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Maternal, Newborn and Child Health

Author(s): 
E Hurtado | M Insua | LM Franco

Region and Country: Central America and the Caribbean, Guatemala

Topics: Maternal, Newborn and Child Health

Partners: 
Guatemalan Ministry of Public Health and Social Assistance (MSPAS)
Year: 
2011
Language: 
English
Description: 
In collaborative improvement, participant facilities organize QI teams that meet periodically to measure and monitor indicators, plan changes oriented to improve gaps identified, test and evaluate the effects of changes to determine which changes were successful in improving quality. Accordingly, QI team performance is essential to effective collaborative improvement and teams that perform well can be expected to improve the quality of care provided.
 
This study assessed team performance of teams that participated in the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) program, ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales). ProCONE used a collaborative improvement approach to improve essential obstetric and newborn care.  The demonstration phase was implemented from April 2007 through September 2008 in 28 health centers in the San Marcos region of Guatemala, and in November 2008 a spread phase was implemented to include 130 health units in 7 additional regions. QI team in each health facilities received coaching from the central and area-level technical teams and teams shared relevant information such as difficulties encountered and best practices implemented to overcome performance gaps with other QI teams. This cross-sectional study assessed team performance in 38 of the 130 health facilities that participated in the spread phase both in terms of implementation of QI activities and the sharing processes and mechanisms teams utilized. 
 
This study had several objectives:
  • 1) To assess performance of QI teams at several levels in the health system: national, health area, and  health facilities
  • 2) To document the QI activities teams performed, including documenting best practices and changes, monitoring and analyzing data, and sharing successful experiences between teams in the collaborative
  • 3) Provide information on results achieved by QI teams in the indicators reported during 17 consecutive months measured as absolute improvement in indicators, speed of the improvement and maintenance of the improvement over time.
The study found that good team performance at the health area and health facility level, the central level was not functional. Facility-level teams performed well on use of QI tools, data analysis and monitoring, and most teams shared their results with other teams. Overall, most indicators tracked by the teams improved by 60-80% over the 17 months of data analyzed by the study. Giving insight into how effective teams should function, QI teams that didn’t share information within their units were delayed by an average of 1.8 months in reaching a performance level of 80% in the ambulatory indicators. Teams with four or more members sharing the responsibilities for QI activities maintained gains over 80% in the ambulatory indicator value an average of 2.2 months longer than teams that had functions more distributed among their participants.
 
The study concludes with recommendations for stengthening QI team performance at the central, area, and facility levels.

 

 

 

 

 

Author(s): 
Y Tawfik | M Segall | E Necochea | T Jacobs

Topics: Immunization, Maternal, Newborn and Child Health

Partners: 
USAID | Jhpiego | MSH | JSI | EngenderHealth | Save the Children | BASICS | ImmunizationBASICS
Year: 
2010
Language: 
English
Description: 

Various quality improvement (QI) models are applied in the health field. All of them aim to improve the quality of health care but have different structures, steps, and terminology. This variation creates an impression of fundamental differences among the models, while in fact a closer look at their core contents reveals common elements. Failure to see the commonalities creates barriers to communication among QI partners, hinders coordination of QI efforts, and misses opportunities to achieve synergies to augment the collective results of QI programs.

This paper attempts to systematically review and compare QI models that have been applied extensively in maternal, newborn, and child health (MNCH) or are potentially effective models for MNCH programs. These models are:  COPE® (Client-Oriented, Provider-Efficient Services) (COPE), Fully Functional Service Delivery Point (FFSDP), HIVQUAL, Improvement Collaborative, Improving Newborn Health, Partnership Defined Quality (PDQ), Private Sector Quality Improvement Package, Quality Design/Redesign, Reaching Every District (RED), and Standards-Based Management and Recognition (SBM-R).  The authors reached a definition of “quality improvement” that encompasses most models: “a cyclical process of measuring a performance gap; understanding the causes of the gap; testing, planning, and implementing interventions to close the gap; studying the effects of the interventions; and planning additional corrective actions in response.”

The paper identifies the models’ essential elements in an attempt to find common ground: a place where those who apply different QI models can discuss them with a common language and understanding. Such common ground can demonstrate the similarity of the various models and hence facilitate dialogue and coordination among partners, donors, and stakeholders who use or support the different models. 

