Evaluation of an obstetric and neonatal care upskilling program for community health workers in Papua New Guinea.

BACKGROUND: 60% of women in Papua New Guinea (PNG) give birth unsupervised and outside of a health facility, contributing to high national maternal and perinatal mortality rates. We evaluated a practical, hospital-based on-the-job training program implemented by local health authorities in PNG between 2013 and 2019 aimed at addressing this challenge by upskilling community health workers (CHWs) to provide quality maternal and newborn care in rural health facilities. METHODS: Two provinces, the Eastern Highlands and Simbu Provinces, were included in the study. In the Eastern Highlands Province, a baseline and end point skills assessment and post-training interviews 12 months after completion of the 2018 training were used to evaluate impacts on CHW knowledge, skills, and self-reported satisfaction with training. Quality and timeliness of referrals was assessed through data from the Eastern Highlands Province referral hospital registers. In Simbu Province, impacts of training on facility births, stillbirths and referrals were evaluated pre- and post-training retrospectively using routine health facility reporting data from 2012 to 2019, and negative binomial regression analysis adjusted for potential confounders and correlation of outcomes within facilities. RESULTS: The average knowledge score increased significantly, from 69.8% (95% CI:66.3-73.2%) at baseline, to 87.8% (95% CI:82.9-92.6%) following training for the 8 CHWs participating in Eastern Highlands Province training. CHWs reported increased confidence in their skills and ability to use referral networks. There were significant increases in referrals to the Eastern Highlands provincial hospital arriving in the second stage of labour but no significant difference in the 5 min Apgar score for children, pre and post training. Data on 11,345 births in participating facilities in Simbu Province showed that the number of births in participating rural health facilities more than doubled compared to prior to training, with the impact increasing over time after training (0-12 months after training: IRR 1.59, 95% CI: 1.04-2.44, p-value 0.033, > 12 months after training: IRR 2.46, 95% CI:1.37-4.41, p-value 0.003). There was no significant change in stillbirth or referral rates. CONCLUSIONS: Our findings showed positive impacts of the upskilling program on CHW knowledge and practice of participants, facility births rates, and appropriateness of referrals, demonstrating its promise as a feasible intervention to improve uptake of maternal and newborn care services in rural and remote, low-resource settings within the resourcing available to local authorities. Larger-scale evaluations of a size adequately powered to ascertain impact of the intervention on stillbirth rates are warranted.

Context specific realities and experiences of nurses and midwives in basic emergency obstetric and newborn care services in two district hospitals in Rwanda: a qualitative study.

BACKGROUND: In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into experiences of these healthcare workers in managing obstetric emergencies are critical for improving the quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. Rwanda has made remarkable progress in obstetric care. However, challenges remain in the provision of high-quality basic emergency obstetric and newborn care (BEmONC). This study is a qualitative part of a broader research project about implementation of an mLearning and mHealth decision support tool in BEmONC services in Rwanda. METHODS: In this exploratory qualitative aspect of the research, four focus group discussions (FGDs) with 26 nurses and midwives from two district hospitals in Rwanda were conducted. Each FGD was made up of two parts. The first part focused on the participants' reflections on the research results (from the previous study), while the second part explored their experiences of delivering obstetric care services. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis. RESULTS: The analysis revealed three main themes: (1) reflections to the baseline research results, (2) self-reflection on the current practices, and (3) contextual factors influencing the delivery of BEmONC services. Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants' narratives of lived experiences of providing BEmONC services are also presented. CONCLUSION: The insights of nurses and midwives regarding the management of birth-related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on PPH management and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health, particularly in low and middle-income countries.

Quality of basic emergency obstetric and newborn care (BEmONC) services from patients' perspective in Adigrat town, Eastern zone of Tigray, Ethiopia. 2017: a cross sectional study.

BACKGROUND: Most of the maternal and newborn deaths occur at birth or within 24 h of birth. Provision of quality Basic Emergency Obstetric and Neonatal Care (BEmONC) is very crucial and the current recommended intervention to prevent maternal and newborn morbidity and mortality. METHODS: An institution based cross-sectional study was conducted among mothers receiving at least one of the signal functions of BEmONC services. A total of 398 women were included in the study. The study participants were selected using a systematic random sampling method. Data was collected using structured interviewer-administered Tigrigna version questionnaire. Data were analyzed using SPSS version 20. Multi-variable logistic regression was used to control the effect of confounders. RESULTS: The perceived quality of BEmONC was 66.7%, which is poor. Clients scored lower quality rates on aspects such as the availability of necessary equipment, lack of clean and functional shower and toilet and administration of anti-pain during delivery and manual vacuum aspiration (MVA). Quality of BEmONC was lower among rural residents (AOR = 0.273, 95% CI: (0.151-0.830). Whereas, Presence of companion (AOR = 2.259; 95% CI: (3.563-13.452) were found with a higher score of quality of BEmONC compared to their counterparts. CONCLUSION: The overall perception of quality of BEmONC services received was poor. Residence, ANC follow-up, and presence of companion during labor or delivery were found to have a significant association with the perceived quality of BEmONC services.

