Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial.

BACKGROUND: Newborn deaths comprise nearly half of under-5 deaths in Ghana, despite the fact that skilled birth attendants (SBAs) are present at 68% of births, which implies that evidence-based care during labor, birth and the immediate postnatal period may be deficient. We assessed the effect of a low-dose, high-frequency (LDHF) training approach on long-term evidence-based skill retention among SBAs and impact on adverse birth outcomes. METHODS: From 2014 to 2017, we conducted a cluster-randomized trial in 40 hospitals in Ghana. Eligible hospitals were stratified by region and randomly assigned to one of four implementation waves. We assessed the relative risks (RRs) of institutional intrapartum stillbirths and 24-h newborn mortality in months 1-6 and 7-12 of implementation as compared to the historical control period, and in post-intervention facilities compared to pre-intervention facilities during the same period. All SBAs providing labor and delivery care were invited to enroll; their knowledge and skills were assessed pre- and post-training, and 1 year later. RESULTS: Adjusting for region and health facility type, the RR of 24-h newborn mortality in the 40 enrolled hospitals was 0·41 (95% CI 0·32-0·51; p < 0.001) in months 1-6 and 0·30 (95% CI 0·21-0·43; p < 0·001) in months 7-12 compared to baseline. The adjusted RR of intrapartum stillbirth was 0·64 (95% CI 0·53-0·77; p < 0·001) in months 1-6 and 0·48 (95% CI 0·36-0·63; p < 0·001) in months 7-12 compared to baseline. Four hundred three SBAs consented and enrolled. After 1 year, 200 SBAs assessed had 28% (95% CI 25-32; p < 0·001) and 31% (95% CI 27-36; p < 0·001) higher scores than baseline on low-dose 1 and 2 content skills, respectively. CONCLUSIONS: This training approach results in a sustained decrease in facility-based newborn mortality and intrapartum stillbirths, and retained knowledge and skills among SBAs after a year. We recommend use of this approach for future maternal and newborn health in-service training and programs. TRIAL REGISTRATION: Retrospectively registered on 25 September 2017 at Clinical Trials, identifier NCT03290924 .

"It builds your confidence you've done well": Healthcare workers' experiences of participating in a low-dose, high-frequency training to improve newborn survival on the day of birth in Ghana.

Background: The majority of newborn deaths occur during the first week of life, and 25‒45% occur within the first 24 hours. A low-dose, high-frequency (LDHF) training approach was introduced in 40 hospitals in Ghana to improve newborn survival. The aim of this qualitative study was to explore healthcare workers' experiences with the LDHF approach to in-service training. Methods: A total of 20 in-depth interviews and nine focus group discussions were conducted in 2016 in three regions of Ghana with healthcare workers who participated in implementation of the LDHF training approach. In-depth interviews were conducted with 20 master mentors and peer practice coordinators; 51 practicing doctors, midwives and nurses participated in focus group discussions. Data were analyzed using a thematic analysis approach. Results: Healthcare workers reflected on the differences between the LDHF approach and past learning experiences, highlighting how the skills-based team training approach, coupled with high-frequency practice and mobile mentoring, built their competency and confidence. As participants shared their experiences, they highlighted relationships established between Master Mentors and healthcare workers, and motivation stemming from pride in contributing to reductions in maternal and newborn deaths as critical factors in improving quality of care at participating health facilities. Conclusion: This nested qualitative study documents experiences of healthcare workers and mentors involved in implementation of a multi-faceted intervention that effectively improved maternal and newborn care at health facilities in Ghana. The way the intervention was implemented created an environment conducive to learning within the hospital setting, thus providing an opportunity for professional growth and quality improvement for all staff working in the maternity ward.

Can a standards-based approach improve access to and quality of primary health care? Findings from an end-of-project evaluation in Ghana.

BACKGROUND: Jhpiego implemented a 5-year project to strengthen the Community-Based Health Planning and Services (CHPS) model in six coastal districts of Ghana's Western Region. The project utilized a quality improvement approach (Standards-Based Management and Recognition [SBM-R]) to strengthen implementation fidelity of the CHPS model. This article presents findings from an end-of-project evaluation comparing quality, access to care, and experience of care in intervention and comparison CHPS zones. METHODS: A non-equivalent, posttest-only, end-of-project evaluation compared 12 randomly selected intervention zones with 12 matched comparison zones. Data from standards-based assessments measured provision of care in three categories: community engagement, clinical services, and facility readiness and management. Access to and experience of care were assessed using a household survey of 426 randomly selected community members from the selected CHPS zones. Bivariate and multivariate analyses were conducted to compare performance on these measures between intervention and comparison CHPS zones. RESULTS: Overall, intervention zones outperformed comparison zones on achievement of standards (83.6% vs 58.8%) across all three assessment categories, with strongest results in community engagement (85.7% vs. 41.4%). Respondents in intervention zones were more than twice as likely to have received a home visit from a community health officer, three times as likely to have a home visit from a community health volunteer, and more likely to have attended a health talk (41.9% vs. 27.0%). Client experiences of care were reported as positive in both study arms. CONCLUSIONS: The evaluation demonstrated improved access to quality care; however, there were very few differences in client experience of care between intervention and comparison zones. As Ghana and other countries are committed to scaling up universal health care, a pragmatic approach such as SBM-R could prove useful to engage both facility- and community-based service providers, as well as community members, to improve provision of care.