Region and Country: Tanzania

Topics: Active management of the third stage of labor, Employee Engagement, Birth preparedness, Motivation/incentives, Performance management, Essential newborn care, Supervision, Essential obstetric care, Task shifting, Training, Infection prevention in delivery care, Maternal sepsis/infection, Neonatal sepsis/infection, Newborn resuscitation/asphyxia, Post-partum care, Post-partum hemorrhage, Pre-eclampsia/eclampsia, Maternal, Newborn and Child Health

Partners: 
Tanzania Ministry of Health and Social Welfare
Year: 
2010
Language: 
English
Description: 

The maternal mortality ratio in Tanzania is estimated to be 578/100,000.1  A great majority of these deaths are due to obstetric complications, 90% of which can be avoided. Some obstetric complications can be predicted and most are treatable if women receive high quality care when needed.2 Care provided by a competent Skilled Birth Attendant (SBA) during labor, delivery and in the immediate postpartum period is a key component of quality obstetric care. The percentage of deliveries assisted by a SBA has become a proxy indicator for reducing maternal mortality.3

Despite the wide coverage of training service providers on Basic and Advanced Life Saving Skills in Tanzania since 2003, there is limited information on maternal and newborn care provider competency or the impact of these trainings. Therefore, the need to determine the competency levels of the service providers and functionality of the health systems was urgent. 
 
Research questions/objectives
The research objectives of this study were three-fold:
1.To determine the current competency levels of the workforce attending to women and newborn during labor, delivery and the immediate postpartum period (first 24 hours)
2. To determine the facility readiness for provision of care during labour, delivery and immediate postpartum period.
3. To provide recommendations for quality improvement in the delivery facilities.
 
Methodology
The study was conducted in eight districts within four regions of Tanzania Mainland,  namely Kisarawe and Bagamoyo (Coast Region), Singida Rural and Manyoni (Singida Region), Njombe and Mufindi (Iringa Region), and Muheza and Korogwe (Tanga Region).  The assessment comprised two parts: (1) a knowledge test consisting of 50 multiple choice and true/false questions covering several topics inlcuding infection prevention, uncomplicated labor and delivery, prevention and management of hemorrhage, immediate care of the newborn including newborn resuscitation and prevention and management of sepsis. The test was scored using a predetermined answer key. And (2) assessment of five skill areas - (i) active management of the third stage of labor (AMTSL), (ii) manual removal of placenta, (iii) bimanual uterine compression (iv) immediate newborn care, and v) neonatal resuscitation by observing participant performance of each procedure on an anatomical model. A total of 194 service providers from these facilities participated. Each participant was assessed in these five areas by trained observers. 
 
Health facilities were evaluated using a checklist for the existence of the essential and enabling factors. These included: human resource, medical waste management, availability of water and source of light, essential medicines, equipment and supplies, functionality of referral system, and availability and use of maternal and newborn guidelines standards.  
 
Results/Findings
The average score for the knowledge test was 56%, with the scores progressively improving with ranking of facility category from 50% for dispensaries to 58% for district hospitals and also with increasing qualifications from 45% among medical attendants to 62% among Medical Officers and AMOs. The average score for active management of the third stage of labor and manual removal of the placenta were 55.3% and 54.5% respectively. Bimanual uterine compression, immediate newborn care (36%) and neonatal resuscitation (25%) were generally poorly performed compared to the others. There were no statistically significant differences between different facility and cadre levels.
 
Regarding facility readiness, some key medicines such as antibiotics and haematenics were available in most health facilities. However, live-saving medicines such as oxytocin and magnesium sulphate were not in stock in more than 60% of the facilities. Organization and sustainability of referral/counter-referral systems and use of maternal and neonatal health standards were also poor. 
 
These findings indicate that gaps to provision of quality maternal and newborn services exist with regard to competency of health personnel, infrastructure and referral systems. There is also indication that minimal investment in training on specific approaches for prevention and management of life-threatening complications will significantly contribute to the reduction of maternal and neonatal mortality and morbidity. 
 
 
1. World Health Organization 2006. Making a Difference in Countries: Strategic Approach
to Improving Maternal and Newborn Survival and Health. Department of Making
Pregnancy Safer. WHO: Geneva, Switzerland. 
http://www.who.int/making_pregnancy_safer/documents/wa3102006ma/en/index.html
 
2. World Health Organization, 2004. Maternal Mortality in 2000: Estimates developed by
WHO, UNICEF and UNFPA). WHO: Geneva, Switzerland. 
 
