in childcare before their first birthday. Because most of these children spend at least eight hours in childcare, we need to assess the quality of the service supplied by professional secondary caregivers (PSC). Maternal sensitivity is defined as mother's ability to perceive and respond promptly and accurately to the child's signals (Bowlby, 1969; Ainsworth, Blehar, Waters & Wall, 1978). The AQS (Waters, 1995) consists of 90 items describing attachment relevant infant behavior; the MBQS (Pederson & Moran, 1995) consists of 90 items describing maternal behavior. 34 child-PSC dyads were assessed in Mexican Social Security Child Care centers with the AQS and MBQS, to explore the factorial structure of sensitivity and secure base behaviors in Child Care facilities. The Child Care-adapted version of the AQS explains 52.99% of the variance (α=.69) and underlines the inconsistency of the relationship. The Professional Secondary Caregiver Q-Sort (PSCQS) explains the 45.35% of the variance (α=.91) with few and less specific factors than those previously reported in the MBSQ.

Caracterización Morfométrica de placentas en embarazos gemelares / Morphometric characterization of twin pregnacy placenta

Se realizó un estudio descriptivo longitudinal retrospectivo en el municipio Manzanillo durante el período de estudio diciembre 2007-dicembre 2008 con el objetivo de caracterizar morfométricamente las placentas procedentes de embarazos gemelares enel Hospital Materno Infantil Fe del Valle Ramos. La muestra estuvo representada por las 35 placentas procedentes de 27 gestantes y los recién nacidos de estos embarazos. En los hallazgos ultrasonográficos y al momento del parto se observó el tipo de placenta,predominando las monocoriónicas, la localización del cordón umbilical central y paracentral predominó en las mismas. Otras variables fueron morfometría relacionada con la placenta, así como el peso de los neonatos. Los bajos peso se relacionaron con la inserción velametosa del cordón umbilical y la inserción marginal del mismo y se encontró un lóbulo accesorio de la placenta en uno de los embarazos. Las malformaciones placentarias predominaron en el tipo monocoriónica.(AU)

A descriptive research was performed in Manzanillo during the period January2001-January 2008 with the objective to characterize morphometrically, the twin pregnancy placenta in Fe del Valle Ramos Maternal and Child Hospital, The sample was represented by the 35 placentas coming from 25 pregnant and the newborns. In the ultrasonography findings and the labour itself it was observed the kind of placenta,prevailing the monochorionic ones; the location of central and paracentral umbilical cord prevailed in the placenta. Other variables were morphometry related to the placenta as well as the neonates weight. The under weights were related to the velamentousinsertion of umbilical cord and its marginal insertion and it was found an accessory lobe of the placenta in one of the pregnant. The malformations of the placenta prevailed in the monochorionic type.(EU)