The effect of implementation strength of basic emergency obstetric and newborn care (BEmONC) on facility deliveries and the met need for BEmONC at the primary health care level in Ethiopia.

BACKGROUND: Basic emergency obstetric and newborn care (BEmONC) is a primary health care level initiative promoted in low- and middle-income countries to reduce maternal and newborn mortality. Tailored support, including BEmONC training to providers, mentoring and monitoring through supportive supervision, provision of equipment and supplies, strengthening referral linkages, and improving infection-prevention practice, was provided in a package of interventions to 134 health centers, covering 91 rural districts of Ethiopia to ensure timely BEmONC care. In recent years, there has been a growing interest in measuring program implementation strength to evaluate public health gains. To assess the effectiveness of the BEmONC initiative, this study measures its implementation strength and examines the effect of its variability across intervention health centers on the rate of facility deliveries and the met need for BEmONC. METHODS: Before and after data from 134 intervention health centers were collected in April 2013 and July 2015. A BEmONC implementation strength index was constructed from seven input and five process indicators measured through observation, record review, and provider interview; while facility delivery rate and the met need for expected obstetric complications were measured from service statistics and patient records. We estimated the dose-response relationships between outcome and explanatory variables of interest using regression methods. RESULTS: The BEmONC implementation strength index score, which ranged between zero and 10, increased statistically significantly from 4.3 at baseline to 6.7 at follow-up (p < .05). Correspondingly, the health center delivery rate significantly increased from 24% to 56% (p < .05). There was a dose-response relationship between the explanatory and outcome variables. For every unit increase in BEmONC implementation strength score there was a corresponding average of 4.5 percentage points (95% confidence interval: 2.1-6.9) increase in facility-based deliveries; while a higher score for BEmONC implementation strength of a health facility at follow-up was associated with a higher met need. CONCLUSION: The BEmONC initiative was effective in improving institutional deliveries and may have also improved the met need for BEmONC services. The BEmONC implementation strength index can be potentially used to monitor the implementation of BEmONC interventions.

The effect of prenatal and intrapartum care on the stillbirth rate among women in rural Ethiopia.

OBJECTIVE: To determine whether community-based prenatal and intrapartum care in Ethiopia results in a lower stillbirth rate. METHODS: Between May and December 2014, a randomly selected sample of women in northern and eastern Ethiopia who had delivered a neonate in the preceding 12months completed a face-to-face survey about their experiences of maternal services and the fetal outcome for each delivery. The stillbirth rates among women delivering at home and at health facilities were compared. RESULTS: Overall, 4442 women completed surveys. Stillbirth was reported by 42 (1.7%) of the 2437 women who had received prenatal care and 53 (2.8%) of the 1921 women who did not receive prenatal care (P=0.01). The stillbirth rate was similar among women who delivered in a health center (27/1417 [1.9%]), in a hospital (6/126 [4.8%]), and at home (62/2725 [2.3%]; P=0.13). However, women experiencing an intrapartum emergency were twice as likely to deliver in a health facility (odds ratio 2.6, 95% confidence interval 2.2-3.0). Satisfaction with health-center care was moderately good (median score 77.5/100). CONCLUSION: The stillbirth rate was reduced among women receiving prenatal care, although delivering in a health facility did not reduce the risk of stillbirth. Improving the quality of health-center care could lead to their planned use for childbirth, which might reduce stillbirth rates.

The development of Basic Emergency Obstetric and Newborn Care (BEmONC) and Maternal Health in the Philippines: A historical literature review

Introduction@#Implementation of Basic Emergency Obstetric and Newborn Care (BEmONC) aims to curb maternal mortality. However, the Philippines failed to significantly reduce the maternal mortality rate (MMR) targeted in the Millennium Development Goals (MDGs). Currently, the country is still far from the targeted Sustainable Development Goals (SDGs). This review describes the historical development of BEmONC in the Philippines over the past 13 years and provides insights on its role in decreasing MMR. @*Methods@#We searched online for journal articles, publications, reports, policies, and other issuances related to BEmONC and maternal health in the Philippines. We accessed updates and data via correspondence with the Department of Health (DOH). Statistics were compiled from public databases. The identified citations were screened, appraised, synthesized, and analyzed in a historical approach. @*Results@#A direct result of the Emergency Obstetric Care Approach, BEmONC was developed to respond to the high MMR in the Philippines, in line with global efforts to improve maternal health. However, BEmONC functionality generally remained inadequate. @*Conclusions@#Although the provision of BEmONC services increased facility-based deliveries and skilled birth attendance during childbirth, this failed to decrease MMR and achieve targeted goals substantially. Further capacity-building is needed, especially in rural and resource-poor areas. Government issuances at the national and local levels should be aligned to complement each other. There should be a health systems approach that considers the building blocks of an efficient health care system and the social determinants that impact them.