Based on the successful results in Niger and the similarities between the socio-economic and health situations in Niger and neighboring Mali, in late 2009, HCI was invited to undertake an Essential Obstetric and Newborn Care (EONC) collaborative in the Kayes Region of Mali, applying approaches and best practices that had been developed in Niger. HCI’s support in Mali was much less intensive than in the original EONC collaborative in Niger. While in Niger, full-time HCI staff members oversaw trainings and the implementation of the intervention, HCI’s Niger staff led the work in Mali through a series of short-term visits. Medical doctors and midwives who were district supervisors, active management of third stage labor (AMTSL) trainers, or members of the Ministry of Health regional management teams were selected as coaches. All coaches received training on AMTSL and essential newborn care (ENC), and coaching techniques. They conducted quarterly supervisory visits to quality improvement teams and spent on average one day per site at the beginning of the intervention and half a day towards the end of the collaborative.
While HCI has demonstrated the efficient spread of improvement interventions within or across regions of a country, little research has focused on studying spread from one country to another. To address this gap, HCI initiated a study on the transfer of the EONC collaborative and best practices from the intervention from Niger to Mali. The objective of this study was to explore the nature, extent and effectiveness of the spread of the EONC collaborative and best practices derived from the collaborative from Niger to Mali. We sought to assess how clinical content and best practices implemented in one country can be transferred to another country in order to develop appropriate strategies to spread improvement interventions from a country to another. Specifically, we wanted to shed light on the experience of quality improvement teams and coaches during the transfer of the EONC collaborative and best practices from Niger to Mali.
This cross-sectional study included quantitative measures as well as a qualitative approach designed to better understand the context in which the improvement of clinical indicators occurred. Fifteen community health centers (CsCom) in two districts (Kayes and Diéma ) in the Kayes Region were included in the study. At each site, three members of the quality improvement (QI) teams were interviewed. Information was collected from QI team members through in-depth interviews and from coaches during focus group discussions. Clinical data were collected from health facilities, but no direct contact with patients occurred. Respondents received explanations regarding the nature of the study and their consent was requested. To maintain the anonymity of the participants, neither the names of respondents nor the name of their facility were included in the findings.
The study found that while baseline indicators performance levels were higher in Mali than in Niger, the implementation of the EONC collaborative and best practices led to significant improvements in clinical indicators in Mali. Adherence to AMTSL increased from 24% to 100% in eight months. Post-partum hemorrhage and adherence to ENC also decreased significantly.
The perceived value of the intervention was unanimous among QI teams and coaches and was confirmed by the improvement in clinical indicators. Improvements were achieved in a short period of time and with much less intensive support from HCI than had been provided of the original EONC collaborative in Niger.
This study shows that that a quality improvement intervention and best practices resulting from the intervention can be successfully transferred to another country with moderate external support when the new country is similar to the original country in terms of their socio-economic and health situations and when the intervention addresses a clinical area deemed a priority by the local health system and stakeholders. Key spillover effects seen in the Mali teams during the implementation of the intervention, including taking initiative, recognition of the importance of data, teamwork, and commitment of providers, are particularly encouraging as they contribute to the overall performance of health centers beyond the improvement areas targeted by the EONC collaborative.
Several quality gaps have been documented across the continuum of maternal, newborn, and child health (MNCH) services. For antenatal care (ANC), despite the progress in increasing its coverage, quality gaps persist. Several studies show that ANC services often miss the opportunity to provide essential services such as counseling clients on danger signs of pregnancy, delivery plans, nutrition, and postpartum family planning. Similarly, services around childbirth are often provided with compromised quality. Common quality gaps include the inadequate or incorrect use of the partograph to prevent the complications of prolonged labor for the mother and the newborn, neglecting to apply active management of third stage of labor to prevent postpartum hemorrhage, poor quality of emergency obstetric care, and failure to promptly detect newborn asphyxia and apply immediate resuscitation.
Quality improvement (QI) offers a powerful a means to increase the effectiveness of MNCH programs in resource-limited countries. QI is based on the understanding that a system is designed to produce the results it produces; in order to obtain better results, the system must change. Hence, in applying QI, teams in health facilities or communities analyze the systems and processes of delivering services, test changes to obtain better results, and measure the effect of the tested changes on pre-determined indicators. Teamwork and shared learning between QI teams allow for rapid spread of best practices.