3. National Bureau of Statistics (NBS) [Tanzania] and ORC Macro. 2005. Tanzania
Demographic and Health Survey, 2004-5. Dar es Salaam, Tanzania. National Bureau of
Statistics and ORC Macro.
 

 

Author(s): 
E Broughton | Z Saley | M Boucar | D Alagane | K Hill | A Marafa | Y Asma | K Sani

Region and Country: Niger

Topics: Essential obstetric care, Maternal, Newborn and Child Health

Partners: 
MOH
Year: 
2010
Language: 
English
Description: 

This study presents results of a costing and cost-effectiveness analysis conducted retrospectively of the 2006-2008 Niger Essential Obstetric and Newborn Care (EONC) Collaborative, which was implemented in 33 facilities in Niger to improve maternal and newborn care oucomes by increasing compliance with evidence-based care standards. This study used outcomes data from routine program monitoring and costs from a number of sources including Health Care Improvement Project (HCI) accounting records and surveys of clinical managers. It compares the costs of attended vaginal delivery and immediate neonatal care in the six months before the QI collaborative started with the average of the last three months of the intervention. The four measures of effectiveness used were compliance with AMTSL, rates of post-partum hemorrhage, compliance with essential neonatal care and compliance with breastfeeding within the hour following delivery. Calculating the incremental cost-effectiveness using HCI and MOH costs including development and demonstration gave low, positive incremental cost-effectiveness ratios.

Author(s): 
E Broughton, I Gomez, O Nunez, J Wong

Region and Country: Nicaragua

Topics: Diarrheal disease prevention and case management, Pneumonia case management, Maternal, Newborn and Child Health

Partners: 
Ministry of Health (MINSA), UNICEF
Year: 
2010
Language: 
English
Description: 

The Pediatric Hospital Initiative was launched by Nicargua's Ministrio de Salud (MINSA) in partnership with UNICEF and USAID though the Quality Assurance Project (QAP) and its successor the Health Care Improvement Project (HCI). The initiative worked to improve the quality of care provided in hospital pediatric wards to children with common infectious diseases. The initiative involved 14 hospitals, which were organized into an improvement collaborative, and focused on children affected by diarrhea and pneumonia.

This study used a longitudinal pre/post design using data from medical records of inpatient admissions to examine the cost effectiveness of PHI initiatives, as measured by the impact on days of hospitalization, disability adjusted life years (DALYs), and deaths attributed to diarrhea or pneumonia from seven of the collaborative hospitals, which were selected based on a minimum criteria of two years of surveillance data for the indicators of interest and where QI teams were actively engaged in monitoring and evaluation of the program and implementing improvement cycles. A total of 2,799 records were examined: 647 records from the year prior to the collaborative and 750 after the collaborative for diarrhea and 647 records before and 755 after for pneumonia.Costs were calculated retrospectively. Those paid by HCI and its partners were determined by the project's accounting records. Hospitalization costs were calculated from a mix of available data from the public sector such as published salary rates and price lists of basic medicines, and from equivalent private sector costs for items such as laboratory blood tests and chest radiographs for pneumonia patients because public hospitals do not account for clinical line items such as these.

The study shows that implementation of the quality improvement collaborative decreased patients' length of stay and the number of deaths and did not increase the cost of hospitalization for diarrhea and pneumonia cases, meaning that the QI collaborative improved health outcomes while decreasing costs to the hospital system.

This study has been submitted to a journal for peer review and will be available when published.

Region and Country: Nicaragua

Topics: Family planning, PMTCT, HIV/AIDS, Maternal, Newborn and Child Health

Partners: 
Ministry of Health of Nicaragua (MINSA), UNICEF, CARE, Japan International Cooperation Agency (JICA), German Society for Technical Cooperation (GTZ) , Pan-American Health Organization (WHO/PAHO), United Nations Population Fund (UNFPA)
Year: 
2010
Language: 
English
Description: 

An improvement collaborative is a shared learning system that gathers many teams to work together, with the purpose of rapidly achieving significant improvements in quality and efficacy of a specific care area, with the intention of diffusing these methods to other sites. The improvement collaborative improvement approach often consists of an initial demonstration (pilot) phase in which improvement teams share their experiences. A subsequent expansion (spread) phase allows for the best innovations to be synthesized and communicated to a larger number of health facilities and enables rapid uptake of best practices across the system.

In 2003, the Ministry of Health of Nicaragua (MINSA), with the technical support of USAID through their Quality Assurance Project (QAP) and later through QAP’s follow-on, HCI, developed three parallel improvement collaboratives for to introduce continuous quality improvement methods for: Essential Obstetric Care(EOC), Pediatric Hospital Improvement (PHI) and HIV-Family Planning. All three collaboratives concluded their demonstration phase in the 2007.  
 
The effectiveness of the collaborative in achieving rapid improvement across the participating facilities is determined by the process of sharing of learning between teams. The objective of this study was to analyze how change ideas are communicated across teams, determine what information is useful for other teams to effectively implement the change ideas, and identify what factors enable or hinder teams from adopting effective change ideas. The study also explored whether certain changes are easier to diffuse than others and what is the speed at which teams adopt new change ideas. It was expected that the study findings would help HCI to improve the process of shared learning so that we can achieve faster and more effective spread. 
 
Methodology
The study was performed in 9 hospitals and 8 health centers of the Ministry of Health. Data were obtained from 50 semi-structured interviews with key individuals and five focus groups.
 
Results
From this qualitative study it was seen that respondents found learning sessions to be the preferred channel for shared learning. The collaborative environment led to a competitive spirit among teams which motivated them to perform better. Learning in the collaborative spread even to facilities not involved in the collaborative thus strengthening the referral system. 62% of respondents said that it is faster to implement change ideas generated within the team rather than those received from other teams. This was said to be due to the fact that, team members are not easily convinced about changes that are developed by other teams.
 
Conclusions and Recommendations
Respondents expressed that learning sessions should be an ongoing activity, performed at least three times a year and to this end, authorities should advocate for funding and technical assistance with cooperation agencies. They also gave some recommendations to improve quality of the learning sessions. Also, other channels for shared learning need to be developed further such as communication over the internet and using the telephone for communication between learning sessions.

 

Region and Country: Malawi

Topics: Emergency treatment assessment and triage (ETAT), Maternal, Newborn and Child Health

Year: 
2010
Language: 
English
Description: 
This retrospective study describes the extent to which ETAT guidelines and protocols have been implemented in three selected district hospitals in southern Malawi and evaluates the impact of ETAT on the quality of care given to under-five year old patients presenting at outpatient departments (OPD) of these hospitals.
 
Methodology
This study reviewed patient files and registers in the OPDs from 1st January and 31st December 2007. A prospective cross-sectional survey of the availability of ETAT-trained staff, recommended drugs and materials was also carried out.
 
Results/Findings
Three years after introduction of emergency triage, assessment and treatment in 2004 (with support from QAP III), it was still being implemented in these three district hospitals, although there were some areas needing strengthening. Use of critical care pathways was only at 57%,and only one hospital had all the required drugs and equipment in emergency trays at the first point of contact. However, the pharmacies in all the three hospitals had all the emergency drugs in stock. There were 1,003 deaths (10% of 9728 admissions) in the paediatric wards during the study period and 824 (82%) were under the age of 5 years; 16.1% of deaths occurred within 24 hours of hospitalisation. Only 2% of the patients deemed to require a lumbar puncture had one done. However, 537 (91.5%) Priority 1 and 151 (75.5%) Priority 2 patients were correctly triaged. Overall 80% of the interviewed staff were trained in ETAT, with 82%, 84% and 79% of clinicians, nurses and non-medical staff trained respectively.
 
The findings suggest that emergency triage, assessment and treatment (ETAT) implementation in the three Malawian district hospitals has continued to improve the quality of care given to under five children but needs to be strengthened and sustained.

 

 

 

Region and Country: Guatemala

Topics: Maternal, Newborn and Child Health

Language: 
English
Description: 

The HCI-supported project for Promotion of Essential Obstetric and Neonatal Care (ProCONE for its acronym in Spanish) introduced a health delivery model that integrates maternal and neonatal health care, linking users (e.g., pregnant women and traditional birth attendants) in rural areas with health services delivery units (e.g., health posts and hospitals). The program was first introduced in the Health Area of San Marcos, and has shown significant results in improving the quality of maternal and neonatal care as well as in the management of obstetric and neonatal complications. Following on this success, the ProCONE collaborative was spread from one health area to 7 new health areas and from 22 facilities in San Marcos to more than 300 health services delivery units in 9 out of 29 health areas in the country, following a consolidation of learning and a publication of best practices.