This paper discusses the role modern QI approaches can play in improving MNCH outcomes and describes specific applications of across the continuum of MNCH care, including ANC, essential obstetric and newborn care, infant and child care, and post-partum family planning. Drawing on examples from the work of the USAID Health Care Improvement Project (HCI) in Africa, Asia, and Latin America, the paper shows how quality gaps in the services addressing the antenatal, intra partum, postnatal, neonatal, and child periods can be closed through modern QI approaches.
This report describes the results of a four-country assessment, funded by the US Agency for International Development (USAID), of high-impact maternal and newborn childbirth practices in the Europe and Eurasia (E&E) region. Conducted between October 2010 and August 2011 in 42 maternities in Albania, Armenia, Georgia, and Russia, the assessment examined the quality of high-impact childbirth and early post-partum maternal-newborn practices in sampled facilities, including the status of cross-cutting health system functions and provider and client attitudes, knowledge, and self-reported practices. The study provides a multi-perspective look at the quality of maternal- newborn care currently provided and as perceived by clients, with an eye toward assessing areas of strength and areas needing improvement.
The assessment found evidence for solid coverage of many best practices in the sampled maternities. Measured results are undoubtedly in part attributable to high stakeholder investment in the region, including by USAID, and most importantly are reflected in the decreasing maternal and neonatal mortality rates. However, despite the narrowing of the maternal and newborn mortality gap between E&E countries and their richer neighbors, the persistently higher rates of maternal and newborn mortality in the region demonstrate a need to hold and expand the gains, with a focus on areas of demonstrated service delivery weakness for high-burden conditions. Moreover, the legacy of highly specialized and medicalized care even for routine, uncomplicated deliveries remains strong in the region yet represents a care model that is unlikely to be cost-effective over the long-term.
Depuis Novembre 2009, le Projet d’Amélioration des Soins de Santé de l’USAID (HCI) travaille en collaboration avec le Ministère de la Santé du Mali et d'autres partenaires pour mettre en œuvre un collaboratif d’amélioration des soins maternels et néonataux. Ce rapport décrit les stratégies mise en place dans la région de Kayes.
From 2008-2012, the USAID Health Care Improvement Project provided support to the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) to improve the quality of health services through improvement collaboratives and the certification of selected health facilities and management processes based on International Organization for Standardization (ISO) quality standards. This study, conducted in late 2011, aimed to learn how much of this support and quality improvement capacity have been appropriated, or institutionalized, by the Guatemalan MSPAS and could be sustained without URC’s support, despite important changes in the Guatemalan political context (i.e., new President with subsequent changes in central level MSPAS authorities and Health Area Directors). Both quantitative and qualitative data were collected from stakeholders across the central level, San Marcos Health Area, and six districts that have participated in quality improvement programs: San Pedro, Tejutla, Concepción Tutuapa, San Lorenzo, Tacaná, and Tajumulco.
The study found that while all MSPAS levels showed commitment and ownership of quality, the districts and health facilities involved in collaboratives and ISO certification showed the most advanced stages of the institutionalization of quality. The Health Area level expressed commitment to quality, but expressed doubt about the central level’s long-term commitment to quality. The central level MSPAS demonstrated a high level of ownership for quality, but also the least amount of certainty about the continuation of quality improvement (QI) without HCI’s support. The study also identified elements of institutionalization that still need further support to sustain and deepen improvements, especially: financial resources for quality, recognition of QI work, capacity-building, and information and communication. Barriers and facilitating factors to further institutionalize quality within the MSPAS were also examined. The study found evidence of common facilitating factors across all levels of the MSPAS, including: leadership, support functions, team work and staff commitment, and technical capacity for implementation. Common barriers were also reported, including a lack of financial resources, weak information systems, and limited personnel and dedicated time.
The USAID Health Care Improvement project (HCI) has supported two initiatives in Guatemala focused on improving the quality of health care. The ProCONE Maternal and Neonatal Health Care Improvement Collaborative was developed by the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) and focuses improving prenatal, delivery, postpartum, and neonatal care. The approach of ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales) was to engage health center staff in quality improvement (QI) teams to monitor compliance with clinical norms and records and improve care through training and coaching, providing Information Education and Communication (IEC) materials and job aids, proving opportunities for shared learning through Collaborative sessions, introducing health improvement activities, and documentation and review of best practices that proved effective in improving process indicators. The demonstration phase was implemented between March 2007 through September 2008 in the department of San Marcos in western Guatemala. In this study, facilities participating in the ProCONE collaborative are referred to as ProCONE alone facilities.
A quasi-experimental research design will be used because the ISO+ProCONE and ProCONE alone study groups were not randomly allocated. The quasi-experimental design takes advantage of the data equally available from both study groups. Data collected in May 2011 in an all-facilities endline cross sectional survey of process variables, patient satisfaction, and patient-provider observation and associated clinical records review. These will be compared with data previously collected in 2009 and 2007.