This study documents changes attempted and the success of implementation by new teams in the spread phase, and identifies which changes were adapted from previous experience by the demonstration collaborative. The study investigates reasons for the uptake of demonstration changes by the spread collaborative, and compares the spread collaborative rate of success to the demonstration collaborative and to changes not adapted from the demonstration collaborative. Data for this study was obtained from the HCI Standard Evaluation System (SES) and additional qualitative interviews with QI team members, coaches and collaborative managers to assess barriers and facilitating factors to uptake of ideas generated by previous groups of teams.

 

Author(s): 
Hurtado E, Richardson P, Broughton E

Region and Country: Central America and the Caribbean, Guatemala

Topics: Active management of the third stage of labor, Antenatal care, Birth preparedness, Essential newborn care, Essential obstetric care, Growth monitoring/growth promotion, Immunization, Infant and young child feeding, Infection prevention in delivery care, Integrated Management of Childhood Illness (IMCI), Maternal sepsis/infection, Neonatal sepsis/infection, Newborn resuscitation/asphyxia, Post-partum care, Post-partum hemorrhage, Pre-eclampsia/eclampsia, Maternal, Newborn and Child Health

Partners: 
Ministry of Health Guatamala
Year: 
2010
Language: 
English
Description: 
The "Mi Familia Progresa" conditional cash transfer program (CCTP) in Guatemala promotes demand for public health and education services by providing subsidies to families with children under 16 and to pregnant women as long as families meet certain conditions, such as visiting health care centers or ensuring that their children regularly attend school. While evidence suggests that conditional cash transfer programs in low-income countries are effective in increasing access to and use of health services, if the quality of care provided at health facilities is poor, then CCTP programs may have limited impact on health outcomes.
 
The USAID Health Care Improvement Project (HCI) supports a quality improvement (QI) initiative in specific low-income regions of Guatemala participating in the "Mi Familia Progresa" program. This study compares service quality at CCTP facilities in that were part of the QI intervention with services in comparable CCTP-supported facilities receiving no such intervention. It examines the intervention’s costs and cost-effectiveness.
 
Methods This cross-sectional study directly observed prenatal and child health care visits to evaluate service quality in 38 CCTP-supported facilities involved in the QI intervention and 12 CCTP facilities that were not part of the intervention. Costs were collected from the QI intervention implementing partners. Multiple logistic regression determined odds ratios of full compliance with quality standards in the intervention compared to the non-intervention groups, controlling for confounders. Using this data, the study estimates the costs per additional service delivered to quality standards in the intervention sites.
 
Results Full compliance with quality standards was 18 times more likely for both prenatal and child health services. in facilities participating in the QI intervention. During the study period, there were about 95,000 prenatal and 280,000 child health visits in these facilities. For a $293,385 total ($0.78 per service provided) for the QI intervention, there were 60,102 additional prenatal care consultations and 122,900 additional child health consultations done to full compliance with clinical norms. This is an additional cost per prenatal visit delivered in full compliance of $1.25 and an additional cost of $1.78 per child health visit in full compliance.
 
Conclusion The intervention was associated with improved quality of care for a low additional cost per service delivered to compliance with norms. With a small additional investment, the Guatemala MOH could implement a QI intervention to increase health service quality in all areas where CCTP is operating to increase the quality of and demand for CCTP-supported services.
 
This study has been submitted to a journal for peer review and will be available when published.

 

Region and Country: South Africa

Topics: Maternal, Newborn and Child Health

Partners: 
USAID Health Care Improvement Project | Management Sciences for Health
Year: 
2009
Language: 
English
Description: 

 

This is the revised version of the Primary Health Care Supervision Manual developed by the National Department of Health and serves as key tool for strengthening the delivery and improving the quality of Primary Health Care services, the cornerstone of the national health care system. It follows on the earlier Clinic Supervisor’s Manual that was originally introduced to the public health sector at a national workshop in October 2000 and adopted in March 2004 for countrywide use.  Since the introduction of the Manual in 2000, the health care system has undergone significant transformational changes as a result of changes in the burden of disease in South Africa. These changes have resulted in the development of new programmes that were not included in the former manual. Materials used in this revised version draw from a number of sources, all of which have been field-tested and have proven to be very useful tools in supervising primary health care programs.

The manual contains guidelines for quality supervision, use of supervision support checklists, conducing in-depth technical program reviews, and tools for working with Primary Health Care Facility Committees.