En el año 2005 el Ministerio de Salud (MINSA) realizó la primera investigación de competencias del personal de salud que brinda atención durante la embarazada, parto, puerperio, recién nacido y sus complicaciones. La investigación se hizo en dos momentos, evaluación del conocimiento y habilidades en donde participaron un total de 1,358 recursos humanos de 17 SILAIS del país. En habilidades se evaluaron 580 recursos, 43% del personal evaluado en conocimiento. Los resultados de esta investigación fueron la base para que el MINSA, en conjunto con las agencias y proyectos de cooperación externa, elaboraron normas, protocolos, y guías de práctica clínica, lo que permitió estandarizar el conocimiento a nivel nacional. Así mismo se trabajó junto a las normas y protocolos, herramientas para la vigilancia y monitoreo continuo de la calidad.
Cinco años después el MINSA tenía interés en conocer ¿cuál había sido el impacto de las intervenciones para mejorar las competencias del personal de salud? Se realizó un estudio cuasi-experimental antes-después de los años 2005 y 2010 (pretest-postest) sin controles. El universo estuvo constituido por cinco de los 17 SILAIS del país. Los criterios que se utilizaran para seleccionar al personal que participó en la evaluación del 2010 fueron: que el personal estuviese laborando en el área de atención a la madre durante el embarazo, parto, puerperio, recién y además que atendiera las complicaciones que se derivan en cualquiera de estos eventos tanto de la madre como del recién nacido. A nivel de hospitales la muestra fue de 30 recursos médicos y de enfermería, que laboraran en las salas de emergencias, obstetricia y neonatología. A nivel de los municipios la muestra fue de 10 recursos médicos y de enfermería. Participaron un total de 260 recursos de salud (156 médicos y 104 enfermeras) de siete hospitales y 12 municipios.
La investigación en 2010 se desarrolló en dos fases. La primera fue una fase de evaluación de conocimientos, la cual consistió en que el personal de salud llenaba un test. Además se incluyó un caso clínico pre-elaborado, a fin de que la información fuese graficada en el partograma e interpretada para la toma de acciones diagnósticas, de tratamiento y/o referencia a un mayor nivel de atención. La segunda fase consistió en la evaluación de habilidades. Se diseñaron seis escenarios donde el evaluador(a) guiaba el caso clínico y el evaluando realizaba el procedimiento a través de modelos anatómicos tanto para obstetricia como para el recién nacido.
En la evaluación de conocimientos de 2010, el personal de salud alcanzó un nivel de 72% incluyendo todos los temas abordados; hubo un incremento del 14 puntos porcentuales con respecto a los resultados del año 2005 (58% a 72%), estadísticamente estos resultados son significativos (p<0.001). Los temas que alcanzaron los mayores porcentajes fueron: sangrado durante la segunda mitad del embarazo, sepsis puerperal, hemorragia post parto, manejo activo del tercer período del parto (MATEP), vigilancia del trabajo de parto, vigilancia del puerperio inmediata y lactancia materna. Los temas que sufrieron reducción en el porcentaje con respecto a los resultados del 2005 fueron la interpretación del partograma de 59% a 51% y la anticoncepción post evento obstétrico de 75% a 74%.
En la evaluación de habilidades de 2010, el personal de salud alcanzó un nivel de 67%, incluyendo todos los escenarios que fueron evaluados, con un incremento de 8 puntos porcentuales con respecto a los resultados del año 2005 (59% a 67%). Los escenarios cuyo resultados los promedios se encuentran por encima del promedio global fueron MATEP, extracción manual de la placenta y atención inmediata del recién nacido. En cambio la compresión uterina bimanual tuvo una reducción de 3 puntos porcentuales con respecto al año 2005 (57% a 54%).
This presentation was given by Dr. Jorge Hermida, HCI Regional Director for Latin America, at the 28th International Conference of the International Society for Quality in Health Care, Ltd. (ISQua), which took place in Hong Kong, China from September 14-17, 2011. The conference theme was, “Patient Safety: Sustaining the Global Momentum.”
Maternal and neonatal mortality are high in Afghanistan; estimated at 460 maternal deaths per 100,000 live births and 45 neonatal deaths per 1000 live births (WHO, 2012). Decades of conflict have negatively impacted Afghanistan’s health infrastructure impeding optimal delivery of health services (Edward et al., 2011). There is an urgent need to improve the quality of maternal and newborn care throughout the country.